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HomeMy WebLinkAbout0083 KNOTTY PINE LANE - Health 83 KNOTTY PINE LANE, CENTERVILLE A=191-077 LOT#8 I 1 ? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville r/ M - 191 P- 177 Property Address �. Diane Lawler Owner Owner's Name h+ information is required for every 20 Mooring Lane, South Yarmouth MA 02664 May 3, 2016 = page. City/Town State Zip Code Date of Inspection m: Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Troy Williams use the return Name of Inspector key. Troy Williams Septic Inspections my Company Name 19 Hummel Drive Company Address team South Dennis MA 02660 City/Town State Zip Code (508)385- 1300 S1682 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority S r May 3, 2016 Inspector's Signa ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 �o �S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M- 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is required for every 20 Mooring Lane, South Yarmouth MA 02664 May 3, 2016 pager; City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 83 Knotty Pine Lane, Centerville M - 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is required for every 20 MooringLane, South Yarmouth MA 02664 May 3, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): I C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts RNIM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M- 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is 20 Mooring Lane, South Yarmouth MA 02664 May 3 2016 required for every 9 Y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Disposal Sewage spore System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 83 Knotty Pine Lane, Centerville M - 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is required for every 20 Mooring Lane, South Yarmouth MA 02664 May 3, 2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V.yy. 83 Knotty Pine Lane, Centerville M- 191 P=177 Property Address Diane Lawler Owner Owner's Name information is required for every 20 Mooring Lane South Yarmouth MA 02664 May 3, 2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? -® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 83 Knotty Pine Lane, Centerville M - 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is 20 Mooring Lane, South Yarmouth MA 02664 May 3 2016 required for every Y page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 15=42,000 gals. g ( y g (gp ))' 14=41,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 3 weeks Date Commercial/industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r 83 Knotty Pine Lane, Centerville M- 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is 20 Mooring Lane South Yarmouth MA 02664 May 3, 2016 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/ADate Other(describe below): N/A General Information Pumping Records: Source of information: Last pumped on 7/7/14 per info from owner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ElTight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M- 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is 20 Mooring Lane South Yarmouth MA 02664 May 3 2016 required for every � y , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank, d-box and leach pit are original to home. 3 drywell chambers were installed on 6/25/99 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18'+ feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'X9'X6' 1000 gallon Sludge depth: 4" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M- 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is required for every 20 Mooring Lane, South Yarmouth MA 02664 May 3, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2'8" Scum thickness none Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M - 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is 20 Mooring Lane, South Yarmouth MA 02664 May required for every y 3, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form F-11 VA Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M- 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is required for every 20 Mooring Lane, South Yarmouth MA 02664 May 3, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order with equal distribution to outlet lines. Speed leveler on outlet to pit. No evidence of solid carry-over or backup in the past was found at the time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M - 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is 20 Mooring Lane, South Yarmouth MA 02664 May 3, 2016 required for every y page. CityJrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 -6'X6'with 2' ofstone ® leaching chambers number: 3-500 gallon with 4 stone ❑ leaching galleries number: 32'X 13'X 2' ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil was sandy. Chambers and pit had a low water level present with no evidence of hydraulic failure or problems in the past found at the time of inspection. