The URL can be used to link to this page

Home My WebLink About0047 LONGBOAT DRIVE - Health 47 Longboat Drive Centerville P / o A.= 193 159 O�� Ih Omrford, NO. 1 21 0 5 /3 ORA :10% G / i t //�9 e d h 0 �k q t Commonwealth of Massachusetts gc3'�j9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 LONGBOAT DR Ik a Property Address i•,� TYSON JENNIFER BARNES Owner Owner's Name c±• information is required for CENTERVILLE MA 02632 5-20-18 every page. Cityrrown 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. Important: A. General Information When filling out /go L� forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 ran Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Q i L�,,l� � 5-20-18 In%V1&cVrs 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: AT TIME OF INSPECTION SYSTEM MET MINIMUM PASSING REQUIREMENTS. FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED FROM THIS REPORT.SYSTEM APPEARS TO BE ORIGINAL. THIS REPORT IS NOT TO DETERMINE THE NUMBER OF BEDROOMS OR DESIGN FLOW, BUT THAT THE SYSTEM WAS FUNCTIONING PROPERLY AT TIME OF INSPECTION. SYSTEM APPEARS TO BE IN PRETTY MUCH THE SAME CONDITION AS LAST TIME IT WAS INSPECTED. SYSTEM FROM 1977 B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts _ v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation,of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a.bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M '< 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. k ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered,a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r GM 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 9 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 LONGBOAT DR Property Address I TYSON JENNIFER BARNES Owner Owner's Name information is CENTERVILLE MA 02632 5-20-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS BUILT SYSTEM CONSISTS OF A TANK D-BOX AND LEACH PIT. fi Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2016 2017-----387 GPD, SYSTEM NOT DESIGNED FOR USE WITH A GARBAGE DISPOSAL Sump pump? ❑ Yes ❑ No Last date of occupancy: currently occupied Commercial/Industrial Flow Conditions: 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupied Date Other(describe below): General Information Pumping Records: 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: 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. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.)' Approximate age of all components, date installed (if known)and source of information: appear to be original Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: moderate t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness light Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? wooden pole Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank was opened and found to be in working order at time of inspection. There was white liguid in the tank at time of inspection. Tank looked typical for its age with some exposed aggregate. Grease Trap(locate on site plan): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): box was viewed by camera and looked typical for its age with some corrosion but functioning properly. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit was opened and had white/gray colored liquid. Inside of pit was viewed with a mirror and found to have about 16 inches of usable space below the inlet invert. Inlet pipe entered the pit near the top of the pit. Clean aggregate was visible through the holes in the precast pit to the water line. This pit appears to be original, future performance under the same or increased use can not be determined from this report. 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 ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property is at a very high elevation above any water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 NN Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °wM 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 5-20-18 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 7 TOWN OF BARNSTABLE LOCATION 7 -ovi SEWAGE ii VILLAGE ASSESSOR'S MAP&PARCEL INSaUSM NAME&PHONE No. SEPTIC TANK CAPACITY a/&00 LEACMNG FACILITY(type) tits` (size) �CiC(P NO.OF BEDROOMS J i OWNER .n PERMIT DATE: CQhH%iiliCE DATE. aS 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 t i �aGIZ a� y � 1 i http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=193159&seq=1 6/5/2018 ps�sm�As-B> t�C�rs Page 2 of 2 ► 0 GAtzsa��, Ito 3 SS G T' '/ �� 1t�r►c TA"i< = 330,, ir�o % - a..956.Rv. ur,f "ir�oo 66�. 12I50o5Ai PtT - locao GAL. (5 I_a' TAT A L: L�ES16tJ = 425 G.i?D. -c6t tj�f . .. , ,,. 1Z is • rO Pt&cC) .oTt O Q �'LsTE ; ! "i -z m w Cnz 1 5• ,P�r nr f ? t,, C3 Ff, 'WO i,0 9s , R�_E�:-t9 t''tE 41, , ga=92;5 Tar FNo?