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0091 KNOTTY PINE LANE - Health
91 Knotty Pine Lane Centerville A = 191 078 Town of Barnstable P# o Py Department of Regulatory Services ' Public Health Division Date -7 �/ • nuwaresl e . >Aas 1639. 200 Main Street,Hyannis MA 02601 Date Scheduled_ fTime U m DD Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: 14`` I D A Ld Witnessed By:D 611/J , LOCATION& GENERAL INFORMATION Location Address -q91$Vtn 1 Owner's Name �t O �L�I F-""r— Address leiAssessor's Map/Pare �IZT V l ~ ` *-T r _ D-7 Engineer's Name 1 NEW CONSTRUC1710N (.�-� REPAIR �. Telephone# Y Land r�p Use 4 � �y t t*k_] Slopes(4o) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well f[ Drainage Way ft Property Line —__ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) n� Z / ,3e `Parent material(geologic) + �D ( - Depth to Bedrock -r Depth to Groundwater Standing Water in Hole: Weeping from Pit Pace Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: in, Depth to soil mottles: Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj,factor— Adj.13rauntiwater Lt vei , PERCOLATION TEST bate�._- Time Observation Hole# 4 Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-611) End Pre-soak Rate MinJlnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) ` s Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 1001 of wetland,you must first notify the, Barnstable Conservation Division at least one (1) week prior to beginning. Q:\S EPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. on i;�tency °k Graven DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil - Other Surface(in) "�� (USDA) (Munsell) Mottling' (Structure,Stones,Boulders. Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.To Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten I Flood Insurance Rate Map: Above 500,year flood boundary No— Yes Within 500 year boundary No Within 100 year flood boundary No✓ Yes . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? e L If not,what is the depth of naturally occurring pervious material? "t Certification (� ' I certify that on �D \ (date)I have passed the soil evaluator examination approved by the Department of Envir mental Protection and that the above analysis was performed by me consistent with . the required training,exper' a xperie a described in 310 CMR 15.017. Signatur Date 8 2b 00 7 Q:\,SE PTIC�PERCFORM.DOC Pressure Dosed System ? Provided pump and piping calculations as re uired. 310 CMR 15:220(4) r) Pressure dosing required on all systems>2000gpd or alternative systems undeF`tmedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvalsl If used in gravelless system - make sure jet is directed as not to scour soil interface [Guidance Document Inspections once per year(systems<2000 gpd)or quarterly rs 000 d ood to note on lan 310 CMR 15.254 2) d nstruction in fill - Did the plan specify that the fill shall meet ecilication of 310 CMR 15.255(3)?ervious barrier and/or retainingwall ? Guidance Document Impervious barrier installation must be supervised by desi ner[310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer 310 CMR 15.255(2)(a) Side slope not exceed 3:1 ? r310 CMR 15.255(2 Breakout requirements met? [310 CMR 15.252(2) and Guidance Document At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) 3I0 CMR 15.255 (2)(e)] Pave � ft Check DEP A roval�letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface �. Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for Lperpetual maintenance a reement? An alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Hasa licant submitted a copy of a maintenance s err a Are the variances listed on the plan ?[310 CMR 15.220 (4)( ) RLS Stamp necessary on plan if a component is within five / feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed - [Refer to 310 CMR 15.4141 L7 Address Sheet 6 of 7 MINIM - - ..,f y.v. Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR / 15.240(l)] ✓_ Required separation togroundwater? 310 CMR 15.212).] Aare ate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or / y >36" deep) [310 CMR 15.241] 1/ Inspection ports specified and within Yfinal grade? [310 CMR / 15.240(13)] V Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] Chambers and Gal. in trench configuration supplied with inlet / every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must be tograde) 310 CMR 15.253(2)] Aggregate I'minimum-4' maximum. 310 CMR 15.253(l)(b) 2'sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)] ON all Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] , 100 feet-maximum length 310 CMR 15.251 1) a Minimum separation 2x effective depth or width whichever / eater(3x if reserve between trenches) [310 CMR 251 1)(d)] Situated along contours 310 CMR 15.251(2) Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] minimum 2 distribution lines 310 CMR 15.252(2)(a)] Maximum separation between lines 6' 310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)( )] Separation between-beds 10' minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only 310 CMR 15.252(2)(i) Address Sheet 5 of 7 is the system in a Designated Nitrogen Sensitive Area(Zone II fo a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? 