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M- 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is required for every 20 Mooring Lane, South Yarmouth MA 02664 May 3, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 83 Knotty Pine Lane, Centerville M - 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is 20 Mooring Lane, South Yarmouth MA 02664 May 3 2016 required for every Y page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I � 0 11E, O O z8� 2- �s l t r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M - 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is required for every 20 Mooring Lane South Yarmouth MA 02664 May 3, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 13.0'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: AIW 247 Zone C 22.8' 2.7'adjustment You must describe how you established the high ground water elevation: Hand augered 4' below bottom of leaching with no water found at a depth of 12.0'. Groundwater adjustment at the time of inspection was 2.7'. Bottom of leaching at 8.0'(pit)was found not to be located in the high groundwater elevation at the time of inspection. Bottom of chambers is 5.5'. USGS estimates groundwater at 38.0'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Knotty Pine Lane, Centerville M- 191 P- 177 Property Address Diane Lawler Owner Owner's Name information is y 20 Mooring Lane, South Yarmouth MA 02664 May 3 2016 required for every , page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 r `'t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 83 Knotty Pine Lane Centerville,MA 02632 Owner's Name: Larry Hatfield Owner's Address: Same Date of Inspection: October 2, 2001 Name of Inspector.(Please Print) James 1bL Ford OCT 1 7 2001 Company Name: James M. Ford Map:19 Ma' Address: P.O.Box 49 Par : 9YH "`Mailing HEALTH L,tN I. Osterville,MA 02655-0049 _ Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have.personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience-in the proper function and maintenance of on site sewage disposal systems.-I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).-The system Conditionally Passes N Fr Evaluation by the Local Approving Authority Fail Inspector's Signature: Dater October 3 2001 The system inspector shall a copy of this inspection report to the Approving Authority jBoard of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments report only describes conditions at the time of inspection and under the conditions:.of use at that-+ time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I r i J �L Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 83 Knotty Pine Lane Centerville,MA Owner: Larry Hatfield Date of Inspection: October 2, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. - The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box.is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 83 Knotty Pine Lane Centerville, MA Owner: Larry Hatfield Date of Inspection: October 2, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of'Realth determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool-or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public-Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil a bsorptionsystem(SAS)and the SAS-is within 100 feet of a surface water supply or tributary to a surface water supply.The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a:private water supply well.-,.- Ile system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a'3., ... private water supply well**. Method used to determine distance - ' ` **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform k ° y bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and�,. x the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other..;'_." failure criteria are triggered A copy of the analysis must be attached to this form. 3. Other: `3 Page 4 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 83 Knotty Pine Lane Centerville, M4 Owner: Larry Hatfield Date of Inspection: October 2, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool surface of the ground or surface waters due to an overloaded or ✓ Discharge or ponding of effluent to the clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than b"below invert or available.volume is less than%2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high.ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or.privy is within a Zone I.of a public well.. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system ismithin 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone H of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered `yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM PART B CHECKLIST Property Address: 83 Knotty Pine Lane Centerville, AM Owner: Larry Hatfield Date of Inspection: October 2. 2001 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system_components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. - I Ilk r a. � 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 83 Knotty Pine Lane Centerville, MA Owner: Larry Hatrield Date of Inspection: October 2, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 4 of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2000- 125 000 jZals.; 1999-120,000 p,als. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seaWpersons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Pumped on July 17198 and May 17199-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: New leach field Jun 25199-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 83 Knotty Pine Lane Centerville, AM Owner: Larry Hatfield Date of Inspection: October 2, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2„. Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): . . _ . Tees were present The liquid level was even with the outlet invert There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 83 Knotty Pine Lane Centerville, MA Owner: Larn,Hatfield Date of Inspection: October 2. 2001 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D box was level There were no signs of solids or leakage There were no signs of backup from the leach field. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION (continued) Property Address: 83 Knotty Pine Lane Centerville, AM Owner: Larry Hatfield Date of Inspection: October 2, 2001 SOIL.ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not rcauircd) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6' (1000 gal.) leaching chambers,number: ✓ leaching galleries,number: 3-500 gal. drywells-32'x 13'(per as built card) leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit had 6"of water on the bottom. The bottom of the leach pit to grade was approximately 8'. The drywells were located but not due im, The bottom of the drinvells to grade u_c s avvroxirnatelv-5'6" CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: 1 Depth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: indication of groundwater inflow(yes or no): a Com ents (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIW_: None (locate on site plan) Materials of construction• Dimensions: Depth of solids: Comments(note. ,condition of soil signs of hydraulic failure,level of nonding condition of vegetation.etc,): �^ r- ti Page 10 of l i OFFICIA1. 1NQ.PT1'CTInN FOPM _ NnT FOR Vnl TTNTAnV AR!RVQQAVSFN'rQ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA-QT (- SYSTEM INFORMATION (continued) Property Address: 83 Knoth; Pine Lane Centerville. MA Owner: Larry Hatfield Date of ins17tetion: October 2. 2001 ]Lfnn• 191 Parcel: 077 Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the bulldiiw. I I A - ay r3i � � a g O Aa, a a AB- 3a 3 � 101 Ay - yC, ,3 y o 10 Page 11 of 11 :TTTIYT T T1T(Y T\T 11TT/lllT T:T\�S T T Tl/1 T1 TT/l TT1 T QN ! ATT- ,r._r,g"�.gRS, eiNNe-E:?. : 54P!N _r. ,ems _,. _ '� ; _r,!pe_ e'f_:a:E�'E' _ ASS .t.;N_n;N e.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA1Q e 1- SYSTEM INFORMATION (continued) �.�_ .... 4� r- nr..- Pro3 Crty A_ua ess, n Levee y r �.•e a Centerville. MA Owner: Larry Hatfield Date off SI'iTE EXAM Slope Sa s"acc w a}cr Check cellar Sha"ot— E e"— Estimated depth to ground water 38' +/- feet (Adjusted High Ground Water Level is 31.2') Please intli_-ate(c rl1 all methodE use_to determ—_ tha b oln _rrun Ohtained from system design plans on record- if checked; date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) L"leck F Fes:.:c.. _ � To-1 c _ Checked with local excavators,installers-(attach documentation) You muso describe how You established the high gratlinnd water elevation: The bottom of the leach pit to grade was approximately 8] Using the Barnstable topographic map and the Cape Cod {nri9ri]]CC]T]11�J/lrr--rn-%rn]---C tZ -- /ert ituei�T e 3 3' i-iv ice•v ii Y"%ier t i.' 3:a n "iir iiL Commission Technical Bulletin the high groundwater adjustment for this site(AI W 247, Zone C, 8101)was 6.8'. n,i.-report has beer.prepared and Ilie system inspecte1.and pass'ed as of the date of inspection. This report is not a warranty or guarantee that the system will function properl>in the future. There have been no warranties i1 N� Gr4 dA- 3 •cp, G"ov" O'r levL zsu�+Mc,14-- /-11w 3�.o Grou,,�w4Te /eve TOWN OF BARNSTABLE N OfATION a 3 ICnUIEJ ?I At- SEWAGE # V',.J GE CC^+Cry ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY JUUb GAi. LEACHING FACILITY: (type) �t X!eADnwells (size) NO. OF BEDROOMS 3 BUII DER OR OWNER '�� 14 PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leach' g facility) Feet Furnished by ?✓-S0-C,(T 0r% x `- A' ► ��� o � . B' A3— 39 3 k 89- 19 Ay- 419 p - 410 y O y No. , Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes 01pprication for �Digozal *p5tem Construction Permit Application for a Permit to Construct((repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.83 e-lorfl pl! le 4^j_e_ Owner's Name,Address and Tel.No. C.