+oo.o [ �/n t1-pow. ,DKr' �~ IOot� t►JJ. ';. (3.r,—L O 7 FL�r;� tW. Gp�• ga•S t ooD � 85.0 ... „Jv. • Lac N' � •A. PST A L-CAI WASHED . ,S.AAJD STONE p f CEC-TIFiE'D PLb?" PR p F t Li✓ L o4A Tl a tJ 1• �t u.-e=s. t WO. trIA:T`-�' Pt,L�.L-� R�F�CRE►.10E Ct�tz rt t '�{ T►�AT. T.1as= 1"0'�1JT�A'i 4qU 54-0,.4j t�lE:k'LntJ Ct• IPL�S W tTtt .Tt1` SivE.Li►-�1=. QEGISrc— LhhlG 5U+2Vi=`fo Ti-�aS I?'r_A> ! ! tJCUT pZEO Ut p� OSTE�a/1L tL v 11rC ASS. ts�l�if�J•.'✓ZC 'k diJG_.lt-`{ ' TtkG c:Fl-5 ��, �it1GWt� A.PP1_{ CA►�t-r 1�.1;.:r �',I=. u-�t=��. rc,• t�r'1'`t�G`.trl - �{11,�T�"D .t�L �ir"�'" �'�.•.�-: .. http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=193159&seq=1 6/5/2018 }3 1� Commonwealth of Massachusetts R3-15 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 LONGBOAT DR Property Address SOD. TYSON JENNIFER BARNES Owner Owner's Name 05 information is CENTERVILLE v/ MA 02632 2-20-16 s required for every page. Citylrown State Zip Code Date of Inspebion m r%3 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 �"0!1 Citylrown State Zip Code 508-420-4534 S14297 Telephonq Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-20-16 J 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 3 Commonwealth of Massachusetts. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: AT TIME OF INSPECTION SYSTEM MET MINIMUM PASSING REQUIREMENTS. FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED FROM THIS REPORT.SYSTEM APPEARS TO BE ORIGINAL. THIS REPORT IS NOT TO DETERMINE THE NUMBER OF BEDROOMS OR DESIGN FLOW, BUT THAT THE SYSTEM WAS FUNCTIONING PROPERLY AT TIME OF INSPECTION. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- .10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 per plan DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS BUILT SYSTEM CONSISTS OF A TANK D-BOX AND LEACH PIT. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2014-----408 2015-----417 GPD, SYSTEM NOT DESIGNED FOR USE WITH A GARBAGE DISPOSAL Sump pump? ❑ Yes ❑ No Last date of occupancy: currently occupied Commercial/Industrial Flow Conditions: 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owners Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupied Date Other(describe below): General Information Pumping Records: 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: 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. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °�M a 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: appear to be original .Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: moderate t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle F Scum thickness light Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? wooden pole Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank was opened and found to be in working order at time of inspection. There was white liguid in the tank at time of inspection. Tank looked typical for its age with some exposed aggregate. Grease Trap (locate on site plan): 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): box was viewed by camera and looked typical for its age with some corrosion but functioning properly. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit was opened and had white/gray colored liquid. Inside of pit was viewed with a mirror and found to have about 16 inches of usable space below the inlet invert. Inlet pipe entered the pit near the top of the pit. Clean aggregate was visible through the holes in the precast pit to the water line. This pit appears to be original, future performance under the same or increased use can not be determined from this report. 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 ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM , 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a - Privy(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.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property is at a very high elevation above any water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 LONGBOAT DR Property Address TYSON JENNIFER BARNES Owner Owner's Name information is required for CENTERVILLE MA 02632 2-20-16 every page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 q7 / TOWNN OF BARNSTABLE LOCATION "I �^o� S►� {✓r' SEWAGE tl aTie►+ VILLAGE I&OW"VA(t ASSESSOR'S MAP&PARCEL t ING&WOM NAME&PHONE NO.�r a q; m J" SEPTIC TANK CAPACITY /&00 LEACHING FACILITY:(type) tTR' (size) ec(p NO.OF BEDROOMS J OWNER /Yyarf PERMIT DATE: CAE DATE: aS Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fee 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 �aclC a� i http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=193159&seq=1 2/29/2016 r` I u0 (�Arrrxnr� .6RI�1D�iZ T.-�radtL-�4 ;;7L�OV-/ s .I1b -4 3 :. 33bLOk/G a5W T T'A,"1C 4-9 r.6.P D. U51- All . DISPQSAi. PIT Sir i000 GaL_• -� 2.S , AV ni yam•. : s. 1 :o ., - 50 C-�.P. � 'fi?