310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] Pumping to septic tank? 31 0 CMR 15.229 Shared System 310 CMR 15.290 Address L 1 - 4 ��`^� C., Sheet 7 of 7 Size OK? '[310 CMR 15.223(1)] Inlet tee located ten inches below flow line 310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227(6) Outlet tee with gas baffle or approved filter 310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR / 15.228(l)] Separation between inlet and outlet tees (no less than liquid depth) 310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CW 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(l) and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (b 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systerrig<1000gpd, / two fors stems>1000 gpd 310 CMR 15.228(2)] V All at-grade covers secured to unauthorized access? [310 CMR 15.228(2) > 10 ft from building foundation [310 CMR. 15.211(1)] Buoyancy calculation Required/Done 1310 CMR 15.221(8) H-20 Where appropriate? 310 CMR 15.226(3) Setbacks from resources 310 CMR 15.211 Required when other than single-family dwelling or flow>1000 d [310 CMR 15.223(1)(b)] First compartment 200%daily flow; Second compartment 100% daily flow 310 CMR 15.224(2) and 3) "U"pipe through or over baffle, outlet of each compartment with as baffle or approved filter 310 CMR 15.224(4)] Address K� �[ �y Sheet 3 of 7 "�� I ,. Located at least ten feet from any water line? [31 00 CMR 15.222(2) Disposal piping at least 18" below water line (when water and sewer cross, see 310 CMR 15.211(1 11]) Cleanouts required/provided ? 310 CMR 15.222(8)] Thrust blocks specified in force mains?310 CMR' 15.221(6)(c) Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs?(.005 within gravity-distributed trenches and beds) 310 CMR 15.251(9) and 310 CMR 15.252(2)(c)) Siphonproblem/ leachfield below pump chamber) Endca s or vent manifoldspecified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8)and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5)specifies various pipe types allowed } Stable compacted base [310 CMR 15.221(2) and 3l 0 CMR 15.232(2)(a) Splash plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)) Riser if deeper than 9" 310 CMR 15.232 3 ( Inside minimum dimension 12" 310 CMR 15.232(2 ) Minimum sum 6" 310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d) Capacity(emergency storage above w CMR 231(2)] orking=design flow)?[310 EM Proper setbacks 310 CMR 15.211 (same as septic tanks)] 77' Watertight 20-in minium access manhole at least 20"MUST BE TO GRADE 310 CMR 15.231(5)] Service components accessible (not too deep,with piping, disconnects accessible) Alarm floats-alarm on circuit Separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6)and (8) Stable Compacted Base 1`310 CMR 15.221(2)) [Buoyancy calculations needed ?Provided? [310 CMR 15.221(8)J Address Sheet 4 of 7 No.s OD f At Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: . Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIPPlication for Migw6aY *pgtem Con!6truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System El Individual Components Location Address or Lot No.ql K 't, Pj lAe Iqe Owner's Name,Address and Tel.No. Ock t KaTe-4,vL Assessor's Map/Parcel 'Ceh{efvil h�_ h I/—ej1 a, ` 413011 Installer's Name,Address,and Tel.No. ,_-nhn Designer's Name,Atddress and Tel.No. uate 13 AA4,sDvt CAP-e 6if 641T_.OVOW I ch At A -69 a Type of Building: Aeres Dwelling No.of Bedrooms Lot Size Ov'349 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ! ) Cafeteria( ) Other Fixtures Design Flow 13AO gallons per day. Calculated daily flow gallons. Plan Date Number of sheets .0e Revision Date Title Size of Septic Tank Type of S.A.S. el Ej U, VJ Description of Soil: i!�, -.4a C) d tsf' Nature of Repairs or Alterations(Answer when applicable)_AA2e>Cj,&1 Z 1 -,ds!a,k 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 thi d of ealth. Signed �VL& Date ? ®� Application Approved by Date Application Disapproved for the following reasons Permit No. Z) 31q Date Issued l Town Of Barnstable Regulatory Services P • • Thomas F. Geiler, Director • LYRNSI'ASE:E, �$ ; 06 Public Health Division '°'�o•ri+'�°' Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date:LAY. Designer:__')AV112 VttkcbDk Installer: Oh� Koj-)Wr Address: . CA-51 �11��C s Address: C d __r On �dM KeLqwas issued a permit to install a (date) (installpc) septic system at C1 K'^ID ?jW' G I_ ased on a design drawn by --� �n (address) hrV 1 D I, RJ dated S q lit 120C)q (designer) J.•certify that the septic system referenced above was installed substantially according to ` 'le design, wvhich may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I cerhfyr,that the septic system referenced above was installed wid'i'major changes`0,'e, greater flim'10' lateral relocation of the SAS or any vertical-irelocation of any component of the septic�system)but in accordance with State&Lo call ;Regeflations. Plan revision or certified as-biillt`by desineF to follow. =bAvio.r7ow (Inst s Si e) B• n :. MASON m No.1066. �I8TS sgNITAA�P� (1) er s Signature) (Afx, a.'s Stamp Here) PLEASE RETURN TO BARPNS�°ABLE-PUBLIC.HEALTH DIVISION. RTIFICATE OF COMPLIANCE WELL' NOT73-TISSU,ED UNTIL 'BOTH.T.H1s iFORM T7Tr� T /'1 i1T ♦TT TT/"If1Y^t Tf9l� 111 tip+ RUIL CARD ARE tcr.i.,r WED BY-TH .BARNSTABLE PUBLIC$E 1 DIVISION THANK YOU. Q1? � HealWe t c/Desi er Certification Form APPLICANT: ADDRESS: Kv4 DESIGN FLOW: �!Pz>. gpd REVIEWED BY: DATE: N/A -. OK