�a7ri�r✓ii/o� ��rs� ��T'�'ir'/� Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 49 Jq»101 V Designer's Name/Address and Tel.No. J s aow Dom. ,(3krr®>s Jos /i �� /3i,arHa.s Type of Building: Dwelling No.of Bedrooms 4-1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repair's or Alterations(An s er when applicable) �j_Z6y// -I — 'Tea ��� ®�r� e./y � Date last inspectgd: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Uealth. Signed 4 n67 Date g� 5' Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No. i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes, PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS V _ rication for Mi!gpoar *pe;tem eoigtruction ertnIt Application for a Permit to Construct(,�,,. epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components` & Location Address or Lot No.93 k'/70trl Pjy-e 4,w,�vy. Owner's Name,Address and Tel.No. Ju� } Assessor's Map/Parcel i.. Installer's Name,Address,and Tel.No.477-O$41 Designer's Nam ,Address and Tel.No. •)o s,rl0W Dt /-3�rroS JosC,00 47t /,3.arsAa.s /2--1 /,-y Type of Building: Dwelling No.of Bedrooms 4f Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision.Date 'Title r r Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable),2 ZZL-&& — S'dO /,',or cult y ,�foH-� r�lWyNi� �- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. ` Signed 6) Date l - y �; Application Approved by i Date Application Disapproved for the following reasons Permit No. Date Issued ------------T-----------------------_--- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( wired ( )Upgraded( ) Abandoned( )by (AA r- V at 8okd,02ne A;f., G G ' s/' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer�103 r;1J! lJi/3ra rs9�4 Designer a � � .moo The issuance oft "s permit shalll not be c nstr ed as a guarantee that the s s. �illtion as d signed. Date— g Inspector, !ram t�i /7 - ----------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ,wi6pogar 6potem Construction Vermit Permission is hereby granted to Construct(4-)'K&pair( )U grade( )Abandon( ) System located at /�Cblo89c/ f/al c ��a� f and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction 7st be/cginpleted within three years of the date of permit. _ � c Date: Approved by 1 v 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, 1osc�l U� /3�rroS hereby certify that the application for disposal works construction permit signed by me dated G- I y concerning the property located at 83 kA7a f the meets all of the following criteria: failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. e soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ,,,-C I ere are no wetlands within 100 feet of the proposed septic system ere are no private wells within 150 feet of the proposed septic system There is --increase in flow and/or change in use proposed ere are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the ma..dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: I r A) Top of Ground Surface Elevation(using GIS information) O, "\�\(`•l\�l� B) G.W. Elevation '� +the iN�Y. High G.W. Adjustment . _ f - 1 D V" DIFFERENCE BETWEEN A and B SIGNED : .li�.� � DATE: (Sketch proposed plan of system on back]. q:health folder:cat kid� �!�-c L��-G TOWN OF BARNSTABLE LgCATION 95 Knorry Aoi 4#4 e SEWAGE 3717 VILLAGE' ASSESSOR'S MAP & LOT 1,71 -077 INSTALLER'S NAME&PHONE NO. 4+77=619y9 SEPTIC TANK CAPACITY /DOO LEACHING FACILITY: (type) ��—Sa0 Gss�.�ru �fi���size) 32X /3 NO.OF BEDROOMS BUILDER OR OWNER L�srrN f�ioTFie/� PERMITDATE: G-2 S'-I9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist. within 300 feet of leaching fa ility) Feet Furnished by oo • .tip " I shad 1 1. A � DATE ;142/3/9)7r" PROPERTY ADDRESS: Edward 'ICelly DEC 1 1997 F TOWN OF BABNSTABIF or 83 Knotty Pine Lane HFAlTNOEPT. Centerville,Mass/ 02632 4b:. L On the above date, I Inspected the s-eptic system at the -above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 1 -1000 gallon precast leaching pit. Ba8ed on my InRoectlon, I certify the following condltlons: 3 . This is a title five septic system': { 78 Code ) 4 . ThE septic system is in proper working order at the present time. Name : J . P . Hacomber Jr., i ---------------------- Company:_J . P_ _ Macomber & Son_Inc , address :_-3a�c-66------�-- - Centervi 1 Le `Mass__02632 Ph one : 508-�Z7S�338------- I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks.CtuP'>O' le 'ohflelds Pump+d L Inst.Ullyd Town Sewer Connections P.O. Box 66 Centerville, MA 02632.0066 7 7 5-3 3 38 7 7 5-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ` I r DEPARTMENT OF ENVIRONMENTAL PROTECTION z - ONE WINTER STREET. BOSTON, MA 02108 617.292.5500 WILLIAN1 F WELD TRUD1 CORE Go�cmor Secre(ar\ ARGEO PAUL CELLUCCI DAVID B STRURS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr PART A CERTIFICATION Property'Address: 83 Knotty Pine Lane Centervill0dress of Owner: 206 Winter Street Date of Inspection: 12/3/97 (If different) Fall River,Mass . Name of Inspector: Joseph P.Macomber Jr. 02720 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & SOn Inc . Mailing Address: BOX 66 Centerville,Mass. 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 2Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails f Inspector's Signature: / 7, Date: �7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the repon to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I)L7 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (ravimed 04/25/97) Page 1 of 10 DEP on the Wortd Wide Web: httpJ/www.magnet.state.ma us/dep Printed on Recycled Paper �1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART A CERTIFICATION (continued) Property Address: 83 Knotty Pine Lane Centerville,Mass . 