>TA L. Turd 1 L:�( Flow 33D 6.PD: Q rpu,�v Al Al HARD job } 1.60 \ G r: 4'yaa IW, GAL. 9D,ij .tzLosJhST FLo \ vB,So>'6o MKT" • 90,2 Sync. l o TANK GAL. �•� g$.o �, LeAr P�T ,u r •i WAS►I6D SAAJD STo►IE p CERTIFIED pLb`r" PL.G.I�3 Pczo �LE LOCAT1O" C�rE-\-/IU..& ►.10 !4 {�1 �1D UAJAT>.L.. 1 GGIZTi i= T1--lAT. T:N� t"pUQUA {�1� 5�lo�ut] Pt:+41�! RE1=Ei�E►.lca 4�l:F�t=t�►J GcVlPLI,(S W ITti TN` SIL7E:LINE . . t�Wt SETT>nCIG S'CQ"tJCEMc►�TS ..OF T" 6 - 1 REG45f�IZ�D I-A1,JD SUZVi=`(off THI5 -0L-A►-! I"S LJO- . U,QS♦=G v� i A`.J OSTE��/1�.LC o tiCASS� 11Jy('L J;✓�f=i�l., 'riJG ./t_� Tt{C 0riz15 �i S1IGWLL-> A P P L.1.C A tom!T ► &.T' fc'�L Ur>i✓ 7c, i�t :1 LLiUl164 5 f -- YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on.this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and-get the Business Certificate that is required by law. DATE: 41 16 Fill in please: s" APPLICANT'S YOUR NAME/S: +44�EL BUSINE,S YOUR HOME ADDRESS: 41 [-Oy o r 60��265-73c5 Cal 1L4A m z G 32 TELEPHONE # Home Telephone Number ! 73z�5- NAME OF CORPORATION: PONTIN4111 NAME OF NEW BUSINESS - . M. ?d►NT� TYPE OF BUSINESS Pi►r�TIuC- NnQ�zTa IS THIS A HOME.00CUPATION? YtS NO ADDRESS OF BUSINESS 41 oN a4.r . r TM MAP/PARCEL NUMBER I q3 15- [Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COM%he S OFF MUST COMPLY WITH HOME OCCUPATION This individu r ed f a it requir ments that pertain to this type of bAND REGULATIONS. FAILURE TO S' ** COMPLY MAY RESULT IN FINES. A COMMENT Q�tn,iln ul �ry 2. BOARDJHEAL1 TH This individual has been info .d of the permitLiremenpertain to this type of business. Authorized Signature** MUSt.COMPLY WIT- H ALL COMMENTS: pAZARno i I$Mapw S-RErt1LA-T .' 3. CONSUMER AFFAIRS [LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Hazardous Materials Inventory Sheet Checklist Date Physical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts -( ie. gas being used to fuel machines, thinner to ' clean brushes all count as hazardous materials) Storage Information -location of storage, how long is storage for? If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -provide a vehicle washing policy and explain it note that it was given - Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. TOWN OF BARNSTABLE Date: ?.-/ z3 / TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM ' NAME OF BUSINESS: Q/LI ` BUSINESS LOCATION: 6, '>v Q6;t1wl�� le44 INVENTORY MAILING ADDRESS: —5Ap TOTAL AMOUNT- TELEPHONE NUMBER: _ 10 o CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: 7��-��7 7tt7 MSDS ON SITE? TYPE OF BUSINESS: ;�//V/— INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product- Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section.31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month re wires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) - O-NEW - ❑ USED Any other products with "poison" labels - - (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): - Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS A licant's Signature Staffs Initials J TOWN OF BARNSTABLE 'LOCATION `I ®D� �� SEWAGE#�c�+'j e�T�d%'► VILLAGE ASSESSOR'S MAP&PARCEL INKS NAME&PHONE NO. *r SEPTIC TANK CAPACITY /c-G-00 LEACHING FACILITY: (type) (size)' fQ NO. OF BEDROOMS OWNER PERMIT DATE: CQhfiffshbWE DATE: =63 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 I i y1. Ids- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION h �t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 47 Longboat Drive Centerville MA 02632 Owner's Name: Ellen Koopman Owner's Address: Same �S r t Date of Inspection: September 21,2005 Job#05-287 Name of Inspector: PATRICK M.O'CONNELL -- Company Name: SEPTIC INSPECTION SERVICES CO. -} Mailing Address: 189 CAMMETT ROAD W, MARSTONS MILLS MA 02648 —� Telephone Number: 508-428-1779 c s' 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 o►r approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes THICK m Needs Further Evaluation by Local Appro ing Authority — M. ;.-— Inspector's Signature: Date: .9/21/05 ��'�, iT�F ?lF�� oQ'�•�� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching pit has 3'of standing water and has never had more than 4'. ****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. Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection: September 21,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: ' B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic'tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection: September 21,2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CNIR 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 I 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 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: Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection: September 21,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _ _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: Y To be considered a large system the system must serve a facility 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D.above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. A Page 5 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection: September 21,2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection`? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up _X _ Was the site inspected for signs of break out _X_ _ Were all system components,excluding the SAS, located on site? _X _ 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? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection: September 21,2005 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#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): Unknown Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Two years total: 145,000 gal.= 198 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/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: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 12/2/77 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection:September 21,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide— 1000 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 11" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear,liquid level at bottom of outlet invert GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection: September 21,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" 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.): No solids or high stains present. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 1 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection: September 21,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit. _leaching chambers, number: _leaching galleries,number: leaching trenches,number, length: _leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Observed 3'of standing water currently in pit and a high stain line indicates pit has never had more than 4'of standing water.Pit is at approximately 66%capacity. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids1ayer: 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: No (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.): Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection: September 21,2005 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. Longboat Drive Water Service . ....................................... 26 25 47 24 l Page I I of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Longboat Drive,Centerville Owner: Ellen Koopman Date of Inspection: September 21,2005 SITE EXAM Slope None Surface water; None Check cellar Dry Shallow wells? None Estimated depth to ground water: More than 12 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: _X_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: s Low area to rear of property is considerably lower than bottom of SAS. 4 1/- Town of Barnstable Health Inspector OFTHe roh, Office Hours y�P� do Regulatory Services 8:30—9:30 Thomas F. Geiler,Director 1:00—2:00 HA NSrwBLY, 0&1% i639• Public Health Division 1�m pTEO1N0�s Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-63C AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE. 1. General Information: Size of Property: Address: )/? < Map lq,2 .Parcel /C)!y Name: !� 04 ��/� Phone # 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms?_'. IvIdl If yes, how many? y 2c. How many bedrooms total are proposed at this property (including the amnesty unit)` 2d. Please include a copy of the floor plans for the entire property - showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label . each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or NO If ttce dwelling is connected to public sewer skip questions#4 through#9?be1Dw x ., 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? & 5. Is the dwelling connected to an. ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES tY0 o � . c1, � 6a. If yes, how many bedrooms were approved according to this permit? edrooffis. 2 7. Were any building permits obtained for construction of additional bedrooms? YES for `A!O Sao > X 8. Is there an engineered septic system plan on file at the Health Division? YES for CVO 9. Has the septic system been inspected by a DEP certified inspector within the last two years YES or tj;VO FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: �'� q care peopo 10, v Signed: Date: O;/health/wpf1les/amnestyapp yq� 'C�io�Aina. RECEIVED -JAN 0 8 2GG3 COMMONWEALTH OF MASSACHUSETTS TOWN-OF BARNSTABLE HEALTH LEFT. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR ' DEPARTMENT OF ENVIRONMENTAL PROTECT O � r COP? � � d W ci p,M SJOv TITLE 5 �T 1pl3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 47 LONGBOAT CENTERVILLE, MA 02632 Owner's Name: ARTHUR HARRISON Owner's Address: 156 GRANBY RD CHICOPEE, MA 01013 Date of Inspection: 12/11/02 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionallyf ffasses _ Needs Furt ht "Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 12/11/02 The system inspector shall submit a,copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. hitip S IncnPrtinn Fnr•m (/I S/*?M(1 I PageT2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 LONGBOAT CENTERVILLE MA 02632 P Y , Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 LONGBOAT CENTERVILLE,MA 02632 Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 LONGBOAT CENTERVILLE,MA 02632 Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. A Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 47 LONGBOAT CENTERVILLE,MA 02632 Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site `. X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems`? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 47 LONGBOAT CENTERVILLE,MA 02632 Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x*of bedrooms): 440 Number of current residents: 1 �'— Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components, date installed(if known)and source of information: 1977 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO 4 F Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGBOAT CENTERVILLE,MA 02632 Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 BUILDING SEWER(locate on site plan) Depth below grade: 20" Materials of construction:_cast iron _40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 14" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGBOAT CENTERVILLE,MA 02632 Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page.9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGBOAT CENTERVILLE,MA 02632 Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD T OF LIQUID IN IT AT TIME OF INSPECTION. STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN T OF LIQUID IN IT. BOTTOM IS AT 8 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): n/a a Page t l off'1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGBOAT CENTERVILLE, MA 02632 Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 SITE EXAM Slope _SUITace water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO. Obtained from system design plans on record - If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n%a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: BAND AUGER- 12 FT. ti __ I t , 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK Address of property I! Owner's name e Date of Inspection 6�� KI J,,y Pu l�o /13 6 /g/�S- . PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, Occupant,Health. p , and Board of None of the system components have been pumped for atwo and the system has been receiving normal flow ratesduringtthat weeks period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. No available with N/A. to if they are not -__sL The facility or dwelling was inspected for signs of s / ewage back-up. Y The site was inspected for signs of breakout. A11 system. components, excluding the SAS hav site. a been located on the _ The septic tank manholes were uncovered, the septic tank was inspected for conditioneofdbaffleshorinter tees, of material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has on existing information or approximated b s been determined based / y non-intrusive methods.. �/ The facility owner (and occupants, if different provided with information on the proper maintenancemof* SSDS,�ere 4b =f,s E SUBSURFACE SEWAGE DISPOSAL SYSTEH 'INSPECTION FORK PART B SYSTEM INFORMATION / FLAW CONDITIONS If residential _ number of bedrooms number of current residents 0 garbage grinder, yes or no* VF5 laundry connected to system, yes or no n�a seasonal use, yes or no If nonresidential, calculated flow: 03' Water meter readings, if available: � `� di3 936`'v Last date of occupancy GENERAL INFORMATION Pumping records and source of information: / cCh wt t +✓h System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Typy of system _ /V 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) * Other (explain) Approximate age of all components . Date installed, if known. Source of information: o Sewage odors detected when arriving at the site, yes or no i 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORN PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) , depth below grade:- L s material of construction: y concrete metal FRP other(explain) dimensions: ,5 /X / U 0 ,- / o Ll //� ' sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness C ,, distance from top of scum to top of outlet tee or baffle -L'__ distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) ,�- c( c� ., w u✓ k i �, a r c r /Vo 5, 6 1L DISTRIBUTION BOX: (locate on .site plan) Q<- A depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation forrepairs, etc.) 6 k r/ e t CG h e i �^ ti./ b✓ >� K ✓. o l S. 4 C y 1 L G- ✓ c.