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HomeMy WebLinkAbout0088 KNOTTY PINE LANE - Health 88 KNOTTY PINE LANE Centerville A= 191 - 100 No. Fee 41C) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es 01pplitation for 33isposal *pstrm Construction Permit Application for a Permit to Construct(V� Repair( ) Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. 6% K not{s P ne L n Owner's Name,Address,and Tel.No. Assessor's Map/Parcel c�M ec u,t(e, _ �� C,du r d G i i se rna r► Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �' 6 rt,�tca�F�;on 50� �I77 0(053 F lc,hec•i� �nu;fol►,on4G1 -77g.q,qu• I1(,(o Type of Building: Dwelling No.of Bedrooms J Lot Size . 4q Acrn sq.ft. Garbage Grinder( ) Other Type of Building ► Fgr,.. horn, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) S30 gpd Design flow provided 3y 19 gpd Plan Date Q '7�I q Number of sheets Z_ Revision Date Title Size of Septic Tank 1000 gall onS Type of S.A.S. (Z) S-00 %atlon GhA Mb-&t Description of Soil Nature of Repairs or Alterations(Answer when applicable) ?%e p(ACe, SAS o nd I) (>ox U S� 0xisi i nq 1000 n0.11nn +o,nk, 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 Certificate of Compliance has been issued by this Board o alth. Signed Date Application Approved by { MY IA. i Date Application Disapproved by - Date for the following reasons Permit No. (�e i I_ Date Issued �r y t No. G( � ' �03 F ! Fee d U * Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipoiitation for 33isoosar *pstrm Construction i3ermit Application for a Permit to Construct(0 Repair( ) Upgrade( ) Abandon( ) ❑Complete System E�,Wividual Components Location Address or Lot No. �$ K no N Owner's Name,Address,and Tel.No. Assessor's Map/Parcel C2�12 �,i ¢, a `C,dw�a r cl G i►S 2 nc,n Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. IQ) C3 �c.ACovcz on T09 W'77-0(05 Z ?7+L)C\L1� tl(0(o Type of Building: Dwelling No.of Bedrooms 3 Lot Size LH Ac�(S sq.ft. Garbage Grinder( ) Other Type of Building S,)4 i, F n rn No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1�30 gpd Design flow provided gpd Plan Date r 1 1-1 J 1 q Number of sheets 7 Revision Date Title Size of Septic Tank 1oo0 ocllonS TypeofS.A.S. (2) ,UU a4a0(or, ���CAmiart Description of Soil Nature of Repairs or Alterations(Answer when applicable) (�¢p�G a. ��A 3 „sue i� lz,ox u 5 c J WOO CX VMot- a r, ,L �i 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 Certificate of Compliance has been issued by this Board o ealth. Signed f,/ Dates Application Approved by 1A Date Application Disapproved by Date for the following reasons Permit No. �� G� 1 Date Issued ---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance � THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by of p J(- o has been constructed in accordance with the provisions of Title 5 d type for Disposal System Construction Permit No.,-0�Gf- f dated Installer Designer #bedrooms Approved design flo gpd The issuance of this ermit shall not be construed as a guarantee that the system wi 1 cf o as desig . Date } Inspector �l No. 7 Q — �l. Fee U G- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction 3pPrmit Permission is hereby granted to Construct( ) Repair(L '� Upgrade( ) Abandon( ) System located at , .� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date Approved by Town of Barnstable ��pftHE Tph� Regulatory Services Thomas F. Geiler, Director • MAS& = Public Health Division �`bAr039. a � Thomas McKean, Director fD MA'S 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: S-l y. /q Sewage Permit# Zo I q- IL 3 Assessor's Map/Parcel 1 ql - Io0 Installer & Designer Certification Form Designer: 'r 66r-rAL Etiu;romcnlm I Installer: jR ii A 6XeruJc��1� Address: Rox 331 Address: IL4 Tc�rr! LPQ On S- $- 1 Q B 4 Q jEXC0.V0.J 1o.,\ was issued a permit to.install a (date) (installer) septic system at $8 Kno iAu P1 r-,c L based on ai design drawn by (address) dated (designer) _ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distrillution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any.component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required) was inspected and the soils were found satisfactory. t DANAD D. staller's Sign rt) HERTY,JR. . 