NO Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u Locus Provided 310 CMR 15.2204 t Plan proper scale? (1"=40'for plot plans, 1"=20' or fewer for com onents) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required 310 CMR 15.412(4) V Location of impervious surfaces (driveways,parking areas etc.) j 310 CMR 15.220(4)(d)] V Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas �l [310 CMR 15.220(4)(e)] 1/ ✓ System Calculations 310 CMR 15.220(4)(f)] daily flow septic tank capacity (required andprovided) soil absorption system (required andprovided) whether system designed for garbage grinder North arrow 310 CMR 15.220(4)( )] Existing and ro osed contours 310 CMR 15.220(4)( )] Location and log of deep observation holes (existing grade el. on each test) 310 CMR 15.220(4)(h)) Names of soil evaluator and BOH representative [310 CMR J �� 15.220(4)(h)and (i) 1/ Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate? [310 CMR 15.242] ✓ , Certification statement by Soil Evaluator 310 CMR 15.220(4) ') Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Location of every water supply,public and private, (310 CMR 15.220(4)(k)] Address 7/ Sheet 1 of 7 t within 400 feet of the proposed system location in the case of surface water supplies and grayel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. 310 CMR 15.220 4)(1)] Water lines'and 6th'd-subsurface"utilities located [310 CMR 15.220(4)(m (if water line cross see 310 CMR 15.211(1)[1 ) Profile of system showing invert elevations of all system / components and the bottom of the SAS 310 CMR15.220(4)(o)] Stamp of designer 310 CMR 15.220 1 and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) 310 CMR 15.220(5)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2)or as approved for an upgrade under LUA at 310 CMR 15.405(1 Test hole adequate to demonstrate four feet of suitable material? 310 CMR 15.103 4) Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3) Benchmark within 50-75'of system 310 CMR 15.220(4)(g)] Materials specifications noted? [various sections of 310 CMR 15.000 System components not> 36" deep(unless Local Upgrade Approval or LUA.requested) 310 CMR 15.405(1 b) 1� Address 1 � � � � Sheet 2 of 7 r _ No. 1 I�U 1. + THE COMMONWEALTH OF MASSACHUSETTS t Entered in computer: es A H UBLIC EALTH DIVISION - TOWN OF BA,RWSTABLE.,lMASSACHUSETTS . ZippYication for Digpozar Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( )'"0 Complete System D Individual Components Location Address or Lot No.qt Knc; -9 pi N e- Ia h ie Owner's Name,Address and Tel.No. Q Ctn j�gTC�� Assessor's Map/Parcel GerTe(Vd 1e M A 41 Kno�y P kr ta►e Thokh p:%on i Geh �- / M o ► -4 0c Installer's Name,Address,and Tel.No.Tom XrnmeOg Designer's Name,Address and Tel.4,704e 13 AAaS©h _ cape Golf 6AfT J ?Ar cv 1 Lh A4 A DFs -69Qq I Type of Building: Aaei Dwelling No. of Bedrooms Lot Size 6.3(® sq.ft. Garbage Grinder( ) Other Type of Building tnhgel )4kj�*- No.of Persons Showers Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date �' /�t..>�C� Number of sheets/ Revision Date ' Title Size of Septic Tank 04e2g2�LCX eT_ft;^______Type of S.A.S. a- !Lq� I G 1(li►t t Mf_I Description of Soil dah, �Io r._►i �.+� Nature of Repairs or Alterations(Answer when applicable) Ah rne�I 1-=m*c e—naA"h�-es: ? d 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 thi B and of1lealth. Signed © U Date G9 Application Approved by Date Application Disapproved for the following reasons Permit No._ D I 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 AjL ' at 411 PAM has been constructed in accordance with the provisions o Title 5 and_the for Disposal System Construction Permit No. 0+ - i dated Installers /� GJ Designer % MW?Q.117 The issuance of this permit hall not be construed as a guarantee that the syst m 1. functio as designed. Date q —Z A- Inspector �11/'! ------- No.0 �l `714 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mig;poe;al 6pztem (Con.5truction Permit Permission is hereby granted to Const u t( )Repair(1.o�Up rade( )Abandon( ) System located at 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 ust be completed within three years of the date of this permit.Date:_, Approved by � C�' �s �`J TOWN OF BARNSTABLE LOCATION �1 SEWAGE# .10o9-31�l VILLAGE ASSESSOR'S MAP&PARCEL/ / ' INSTALLER'S NAME&PHONE NO. / �j /7��1/°j��[.l /� )��, -7/7 7 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO.OF BEDROOMS OWNER s�/n PERMIT DATE: a cf La el COMPLIANCE DATE: Q G7 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 L�aching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY f � ��� r __ ���` ��` ��� �� 3� �r� �� ��". � � �� TOWN OF BARNSTABLE a? LOCATION 17 ci 12,"a, L,, SEWAGE# i VILLAGE ASSE/SSOR'S MAP&PARCEL 191 y7y INSTALLERS NAME&PHONE NO. t-764,'^-J- '~ ') 7,P—97 7 2 SEPTIC TANK CAPACITY /5 C---- LEACHING FACILITY:(type) /66-0 (size) G �'• NO. OF BEDROOMS 3 OWNER l.7.6 0/c' Z PERMIT DATE: .3.Z3- c ? COMPLIANCE DATE: S p ' Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of aching Facility Feet Private Water Supply Well and Leaching Facility(If an wells exist on site,or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any w ands exist within 300 feet of leaching facility) 7 Feet FURNISHED BY r � � F 3 L/ i No:. Fe�25.00 THE COMMONWEALTH OF MASSACHUSETTS E red in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACH es 01pplication fOr iqoal *p$tem Cowgtrurtton VCrmtt Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 61 7—5 6 3—51 1 4 91, C�1p tty Pine Ln Cent Ville Fred Dooley Assessors apWlej �y 61 Amelia Way Marstons Mills Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Type of Building: Dwelling No.of Bedrooms k) Lot Size sq.