02632 Owner: Edward Kelly Date of Inspection:12/3/97 BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or oos:r_..ec pip-e(s) or due to a broken, sertled or uneven distribution box. The system will pass inspeclion if (with approval 01 :-'�e Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced /LO The system required pumping more than four times a year due to broken or obstructed pipe(s). The system -J: pass inspeciion if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /Qi) Conditions exist which require funher evaluation by the Board of Health in order to determine if the system is failing :o oroleO !-ne public health. safety and the environment 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A WHICH WILL TECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 1�' PRO l, .) C,-y Vl'or privy is within 50 feet of a surface water rI or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETER�si,,ES TH4T THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: A,b The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supp�. o, tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply . eii The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supp -e The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more iro•T, a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds ncicates :n•a: the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen s K-a. :o o, less than 5 ppm. Method used to determine distance A)A/ - (approximation not valid) 3) OTHER (revised Y49. 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 83 Knotty Pine Lane Centerville,Mass . owner: Edward Kelly Date of Inspection: 2/3/9 7 D) SYSTEM FAILS: You must indicate er; er "Yes" or "No" as to each of the following: kP6 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CmR 1; 303 7ne oa>;s for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to core; the failure Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaoea or cloggee S-\S o, cesspool -A)O,rJe- /ir Static liquid level in th ,distribution box above outlet inven due to an overloaded or cloggec SAS or cesspoo. Liquid depth in r, a ,s less than 6" below inven or available volume is less than 112 day flo, Required pumping more than rmes in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped it4 Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a suriace �a:er suppi. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply weii w11.'1 nc acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of weH a;er ana�ysn :or coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) URGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above. ,,LL The system serves a facility with a design flow of 10,000 gpd or greater (large System) and the system is a sign,f;can: mrea; to public health and wfery and the environment because one or more of the following conditions exist Yes No A—d the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mappeC Zone ii o a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater trea!--e-,: Drr>g:6— requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Depanment lot further nformal.on (r.vi..d 04/25/17) D.y. 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 83 Knotty Pine Lane Centerville,Mass . Owner: Edwad Kelly Date of Inspection: 1 2/3/97 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No lX Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, /eaxcluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revised 04/25/97) Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 83 Knotty Pine Lane Centervi1 le,Mass . Owner: Edward Kelly Date of Inspection:1 213197 FLOW CONDITIONS RESIDENTIAL: Design flow: W .p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:Q Garbage grinder (yes or no):V1 Laundry connected to system (yes or no):_Jej Seasonal use (yes or no): -,k c. Water meter readings, if available (last two (2) year usage (gpd): 1��1�Q7��`,y�� ��� eil1© Sump Pump (yes or no): 4� i yto ' D pyr = tv'� TOO Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: 04 Design flow: ,(J,¢ Rallons/day Grease trap present: (yes or no)ZL� Industrial Waste Holding Tank present: (yes or no)I&W Non-sanitary waste discharged to the Title S system: (yes or no)-A)—A Water meter readings, if available: ,dIA Last date of occupancy: ' OTHER: (Describe) �:^f Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)" If yes, volume pumped: /Ll4 gallons Reason for pumping: TYPE OF SYSTEM Septic tank/d+stnbvtiorr x/soil absorption system Al1J Single cesspool Overflow cesspool Privy 4/G Shared system (yes or no) (if yes, attach previous inspection records, if any) ,t 0 I/A Technology etc. Copy of up to date contract? Other 4,4 APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 83 knotty Pine Lane Centerville,Mass . Owner: Edward Kelly Date of Inspection:) 2/3/97 BUILDING SEWER: ilocate on site plan) p Depth below grader Material of constructro c iron _ 40 PVC — other (explain) Distance from Private w ter supply well or suction line G� Diameter Y� Comments: (condition of joints, venting, evidence of leakage. etc.) r' v 41 SEPTIC TANK:-1—"j' 1'ezL 5; (locate on site plan) 1/ Depth below grader material of construction: Z/Concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age t�/? Is age confirmed by Certificate of Compliance 09(Yes/No) Dimensions: -'/.