4 (Designer' Signat. ) (Affix Desig p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:office formsWesignercertification fonn.doc TOWN OF BARNSTABLE LOCATIONS? kn.MAQ LO SEWAGE# ZOIc( - I1,3 VILLAGE Q-cmAc.c-u;IXL ASSESSOR'S MAP&PARCEL IS - 00 INSTALLER'S NAME&PHONE NO. -R 4 R EXCayaAt O--, 4')1. OLS3 SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type) 5o0!jc3-J (size) )3 X Z S A Z NO,OF BEDROOMS . OWNER G' G ^ PERMIT DATE: S-$• J Q 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 facility) Feet FURNISHED BY AI- Zy ' 81" Al' Z%) 32-' 29 ;ZEAR Ay• *) o ' 3 a f 4��FTHE Tp�� Town of Barnstable Barnstable ° Inspectional Services 1caC HARNbTABLE, MASS.. Public Health Division i6gq. �� m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4988 2026 April 17, 2019 GILSENAN, EDWARD J TR 88 KNOTTY PINE LANE CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 88 Knotty Pine Lane, Centerville, MA was inspected on 03/27/2019 by Brett Hickey, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Needs Further Evaluation by the Local Approving Authority" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Septic tank is leaking. • Staining observed in leaching pit above the top row of leaching holes and in the stone. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Vcan, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\88 Knotty Pine Lane Centerville.doc B B OFFICE From: Stanton,David[David.Stanton@town.bamstable.ma.usj Sent: Tuesday,April 2,2019 3:50 PM To: B&B OFFICE(office@bandbexcavation.net) Subject: FW:Stain Line Question From:McKean,Thomas Sent:Monday,April 01,2019 9:38 AM To:Stanton,David Cc:Desmarais,Donald;Lavelle,Timothy;Malkus,Karen;McKenzie,Marybeth;Miorandi,Donna;O'Connell,Timothy; Parziale,Jim Subject:Stain Line Question I contacted Brian Dudley of DEP and received the following informatic If a private inspector has a question about a stain line and he/she fee �— indicate the system"Needs Further Evaluation." pep The local approving authority would have to make a final determinati The approving authority can ask the following questions,to,Has the home been vacant for awhile? 3+ Wetk, �weeRewds) h"� Z�t rs What was the degree of staining? S+c:%nad over }oe cou air 14 What was the extent of it? Soma Sloan' P„te, "/ I II What was the coloration? (Mack �U br Were there any other indications of failure? S+*.& f-k d•+tcdoc Did he/she notice any staining in the d-box? W o D-Bew io Sysic Is it a cesspool or a Title V system? —r. V The Health inspector may wish to observe the conditions himself/herself.This is at approving authority's discretion. GondiklonS OIOSeru<A �°~ 'cn$�eolion 88 Knai(� Q;na Lone. Ick �k 7wnk hod oat. w of wo+\-cc ,,. kt,a boAcm 4 Ltack, e-V SW.,*6 ov4- i-ap cow of hafts 1 i vx �r B _B OFFICE From: Stanton, David [David.Stanton@town.barnstable.ma.us] Sent: Tuesday, April 2, 2019 3:50 PM To: B & B OFFICE (office@bandbexcavation.net) Subject: FW: Stain Line Question From: McKean,Thomas Sent: Monday, April 01, 2019 9:38 AM To: Stanton, David Cc: Desmarais, Donald; Lavelle,Timothy; Malkus, Karen; McKenzie, Marybeth; Miorandi, Donna; O'Connell, Timothy; Parziale, Jim Subject: Stain Line Question I contacted Brian Dudley of DEP and received the following information. If a private inspector has a question about a stain line and he/she feels it is indicative of a potential failure, he can indicate the system "Needs Further Evaluation." The local approving authority would have to make a final determination. The approving authority can ask the following questions,to the private inspector during the further evaluation: Has the home been vacant for a while? 3-* Weas (weak.4f%d5) 3,000 450M01-4 04 WQAt- 05ed► o,4 V- What was the degree of staining? S}o►►nod �o(+ rou off- ] p ov�,r �,Q,c�„' holt.. What was the extent of it? 5 ,ena 51rci.m m_, What was the coloration? (3Ioc,4. Were there any other indications of failure? S+o„q ' •, �•!- d�scolo«d Did he/she notice any staining in the d-box? Wo D- 60 ;� SyS1t� �TantR P�k� Is it a cesspool or a Title V system? V The Health inspector may wish to observe the conditions himself/herself.This is at approving authority's discretion. Condi�ioa3 O'45erU¢d v or '�n ¢C�ion $8 knoi4V —Tani- had onl-� (o" o4 wo.-tc j, kV c, bAlry\ aK Lead p � S}a; ,eo oY�c fop cow of hales I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '0 88 Knotty Pine Lane Property Address �cj Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every .p_ page. City/Town State Zip Code Date of Inspection A,,'s Inspection results must be submitted on this form. Inspection forms may not be altereil'in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information i5i# 13CQ qc� on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 w Company Address Sandwich Ma 02563 City/Town State Zip Code ,emu (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑■ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey 3-27-19 6eb:201B.OM1.Q]161]:10 Le9O Inspector's Signature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 T ,I f V t f Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane �V Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I .� Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L/ 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r Commonwealth of Massachusetts j� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane V Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 P 9 9 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. c. Other: The septic tank was found to have only 6"of water in it when inspected showing the tank is leaking.The SAS(leach pit)was found to be dry, but stained over the top row of leaching holes when inspected. Per Barnstable Board of Health regulations the system"Needs Further Review". 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ O Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS orcesspool ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a rivate water supplywell. P ❑ El 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ Q 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane v� Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ED Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ El Has the system received normal flows in the previous two week period? ❑ O Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ 0 Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ 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? ❑ El 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: ❑ El Existing information. For example, a plan at the Board of Health. El ❑ 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(5)] t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans 3 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA Description: No design plans on file at Board of Health Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes R1 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage (gpd)): See below Detail: 2017- 2,000 gallons 2018- 1,000gallons Sump pump? ❑ Yes M No Last date of occupancy: 3 weekend ago Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane V Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: � Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If es discharges to: yes, 9 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Owner-exact date of last pump is unknown(maybe 2 1/2 years) Source of information: Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: I t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 16 cam•, Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane V, Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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 ❑ Tight tank.Attach a copy of the DEP approval. El Other(describe): Tank and Pit Approximate age of all components, date installed (if known)and source of information: unknown due lack of records Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 1'8" Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 8" 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 1 Dimensions: 000gallons "Tank leaking" Sludge depth: If if Distance from top of sludge to bottom of outlet tee or baffle If If Scum thickness It 11 Distance from top of scum to top of outlet tee or baffle of if Distance from bottom of scum to bottom of outlet tee or baffle viewed How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank had only 6" of standing water when view. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 l Commonwealth of Massachusetts Title 5 Official Inspection Form °l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` cam 88 Knotty Pine Lane v Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet 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: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts I Title 5 Official Inspection Form f' le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): NA Depth of liquid level above outlet invert 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: Elleaching pits number: (1 ) 6'X6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was dry when viewed but had high staining over top row of holes in leach pit. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert layer Depth of solids la P Y Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments note condition of soil signs of hydraulic failure level of ondin condition of vegetation, ( 9 Y P 9� 9 , etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 •1 Commonwealth of Massachusetts Title 5 Official Inspection Form I°I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane v5V11 Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r cam° Commonwealth of Massachusetts ip Title 5 Official Inspection Form �_ p I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane v Property Address Edward Gilsenan Owner Owners Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 A Al-2F A2.2W ( 2 J A3.33' �✓ BI-25' 132-2V B3.31' t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 I o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ❑■ Check cellar ❑■ Shallow wells Estimated depth to high ground water: NoGW@12'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 0 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) ED Accessed USGS database-explain: USGS and town topo maps show property is >12' above high ground water You must describe how you established the high ground water elevation: Bottom of SAS is >4' above high ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane V Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. �■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 4 s` t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 sob to TOWN OF BARNSTABLE e'v,f-J4,7' ,9-,—7 LQCATION SEWAGE # ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Cass /- (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER ' BUILDER OR OWNER DATE PERMIT ISSUED: /97D DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �c. 6 0 rivy�/y j�,r,�i lave, ASSESSOR'S MAP NO. PARCEL ,10( l4`. CATIO _ rN AGE PE„RMi� N0. o�T 00'' VILLAGE Lo�� I INSTALLER'S NAME A ADDRESS W_ a . S UILDER R OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED F_t)W t s 131� a i'1(—c>cx- . �� '` �ir L ` ,t '. f ���� .� c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is required for every Centerville Ma 02632 3-27-19 page. City/Town State Zip Code Date of Inspection 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. fmngoutf Important: A. Inspector Information filling out forms on the computer, Brett Hickey use only the tab y key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Ito Company Address Sandwich Ma 02563 City/Town State Zip Code rx (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. 0 Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dr X.1,cIOnW Gy Brett Wtluy Brett Hickey W.._­.1-Y.......m,_o ®�,.de,.�..o...n.—S 3-27-19 le:]O1B 0<.tt110:1�:10-0C'W Inspector's Signature pe 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. CityFrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Knotty Pine Lane u� Property Address Edvyard Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `F 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: The septic tank was found to have only 6"of water in it when inspected showing the tank is leaking.The SAS (leach pit)was found to be dry, but stained over the top row of leaching holes when inspected. Per Barnstable Board of Health regulations the system"Needs Further Review". 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �^ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ O Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ O Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Q Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ O Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ E Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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. 5) 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 CA. 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y � 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ [I Were any of the system components pumped out in the previous two weeks? ❑ 0 Has the system received normal flows in the previous two week period? ❑ O 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 El NA available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ O 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: ❑ F] Existing information. For example, a plan at the Board of Health. Q ❑ 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(5)] I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts is ,lp Title 5 Official Inspection Form = I?1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane u� Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans 3 Number of bedrooms (design): Number of bedrooms (actual): NA DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: No design plans on file at Board of Health 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes [E No See below Water meter readings, if available (last 2 years usage (gpd)): Detail: 2017- 2,000 gallons 2018- 1,000gallons Sump pump? ❑ Yes 0 No 3 weekend ago Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c � Commonwealth of Massachusetts i= Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Owner-exact date of last pump is unknown(maybe 2 1/2 years) Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c°�•� Commonwealth of Massachusetts r ,p Title 5 Official Inspection Form col Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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 ❑ Tight tank. Attach a copy of the DEP approval. 