-,ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new line, d—box and outlet T 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 of He �A G 17 Signe �G / Date Application Approved byL'A Date Application Disapproved by: Date for the following reasons Permit No. o Date Issued ��o No. . Fee-2 5 0 0 THE COMMONWEALTH'OF MASSACHUSETTS E tered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACH SETT- es Z(pprication for i!5pogar *pgtem Congtruction Permit Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 61 7—5 6 3—51 1 4 91 K�r�t Pine L Cente Ville Fred Dooley Assessor sMap-/Y-arce y 61 Amelia Way Marstons Mills Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic P Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building I No.of Persons Showers( ) Cafeteria( ) Other Fixtures 1! Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when-applicable) Install a new line, d—box and outlet T 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 of Heal Signed /� Date Application Approved by / Date Application Disapproved by: Date for the following reasons Permit No. O Date Issued 3 <23—D T THE COMMONWEALTH OF MASSACHUSETTS L; e d-hGX �)` o.l y BARNSTABLE,MASSACHUSETTS Dooley Certificate of Compliance, THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (V) Upgraded Abandoned( )by Wm E Robinson Sr Sen_ tic Service at 91 Knotty Pmne Ln, Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. --)&n—7—/u L/ dated 3 - 2 Installer Designer #bedrooms 1.J ✓}— Approved design flow A/ gpd The issuance of this permit shall not befconstruee'das a guarantee that the system will unction9 d{eJsig/iaed. - Date Inspector_ -------------------------------------------- No. '•" q Fee $2 5.0 0 THE COMMONWEALTH OF MASSACHUSETTS DoolNJBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lwiqoof tp ens Congtruction Permit Permission is hereby granted to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) System located at 91 Knotty Pine Ln, Centerville and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: onstruction must be completed within three years of the date ofMTQ Date Approved by TOWN OF BARNSTABLE ,LOCATION SEWAGE# o"7 r, VILLAGE e67-f e ASSESSOR'S MAP&PARCEL 191 INSTALLERS NAME&PHONE NO. L 6F7 SEPTIC TANK CAPACITY Li G-- ` LEACHING FACILITY:(type) (size) NO. OF BEDROOMS 0 OWNER 1Z OF PERMIT DATE: 3-.2-3-a 7 COMPLIANCE DATE:3;Z ;;., Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of aching Facility Feet Private Water Supply Well and Leaching Facility(If a wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any w ands exist within 300 feet of leaching facility) Feet FURNISHED BY F V 9 r y A° n COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION J 4 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_ 91 Knotty Pine Lane Centerville Owner's Name: Fred Dooley ; Owner's Address: 61 Amel i A Wad Date of Inspections Name of Inspector:(please print)_Wi 1 ' am _ . Robinson Sr, Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 } Centerville, MA wG Telephone Number:_ (508) 775-8776 k rq 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 15340 of Title 5(310 CMR 15.000). The system: is Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Dute: X—(5-7 L 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 seat to the system owner and copies sent to the buyer,.if applicable,and the approving authority. Notes and Comments ""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. Title 5 Inspection Form 6/15/2000 page 1 v , Page 2 of t 1 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner: Pred QooleV Date of inspection:3 ,S-- Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: 1 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 A .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 me I 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 a plain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obs cted pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(witty appr(wal of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND plain: The system required pumping more than 4 times a year due to broken or obstrmUd pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction isumovod ND explain: I Y � Page 3ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:91 Knotty Pine Lane Centerville Owner: Fred Dooley Date of Inspection: . C F rther Evaluation is Required by the Board of Health: of ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing o protect public health,safety or the environment. 1. Sy item will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sys em is not functioning in a manner which will protect public health,safety_and the environment:, Cesspool orprivy is within n 50 feet of a surface water Cesspool or.privy is within 50 feet of a bordering vegetated wetland or,a salt marsh 2. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 frond a brivate water supply well•• Method used to determine distance "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. 