�. c J t ✓ w �/ eti ... �— � C o ✓ v i 7 c c .,� c t H J- U • S —�i�vr c PUMP CHAMBER (locate on site plan) pumps in working order, yes or no Comments : (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISP08AL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) :V_ (locate on site plan, if possible; excavation not required,, but may be approximated by non-intrusive methods) If not determined to be present, explain: ------------ Type. leaching pits and number O H leaching chambers and number �` leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure,er� level of ponding, condition of vegetation, recommendations for main�tan�e or repairs,etc.) S ; C. Ato CESSPOOLS (locate on site plan) : N� 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 (cesspool must be pumped as part of inspection) Comments: - (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments : i note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) ' 11 SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE E:SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' d /000 Y G h ❑ • Ste' y7� as � e DEPTH TO GROUNDWATER depth to groundwater method of determination or a proximation: v b G L, 0 r BQBSORFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA t Indicate yes, no, or not determined (Y. N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the surface waters? ground or Static liquid level in the distribution box above outlet' invert?rt? N�A Liquid depth in cesspool <6" below .invert or available volume< flow? 1/2 da} .� Required pumping 4 times or more in the last year? number of times pumped Septic. tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: L below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a sur a water supply? �' f ce within a Zone I of a public weil? Mwithin 50 feet of a bordering vegetated wetland o (cesspools and privies only, not the SAS) ? r salt marsh Nwithin 50 feet of a private water supply well? ,y less than 100 feet but greater than 50 feet from a private wat supply well with no acceptable water quality analysis? If theewe11 has been analyzed to be acceptable, attach copy of well .water anal}-. for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEH INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name rOy I , N y� c -� s J e`O 7Li �S�.c c�,, �. s Company Address 41b d /c/ 94ss Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are * consistent with my training and experience in the proper function and manntenance of on-site sewage disposal systems. one: VI have not found any information which indicates that the system to adequately protect public health or the environment as defined in310 CMR 15.303 . Any failure criteria not evaluated are As stated in the FAILURE CRITERIA section of this form. I have. determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303.. . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signatur S !� Date Original to system owner Copies to: - Buyer ( if applicable) Approving authority � � � o � v ��• 45a'f �r. o N Y� LO CA<T I. S E A G E PE RM'IT INtA . . 6, 0 v I L . . L�? INS TAA` ER'S NAME & ADDRESS B U It,&. R. 0 OWNER DA T:t-:' P:ERMIT I S S U D DATE :' :`OMPLIAN`CE ISSUED �l � Su•1 5.: Yi 7 _ .. _ a _ Yoe 7' 1 ,- Page 10 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGBOAT CENTERVILLE, MA 02632 Owner: ARTHUR HARRISON Date of Inspection: 12/11/02 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. PS L 0QcK C A.a '�� 6 C ��l in UPS 14 tKl T7IAXA. ll#O C�ARgAGI✓, �RI.�tD1L Lid t Lam( >*Low � I t b ,c 3 : 3'3 O G•P•TJ / .EQT"IC TAt•tk = 3�0J ISO % * 4-95 CJ Ste- t C>C>C7 G A.L. '+1 lo1.5S S�15PC?SAL 'PIT .- USE loco Gam, � 1 t LV ALL 5FF ,c rZ S = 37S.G.P.D. •� sb TC>-rA4:. .,-C;l ESIGIJ i `T-oTA L C>/S 1 i�f rLU4cf s 330 6.PD: Q srK C 2GDt-�T10IJ • CZl�TE tQ 2 �4ltQ OiZ Lt%. IZ /S ./ #r O E,r1' r r� D-.SUi11dFl�� - `��FltiKt Ellc,� 10 IN, YY�.vGse :V«t TOT Pwo L 100.0 ELF .�t"gee — tuy� g1.cb vA loco OI< �SNCL F Lao�� r 4 pp� > ,T iw• &4L qo.y vBSDibS&nc1 INV. DbD 1 ,o tNV. tW. ' LL g WD �AcN A FIT WAS�IRD .SAAID STO 4C O Ao C.E.IZ''('l V- all ` PR o1=t t L OC AT 10 1,4 Es trEk.�I Lt..C�, _IG, a10 ScA.Le=;- GCAL �,�� a bA.Ti= 11 /4 /-1? j. C G IZ T I T"A T T 14 Ir 5"Oa kj Pt._A I.1 R r=;r, 1 C Gcaar�PL�eS W ITI4 TPiZ:. 51DE'A-I►-tE: TNT.. LoT 6-4 -Tc?wtj. 'or-- �Bk�-i 5OSt.E BIS,�CTC4Z, <:- tlY� two.. ' t2EGlS�t'C-.tZ�D 'i.lal.tG 5U��1�:.YoI�S 0S'TElZV%L , � _ Ut AN' I-t:._ ` .o J1iCAS�i. A TI-it� 17r_At-! G,r LA L >E.'D . 1t.15yt�'�Jt✓�C;t.iT �ic�tr�11�`C CUL— C3FI=5 r, SI��wLD APPL1CAh!'T" LO-V LIwe5 1 4ti IiA�i O Nus~ E ;, E R 11lIql 1'T N 0. SAT I � 6 _ ; VI° LACE I. NSTA LLER'S .4A. E & A V 0 R E S S 0 OW r , DATE P 9MIT. ISSUED IDAT .E COMPLIANCE .ISSUED i t Y �i • i r TOWN OF BARNSTABLE LOCATION QCtt SEWAGE # V1':LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 00 / LEACHING FACILITY: (type) (size) r �� NO. OF BEDROOMS BUILDER OR OWNER PERMTIDATE: 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 wetl exist . within 300 feet of leaching facility) 1 �((�,� Feet Furnished by ec�L AA Rc �J) A lAw, l�� ( F��rs�J - � �y 77 ® _ I ................