0 Other(describe): Tank and Pit Approximate age of all components, date installed (if known) and source of information: unknown due lack of records Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 11811 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c � Commonwealth of Massachusetts �= l Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "F � 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 8" 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 1 Dimensions: 000gallons "Tank leaking" Sludge depth: n n Distance from top of sludge to bottom of outlet tee or baffle r� rr Scum thickness n n Distance from top of scum to top of outlet tee or baffle 11 " Distance from bottom of scum to bottom of outlet tee or baffle viewed How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank had only 6" of standing water when view. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form '= 1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): NA Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 cam, Commonwealth of Massachusetts �n ,p Title 5 Official Inspection Form �= �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Knotty Pine Lane v� Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach co of current pumping contract(required). Is co attached? Yes N copy p p 9 copy ❑ ❑ o 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information. (cont.) 10. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: (1 ) 6'X6' leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form IR j1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was dry when viewed but had high staining over top row of holes in leach pit. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 f cry Commonwealth of Massachusetts Title 5 Official Inspection Form l'.l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 88 Knotty Pine Lane v Property Address Edward Gilsenan Owner Owner's Name information is required for every Centerville Ma 02632 3-27-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 i - Commonwealth of Massachusetts Title 5 Official Inspection Form '= I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..�/� 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is required for every Centerville Ma 02632 3-27-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 A B Al-26' A2.29' A3.33' B9.25' B2.28' B3.39' 0 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 cam, Commonwealth of Massachusetts �_ Title 5 Official Inspection Form ii. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville Ma 02632 3-27-19 required for every page. CityFFown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑ Surface water ❑■ Check cellar ❑ Shallow wells Estimated depth to.high ground water: No GW @ 12'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 0 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: USGS and town topo maps show property is >12' above high ground water You must describe how you established the high ground water elevation: Bottom of SAS is >4' above high ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �= 1,` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Knotty Pine Lane Property Address Edward Gilsenan Owner Owner's Name information is Centerville J Ma 02632 3-27-19 required for every page. CityTTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ■❑ B. Certification: Signed & Dated and 1, 2, 3, or checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOP OF FOUNDATION COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM PROFILE Flaherty Environmental Services BROUGHT TO WITHIN 6"OF (not to'scale) - EL. 60.0' EL. 58.0' FINAL GRADE INSP. PORT W I 3" OF GRADE U CLEAN SAND P.O. Box 331 2"of e"to z" DOUBLE WASHED PROP. EL. 58.0' Hanvkh, MA 02645 4"CAST IRON or EQUIVALENT PEASTON5-OR GEOTEXTILE MIN. PITCH 1/4" PER FOOT FILTER FABRIC 774.994.1166 a"SCHEDULE 40 PVC PIPE 4" SCHEDULE 40 PVC PIPE . FLOW LINE flfstZ b be/even VENT IF REQUIRED 5' 2.8% •.�' ' L.EXIST. 14 ~� o0 00 o0000e EL EXIS 0000000000 0 0000o0o0c EL55.6' 000 000 00 . EL 54.73, 000°0° 00000000 ® ® 00000000c 0 0 00000 °oo° Ooo° e2.0 1.54.9' 000000 ®� 0000 ' GAS BAFFLE EL 54.7' 0°0°0°0°00°00°0°0 ® N Q��� 0°0°0°0°c_ 0 0 0 0 '...�. 000000000° 000000 . �4' • A . 