3. Other: f 3 r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner: Fred Dooley Date of Inspection: 9 J. G 1 D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Ye o _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of etfluentto 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'/a 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 I00.feet of a surface water supply or tributary to a surface water supply. y portion of.a cesspool or.privy is within a Zone l of a.public'welt y 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 forma Yes/No)The system fails. 1 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: be considered a large system the system.must serve a:facility with a design-flow of 10,000 gild to 1`5,000 9p Yo must indicate either"yes"or"no"to each of the following: e following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet ofa tributary to a sm1ace drinking water supply _ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If u have answered"yes"to any question in Section E the system is considered a significant threat,or answered . ..y s"in Section D above the large system has failed.The ovens r yr operator of any large system considered a si ificant 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 i ' Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 91 Knotty Pine Lane en ervi e Owner• Fred Dooley Date of Inspection:_3—d"'- S—G-f1 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 7 2_ Has the system received normal(lows in the,previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ILA 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? _ �as 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 pp xtmatton of distance is unacceptable)13 10 ClAR 15.302(3)(b)j 5 1 , Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 91 Knotty Pine Lane Centerville Owner: Fred Dooley Date of Inspection: 5— 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 N of bedrooms): L O Number of current residents: Does residence have a garbage grinder(yes or no): /—O Is laundry on a separate sewage system(yes or no):N vv [if yes separate inspection required] Laundry system inspected(yes or no):/L v Seasonal use:(yes or no):ki2 0 0 6 — .1 1 0 0.0 Water meter readings,if ava lable(last 2 years usage(gpd)): Sump pump(yes or no): A,0 -- I -i , uu0 Last date of occupancy: =-C�r7 COMMER/hding IND STRIAL Type of estaent: Design flow o 310 CMR 15.203): _____gpd Basis of des seats/persons/sgft,etc.): Grease trap yes or no):_ Industrial wding tank present(yes or no):—Non-sanitadischarged to the Title 5 system(yes or no):Water metegs,if available: Last date ofnty/use: OTHER(d ): GENERAL INFORMATION Pumping Records Source of information: fit/ ,d Was system pumped as part of the inspection(yes or no): A., d If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: T—YP F SYSTEM�tic 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/Altemative 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: Nib Were sewage odors detected when arriving at the site(yes or no): 6 I N&C 7ofI OFFICIAL INSPECTION F 01N1-NOT FOR VOLUNTARY ASSL;SSAIENTS SUBSURFACE SEWAGE DISPOSAL SYSTLA1 INSIILC"1'10N F0101 PART C SYSTEM INFORMATION (continued) Property Address:_91 Knotty Pine Lane Centerville Owner: _ Fred. Dooley Dille of Inspection: UUIL.UMG 5L' Lit(locate oilsilt plan) UcpUt below dc: Materials of a nstnrclion:_case iron► _dU PVC_vtlrer(explain). Distance fro I private water supply well of suction lint:_ Cununcnts un condition of joints,venting,cvidcncc of Icakagc,etc.): SEPTIC TANK: _(locate on site plan) Depth below grade: Material of plain) tuaio _olhc r(explaln cte_m J etal_fiberglass rulycdrylcne If tank is metalmetal list ccrtificat age:_ Is age cunf►rnted-by a Certificate of Compliance (ycs or nu):_(attach a copy of t Dimensions: Sludge depth: Distance front lop of sludge to buuun►of out lct Ice or bafllc: ,3 6 r Scwn thickness: ;L. - 3 v Distance from to of scum to 101,of outlet Ice or bafllc: Distance Gom bottom of scum to bosom o uhtet Icc or battle: /Z) I low ss•cre dimensions determined: d w• ,p s, ►� Cummcnls fun pumping recouunendations,inlet and outlet tee or bafllc eonditicn, srruclwal inrcbrily,liquid Ic%.cls as related to oullct bhvcn,cvidcncc of leakage,etc.): , / b c, GILEASE TRAP:_(local un sile plan) Dcpdt below grade:_ Malelial ofeonsUuction: cunucte metal fiberglass_pulycthylene _o111cr Dimensions: Scum thickr►css: Dislancc (tom top Scwn to top of uutict Icc or bafllc:_ Distance Gom but In of`scunh lu buuum of uutict tcc or bafllc: Datc of last punt ing: Conuncnts(on umping tccununcnJatiuns, inlet and uutict tcc or bafllc cunJitiu:►, sUucUual integrity,liquid Ichcl, as tclalcd(u o Del illml,irviticncc of leakage,cic.): 7 c ,'age 8 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUUSUIU�ACE SEWAGE DISPOSAL SYSTEM INSPECTION F01tNI PART C SYST01 INl'0101ATION(continued) Properly Addrt33: A 1 Knotty Pine Lane _Cent to Ile Owner: D&It of lospcclloo: TIGHT or 110LU1 TANK; tar_( Jc must be pumped at lime o(inspection)(lucate on site plan) Dcplh below grade: hlalerial of cons) lion:__concrete_metal_(iberglass_lpulyethyltne olher(explain): Uimcnsions: Capacity: alluns Uesign Flow: gallons/Jay Alarm Pic (ycs of no): Alarm Icvcl: Alann in svurkin order ]Date o(lasl pumping: 6 V'cs or nu):_ Cunvnents(condition of alum and float