*Gy (:�7-7 /11' Sludge depth:_*1 j/ Distance from top of sludge to bonom of outlet tee or baffler Scum thickness �Z// Distance from top of scum to top of outlet tee or baffler Distance from bonom of scum to bonom of outlet t e or baffle: �rf How dimensions were determined: Comments: (recommendation for pumping, condui of inlet and outlet tees or baffles, depth of liquid Lev I in relation to outlet inven, structural me n evidence f leakage, etc.) ` ti I `NcT GREASE TRAP: (locate on site plan) Depth below grade:L614 material of con st run ion:A/Aconcrete., netabf/AFiberglass V4 Polyethylene.,C�other(explain) R � Dimensions: Scum thickness:_(L Distance from top of scum to top of outlet tee or baffle: vq Distance from bonom of scum to bonom of outlet tee or baffle: 4/9- Date of last pumping: N.,f Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integriry, evidence of leakage, etc.) (r.vl..d 04/25/97) P.g. 6 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 83 Knotty Pine Lane Centerville,Mass. Owner: Edward Kelly Date of Inspection: 1 2/3/9 7 TIGHT OR HOLDING TANK:il�'6,1(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grader material of construction:kUlficoncretekl4 metal,v�Fiberglass 4/4PoI yet hylene 4,4other(explain) log AX . Dimensions: 4114 Capacity: V4 gallons Design flow: V,4 gallons/day Alarm level: -- evel:�—Alarm in working orderN/?Yes;A/A No Date of previous pumping: 4J4— Comments. (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:4vi 2' (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:-2Z,,A e- (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No)—A!Z? Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (zevls•d 04/25/97) P.g• 7 of 10 1 � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 83 Knotty Pine Lane Centerville,Mass . Owner: Edward Kelly Date of Inspection: 1 2/3/9 7 SOIL ABSORPTION SYSTEM (SAS): lO V'/WvtO.U,Q/1�1_1 ;locate on site plan, if possible, excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length:-�-- leaching fields, number, dimensions: �7 overflow cesspool, number Alternative system: Name of Technology: V Comments: (note cond ion o soil, sins of hydraulic failure, level of ponding, condi ion of vegetation, etc.) r CESSPOOLS: AjafJe- (locate on site plan) Number and configuration: �✓� Depth-top of liquid to inlet invert: Depth of solids layer: 111W Depth of scum layer: cif' Dimensions of cesspool. Materials of construction: Indication of groundwater: 1144 inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) WdC PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs pf hydraulic failure, level of ponding, condition of vegetation, etc.) i (r•vl••d 0�/75/97) P•g• 8 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropentAddress:83 Knotty Pine Lane Centerville,Mass . O"ner. Edward Kelly Dale of impect,on1 2/3/9 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: ^•crude ties to a( least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) —004 if =4.1J1 tt 0 -4-Ilan U.1�t L,I �Jano� of q d-,j d,d a -a Furl V 000l N Ur1 X o . >� P.g. 9 of 10 SUBSURFACE SEWAGE DISP(. t. SYSTEM INSPECTION FORM I . C SYSTEM INFOI;•.. .'ION (continued) t Property Address: 83 Knotty Pine Lane Centerville,Mass . Owner: EDward Kelly Date of Inspection: 1 2/3/9 7 Depth to Groundwater—�3 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record observation of Site (Abuning property, observation hole, basement'sump etc.) _Z-D,termine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Grouncfwa1crElevation. (Must be completed) Used Ground Water Contours Map. Gahrety & Miller Model 12/16/94 (revised 04/25/97) Pec. of 10 .- - •r.nr-r.—n .r. Tr� rrr-aer.nsrr'rnnre-r.rr..r,:•.�+-r-rarr:. TOWN OF Barnstable BOARD OF HEALTH 1 Sll[)SU[IFACR 9F.HAGF DISPOSAL ,SY�STF;M IN�9I' CTION FORM - PART DR- CEIZTIFICATION ­� ' a -TYPE OR PRINT CI,EARL1•- PROPERTY INSPECTED STREET ADDRESS 83 Knotty Pine Lane Centerville,Mass. ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Edward Kelly PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sen- Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City Stat• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one ; System PASSED The inspection which I have conducted has not found any information . which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 . Any failLir-e criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have conducted has found that the system fails to Protect the 'public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 12/3/97 One copy of this certification must be provided to the OWNER, the BUYER ( Where applicable ) and the DOARD OF IIEALI'li. * It the inspection FAILED, the owner or"" I?erator shall upgrade the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 . partd . doc r^ <� .S - w r� ti S blil 3��l THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVTRONMMNTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. Junc s. 1995 *ActjngD1r,cczor of Lhc -on ,( Witcr Pollution Control c