00000000c EL.52.7' (H 2O o-BOX) ' •3:'' `:'; 6"CRUSHED STONE OR SOIL ABSORPTION SYSTEM 1000 GALLON SEPTIC TANK MECHANICALLY COMPACrEo (2) 500 GALLON H-20 CHAMBERS (DATUM: ASSUMED) EXISTING WITH 4'STONE AROUND IN A 5.2' �" to 1 " DOUBLE WASHED STONE 12.83'X 25'X 2'CONFIGURATION BOTTOM OF TEST HOLE EL. 47.5' EL. 47,5' USGS ADJUSTMENT: N/A LOCAT/ONMAP / ANO1-7y BENCHMARK: GROUNDWATER ELEV: N/A �IN` 4fy C/ ��� EL. 0.0 NDN IVTH ' IS0,00' LOCUS Menemshe Ln. > > DRIVEWAY EXISTING 3 BR NTS yi Or GSLAB) DWELLING DA !D G F J R. LOT 31 I 0.44 ACRESf 21 7 4' MAP 191 PLOT 100 O EXIST. S.T. 18TER``® CA 411TA i OATS'5/712019 REV/SED. 180,00' N 14,3' SITE AND SEWAGE PLAN FOR B& B EXCAVATION,INC./ EDWARD GILSENAN 88 KNOTTY PINE LANE (CENTERMLE) BARNSTABLE, SCALE: 1" = 30' MA REP LCP 32aga-B SH I PAGE i OF2 ..................................................................................................................... .................................. ............................. ................................................................. ................................ ................... ...................................................................... ...................................................................................................................................................................................................................................................................................................................................... GENERAL NOTES DESIGN CAL CULA TIONS S YS TEM DETAIL Flaherty Environmental Services P. 0. Box 331 I. ALL PRECAST COMPONENTS TO BE H-10 Harwich, MA 02645 RATED UNLESS OTHERWISE SPECIFIED. NUMBER OFACTUAL BEDROOMS 3 774.994.1166 DISTRIBUTION BOX(ES)AND ANY COMPONENTS WITH ANY ANTICIPATED GARBAGE DISPOSAL UNIT NO VEHICULAR TRAFFIC TO BE H-20 RATED. 2. THE DESIGN OF THIS SYSTEM DOES NOT TOTAL ESTIMATED FLOW (110GAL/BRIDAYX3BR) 330 GAL.1VAYq ALLOW FOR THE USE OF A GARBAGE GRINDER. REQUIRED SEPTIC TANK CAPACITY 660 GAL, 3. MUNICIPAL WATER IS AVAILABLE. 25' 4. ALL CONSTRUCTION TO CONFORM WITH SIZE OF SEPTIC TANK 1000 GAL.(EXISTING) 310 CMR 15.000 AND ALL OTHER APPLICABLE LOCAL, STATE AND FEDERAL SOIL CLASSIFICATION CODES AND REGULA TIONS. 5. INSTALLER/CONTRACTOR TO REVIEW& DESIGN PER TION RA TE <2 MINAINCH' VERIFYALL ELEVATIONS AND DETAILS EFFLUENTLOADING RATE a 74 GAL.IDA YIF T2 AND REPORT ANY DISCREPANCIES TO 33' DESIGNER PRIOR TO CONSTRUCTION OR ASSUME ALL RESPONSIBILITY, LEACHING AREA (2)x(25.0'+ 12.83)(2) = 151SF 6. INSTALLER/CONTRACTOR IS 25.0'x 12.83' =320 SF RESPONSIBLE FOR MAINTAINING SAFE 471 SFx a 74 =348 GPD WORK AREA, VERIFYING ALL UTILITIES AND NOTIFYING "DIG SAFE" USE(2)500 GALLON H-20 CHAMBERS WITH 4'STONE (1-888-344-7233) 72 HOURS PRIOR TO INA 12-83'X25'CONFIGURATION ASDIAGRAMMED CONSTRUCTION. 7. ANY CHANGES TO OR DEVIATIONS FROM RESERVE LEACHING CAPACITY NIA GPD THIS PLAN MUST BE APPROVED IN WRITING BY FLAHERTY ENVIRONMENTAL SERVICES AND LOCAL BOARD OF HEALTH. 8. FINISH COVER OVER COMPONENTS IS NOT TO EXCEED 3'PER 310 CMR 15.000 (NTS) UNLESS SHOWN PER PLAN. 9. ALL ABANDONED SEPTIC SYSTEM COMPONENTS TO BE PUMPED DRY AND SOIL EVA L UA TION FILLED WITH CLEAN SAND OR REMOVED TESTHOLE#1 F#19-16 TESTHOLE#2 P#19-16 OF bq AND REPLACED WITH CLEAN SAND. Evaluator. David D.Flaherty Jr.,RS,REHS Evaluator. David D.Flaherty Jr.,RS,REHS YIN, 10.ALL COMPONENTS TO BE PROVIDED SE#2755 SE#2755 WITH WATERTIGHT ACCESS PORTS BOH Witness: David Stanton,RS BOHWWb7a=. David Stanton,RS Date, May2,tors Date: May2,2019 WITHIN 6"OF FINISH GRADE. F R in I 1.ALL SEPTIC TANKS, DISTRIBUTION TH-I ELEV.56.0' TH-2ELEV 58.0' 2 BOXES AND PIPING TO BE INSTALLED WATERTIGHT. 0'-98" A SL 10YR&2 0'-96" A SL 10YR&2 IST 12.NO KNOWN WETLANDS OR WELLS 9.-,W. 6 SL 10YR 516 IVIT R% 9'-40" B SL 10YR 516 WITHIN 100 FEET OF PROPOSED LEACHING. 13.THIS IS NOT A CERTIFIED PLOT PLAN AND UNDER NO CIRCUMSTANCES IS THIS (W-) Pem 7 certify that on November 12,2002,fhavepassed F/ SITE AND SEWAGE PLAN PLAN TO BE USED FOR ZONING OR the examination approved by the Department of BUILDING PURPOSES. Environmental Protection and that the above analysts FOR 14.LOT IS SHOWN AS ASSESSOR'S MAP 191 has been performed by me consistent*0 the 8 Bic EXCAVATION, INC./ 40"-126' C CMS 2.5Y 614 40"-120' C CMS 2.5Y614 required fairing,expertise and experience described LOT 100. 5 gravel 5%gravel In 310 CMR 15.018(2). EDWARD GILSENAN 15,LOCUS PROPERTY IS NOT LOCATED WITHIN AN AQUIFER PROTECTION 88 KNOTTY PINE LANE DISTRICT(ZONE II). G.W.ELEV.NIA G.W.ELELEV.NIA (CENTERVILLE) BOTTOM TH-1ELEV 47.5'1 BOTTOM TH-2 ELEV. 48.0' BARNSTABLE, MA PAGE20F2 .......................................................................................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................