switches,etc.): DISTRIBUTION BOX: ✓ (if lirescrrl must be opcncd)(locate on site plan Depth of liquid level above Outlet invert: Conuncu(s(Hole if box is level and distribution to outle leakage into or out of box,ctc.): is equal,any evidence of solids Carr}over,arty evidence of 1'UAII'CIIAMBLIt• (locate on site plan) Pumps in working der(yes or nv):_ Alamos in workir Order(yes or no): Commlienls(1101 condition of pump chamber,condition of pumps and appurtenances,e(c.): Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner: Fred Dooley Date of Inspection: 3--� S- SKETCH OF SEWAGE DISPOSAL SYSTEM 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 building. V� / �D • a � y 10 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner: _ Fred Doole Date of Inspection: '3 "7 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,ezcavation'not required) _ If SAS not located explain why: Type -,i!-leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (c spool must be pumped as part of inspection)(locate on site plan) Number and configur ion: Depth—top of liqui to inlet invert: Depth of solids lay r: Depth of scum lay r: Dimensions of c sspool: Materials of co struction: Indication of oundwater inflow.(yes or no): Comments( 5te condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: locate on site plan) Materials f construction: Dimensi ns: Depth f solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 ' 'Page 11 of I 1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner. Fred Doole Date.of Inspection: ��� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground waters feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: 96served 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: You must describe how you established the high ground water elevation: 11 Town of Barnstable �pf 1MF Tp� do Regulatory Services ;QABLE Thomas F. Geiler,Director M . •�� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 10 2007 Ms Cynthia Dooley 61 Amelia Way Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 91 Knotty Pine Lane, Centerville, MA was last inspected November 9th 2006 by William E. Robinson Septic Service, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Outlet tee was rotted, needs to be replaced. In let cover was unable to be opened as there was a deck post sitting on it. You have 2 years from the date of the system failure to bring the system into compliance,by making the septic tank accessible to pumping and by installing a new outlet tee. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. TABLE HE TH EPARTMENT omas A. McKean, R:S.. C.H.O. Agent of the Board of Health SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. gent ■ Print your name and address on the reverse 7d'❑Addressee so that we ca�1 return the Card to you. ece' ed b,(P' ed Na ) ate of e�gry ■ Attach this card to the back of the mailpiece, T ` o, (b/ or on the front if space permits. D. I delivery address different fr i 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No Ms Cynthia Dooley 61 Amelia Way 3. Service Type ' Marstons Mills, MA 02648 ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. f- 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service label) 7 0 15 116 0; 0 0.0 0 , 0191 2762 PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STAT • Sender: Please print your name, address, and ZIP+4 in this box • I I PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE 200 MAIN STREET hYANNIS, mASSACHUSSETS 02601 �`-�"��-.��►'�"�:+1 at.� 111t!!!!�!ll��ttl�Itlt�ttiftl�fllt��t� n COMMONWEALTH OF MASSACHUSETTS �D EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIONkq ip- . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Properly Address: 91 Knotty Pine Lane Centerville Owner's Name: Cynthia Dooley Owner's Address: J61AmmSellia Way 1A Date of Inspection:_ 111910(. Name of Inspector:(please print) - Sean Jones' n' CompanyName: William E. Robinson Septic' Service' Mailing Address: P O Box 1089 Centerville, MA Telephone Number: t508) 775-8776 t CERTIFICATION STATEMENT _ a 1 certify that I have personally inspected the sewage disposal system at this address and that the info ation rep.arted . . 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 systemsI°yam a DFsPs approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The systetf ��- C � R 77 P ses , tl onditionally Passes cc Needs Further Evaluation by the Local Approving Authori Fails M .._,t r� Inspector's Signature: Date: - 1 as 8F, The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Neatthvr. DEP)within 30 days of completing this inspection.if the system is a shared system or has a design now 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 approxing authority: Notes and Comments iveejs r+ttr btccVice -5yS1��- loe&fe.. Ws tea.,, pt6 )q,,, ko,;e 11 v-1aQcs,6tc. "This report only describes conditions at the time of inspection and under the conditions of use at that lime.This inspection does not address how the system will perform in the future un.de the ame or different conditions of use. Title 5 Inspection Form 6/152000 page I Page 2 of I I r OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SU BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner: C nthia Dbole Date of inspection: 1 I G u6 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: n/ 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: /,4- N 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 ying 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 Idgh static water level in the distribution box due to-broken or obstructed pipes)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 obstucted pipe(s).The system will pass inspection if(With approval of the Doard of Health): broken pipes)are replaced obsttuctian is nmovod ND explain: Pae3of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner: Cynthia Doole t. Date of Inspection: . 11 ell/D b 11 C—/uC— urther 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 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 l 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 froal 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 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. 3. Other: Lee.C Pn'f/ s �0 C-C. � a/,.,Cl.� I �j i s o/vs� Isa !'[F I C7-y/V Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner:_ Cynthia Dooley - Date of Inspection: q o b 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 efYluentto the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool N1R 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'h day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Numbcr 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 I00,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. J, .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(lie 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.] (YeslNo)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. LargeSystetns: To be considered a large system the system must serve alacility with a design-flow 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 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 11 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 arty large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3I0 CMR 15.304.The system owner should contact the appropriate.regional office of the Department. 4 I Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 91 Knotty Pine Lane Centerville-- Owner: Cynthia Doo 7—q Date of Inspection: 11 0(7 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes N _ 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? _ NIA` Were as built plans of the system obtained and examined?(If they were not available note as N/A) J _ Was the facility or dwelling inspected for signs of sewage back u ? g g p Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? J _ 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 nod _/_✓ 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)13 10 CMR 15.302(3)(b)] PP 5 Page 6 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 91 Knotty Pine Lane Centerville Owner: Cynthia Doole Date of Inspection:_ 11 1 9 o G FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 3�o bP� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no):IVVO Is laundry on a separate sewage system(yes or no)� [if yes separate inspection required] Laundry system inspected(yes or no):/�/ A Seasonal use:(yes or no):jVo Water meter readings,if available(last 2 years usage(gpd)): 2005 — 13,000 Sump pump(yes or no): IVO 2004 — 0 Last date of occupancy: COMMERCIAIANDUSTRIAL !V)A . Type of establishment: Design flow(based on 310 CUR 15.203): gpd Basis of design flow(seatslpersons/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: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: Qallons--How was quantity pumped determined? Reason for pumping: a TY t OF SYSTEM _Septic tank, it absorption system _Single cesspool Overflow cesspool —_Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Altemative 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: OrA SV&k— !975�� Were sewage odors detected when arriving at the site(yes or no): 4,41 6 1'agc 7 of OFFICIAL INSPEC HON FOINI—NOT FOR VOLUN-FARM ASSESSNIEN7'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0101 PART C SYSTEM INFORMATION (continued) Proptrly Address: 91 Knotty Pine Lane C.entervi e Owncn Cynthia Dooley Dale of Insptctlon. l lI vDb BUILDING SEIYEII,(locatt On silt plan) ucpUi below grade: ( - Matcrials of construcliott: cast iron ✓40 I'VC_other(explain): Distance from private water supply well or suction lint: CUriirnMIS(on condition of juuits,venting,evidence of Icakagc,etc.): ®.-,4-s t—/" O°E- �vD -Pa ke- e SEPTIC TANK: (locale on site plats) Depth below grade: J ,� Material of construction. oncrctc metal fiberglass pulycUiylcne _uthcr(txplain) — — Iftank is meta)list age: Is age cvnrumed-by a Certificate of Compliance(des or nu):-(attach a cup}of certificate) Dinttnsions: 000 s Sludge depth. /p j. Distance from sup of sludge Sewn Uiickncss: D' to bvlluni of outlet Ice or baflic: ` Distanct from top of scum tv Ivp of outlet Ice or baflic: _ Distance from bottom or scum to bottom of outlet Ice or Gatlle: Ilose ss•cre dimensions detcimined: �Ptne� LOB' 7�tC vt.r�, viz -- —1—__ _S Cvmnicnis fun pumping recommendations,inlet acid outlet ice or baflic condition,sttuclwal intc6rily,liquid levels as related to outlet uivcrt,evidence of leakage,etc.): o�I e►- b�l GLe oN�s ��r e>= ewfl R e a,,.4 S moo _ Ae,-Jj iz be itPl�r<ccE� 1 I c•f— s v✓t�die il? b-e Me GIIEASE TMI': ,(locate un site plan) Dcpdi below grade:_ Material of construcliun:_concrete etal hberglass_pulycilq•Icnc _oilier (o<plaui): _m Dimaisions: Scum thickness: Distance from lop of stunt lu top of Outlet Ice or baflic:_ Distance from bottom of'scum to buttom of outlet ice or baflic: Dale of last pumping: Cununenis(on pumping tccununcndalium,inlet and outlet ice of baflic condiliv:t, situctutal inicb(ity, liquid lcv cis as rclalcd to oullcl ins•cil,ccidencc of leakage,cle.): 7 Page 8 of I I OFFICIAL INSPECTION DORM -NOT FOR VOLUNTARY ASSLSSMLN"I'S SUUSUIWACI. SLIVAGL DISPOSAL SYSI-EM INSPECTION FORM 1 AIZT C SY6TL'(11 INFORMATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner: r`�,nthi le Dolt of lospc jlon; 1 l y n� TIGHT or HOLDING TANK: A/� _(tank must be I um1 icd at time of inslit rtion)(lucate on site plan) Depill below grade: Material of eoustruction:__conuete_mretal_fiberglass_�tulyci)lyletre other(explain): Uinrcnsions: Capacity: ralluns Design flow: gallons/Jay Alanrr present(),es or no): Alarm level: Alann in svurkin urdcr Date of Iasi pumping: 6 (J'cs or nu): Cununents(condition of alarm and flual stvikhcs,etc.): DISTRIBUTION BOX: (if present"rust be o rcncd locate 1 )( on site �c l lam) Depth of liquid level above outlet invert: ComUmenls(note if box is level and distribution to outlets equal,ally evidence of solids carr)•over,any evidmce of leakage imu or out of box,etc.): 1'U611'.CIIAMBCR. rip(locate on site plan) Pumps in working order(ycs or nu):_ Alarms in working order()cs or mo): _ Coml"cnls(nine condition of pump clraurbcr,cundiliun of pumps and appurtcman(cs,ctc,). Page 9 of I 1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 91 Knotty Pine Lane en ervi e Owner: Cynthia Dooley Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T leaching pits,number: /000 (x HoA1 leaching chambers;number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,.level of ponding,damp soil,condition of vegetation, etc.): L,awl.r°/t i,a s 1 �C Gthc 1`4 ri C- A /5;�' over of CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:PJ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY`ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 91 Knotty Pine Lane en ervi e Owner: Cynthia oo U016 Date of Inspection: I I SKETCH OF SEWAGE DISPOSAL SYSTEM 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 building. p 3 O Teti` A-a .a7° 3.s A-3 = a ' 10 f w Pagel 1 of 1 l OFFICIAL INSPECTIOMFORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 91 Knotty Pine Lane Centerville Owner. Cynthia Dool L-yil Date.of Inspection: 1! SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water S feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: You must describe how you established the high ground water elevation: 11 ASSESSORS MAP :- �/9/ ---.__ ._ _ TEST HOLE LOGS NOTES: v PARCEL : 78 FLOOD ZONE: �� �9P G1C ' ..� SOIL EVALUA' OR --WI19 '5.. N111� G% i W I TNESS: 'ill W1V1Aj D- 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: / � �� - �� � DATE: I ZC� Health Regulations. PERCOLATION RATE: 2) The installer shall verify the location of utilities, sewer inverts and septic 7- G ���/ _ components prior to installation and setting base elevations. .9, _.___.__-_._ TH- 1 TH-2 �. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first A� two feet out of the d-box to the leaching shall be level. L` 4) This plan is not to be utilized for property line determination, construction I 0 '��/4 �, la (13 I nor any other purpose other than the proposed system installation. U Lol�v�n. 6N V; � 5) All septic components must meet Title V specifications. t 10 �7� no 6) Parking shall not be constructed over H10 septic components. MAP ' c���� ��b 7) The property is bounded by property corners and property lines as shown. LOCATION �`� I 8) The property owner shall review design considerations to approve of total Ito ` 6Aqc) 1`gfw. IY� design flow and number of bedrooms to be considered for design. Receipt G of payment for the plan and installation based on the plan shall be deemed 10��1 approval of the design flow by the owner. t a 9) The existing leaching or cesspools shall be pumped and filled with material 'A i per Title V abandonment procedures. Those within the proposed SAS shall 8 be removed along with contaminated soil and replaced with clean sand per -- o Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM DESIGN applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. FLOW ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the 2 owner to ensure such. 3 BEDROOMS AT GAL/DAY/BEDROOM • ✓ GAL/DAY 12)The installer is to take caution in excavation around the gas line if such exists. ' 13)The installer shall verify the location, quantity and elevation of the sewer l SEPTIC TANK lines exiting the dwelling prior to the installation. ?WGAL/DAY x 2 DAYS - WOt GAL USE 1'ODn GALLON SEPT I C TANK IobD ' al�f ��Cft!148%Rp 10N SYSTEM._ r A yip r j . .. • Ai"N4'�'"' IJ '�" � F.✓'�"`1`�•!5...�'" ♦i%.I.,/�`�`•^'P L.f' -:f � SIDE AREA: ZX - ,�. � ,Jv7- X 2. Dr7 , . f�/, !; 7 BOTTOM AREA: �c a / ASEPTIC SYSTEM SECTION fo lip ova G,►_�!?+4�� / w lq 6 1k'11»til ., \ ,1 4�� � ("wP 0 C�CC GAL SEPTIC TANK _ ` mac/ t —�'� `� �� ' �D Zg' Z�►'' � �'�`�. ., �1A�DlrCT SITE AND SEWAGE PLAN 9b LOCATION : 1 oiT �Awr' PREPARED FOR 7tV) P-12W SCALE: w DAV I D B . MASON 'R`- DATE: DBC ENVIRONMEN�fAL DESIGNS EAST SANDWICH . MA z DATE HEALTH AGENT ( 508 ) 833- 2 1 77 °I II 2�t ► ,v, Pt1G "DF ....-..__-.......... _ .