` ...... THE COMMONWEALTH OF MASSACHUSETTS q 7�3 BOARD HEALTH � --------- ............OF........ 444�- ...... AliptirFatiun for Bhivoii al Works Tonstrurtiun Prrutit Application is hereby made for a Permit to Construct (r) or Repair ( ) an Individual Sewage Disposal System at: � ............ ........................ dee-- -f:4,z;, -4:z................................................... Location- ddress l or Lot o. ............ r.z�' , t ? ... ®:ei_:. .Q,�1 ....s ......... . Owner Address a, .� t _ .y-•--------:--....•--•........................... C' car �...f�9 ..----.$r P,s .� .. Installer M Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms._.._ ..a.........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ------._-________________- No. of persons:t&?Q---------------- Showers (oA) — Cafeteria ( ) dOther fixtures -- ---------------------------------------------•---•-•------- ............................................................. Design Flow....e............. .. gallons per person per day. Total daily flow____ WSeptic Tank—Liquid capacityZ�`gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width_.......... .._.. Total Lengjh....................Total leaching area....................sq. ft. Seepage Pit No---------/.._______---Diameter........W._ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) ') Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------•-------------•.. Date........................................ ,.� Test Pit No. 1........2—....minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2........? minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ ---•--------------------------------------------------------------------------------------------- -------------------.----------------- ----------------- 0 Description of Soil---- - .......... .... ..... ---------------------------------------G-.D s -------s'� --- � w -� � _j=r- VNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------- ------------------------------------------------------------------------- -----------------------------••---------------------•--------•-------------.....---------•-------------------........-------- Agreement: I _ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued bty the b d of health. 7 Signed ......--•-•---------- `7:.......7 / Date ApplicationApproved By----------- ----�• .....--....------..........-•--------•--•--••..........••--...--•--......-- ........... /- /7-.2.7 Date Application Disapproved for t e f ollowing reasons:............................................................... ...._„... a, ----------- ••...•---•....... -••---•••---------------------------•------------------------------------------------•---•-----------------•------------riJ <'----------�-------- --------------------------- Da Permit No........Z�.l................................... Issued•- ........ ................. No------- FEE............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F.......................................------.------------............................__.. Appliration for Dhipos al Vorkg Tonuitruriion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: ................__.............................................................................. ...--•---•--•---•-•------•-•----••-•-••-----•-••-•---•----------•------....._.....---•--•--....... Location-Address or Lot No. ---•...............•.._.....................................-----............_................... ...................•-•---..._..._._............_......----•--•••-•............................^-- Owner Address W Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p,I Other—Type of Building ............................ No. of persons-------_.................... Showers ( ) — Cafeteria ( ) aI Other fixtures . ...-•-• - W Design Flow....-..................................gallons per person per day. Total daily flow-----------..........._....................gallons. WSeptic Tank—Liquid capacity...!.6 .gallons Length................ Width................ Diameter__-__.__-___-- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------I--------- Diameter......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `4 Percolation Test Results Performed by.......................................................................... Date........................................ ,_l Test Pit No. 1--------A%___minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0-4 Test Pit No. 2_..._.__`,minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------------------------------------------- .... --------------------- ------- •••----- .---- ------------------------------------------------------ 0 Description of Soil......_-............................. V .....-••---•--•......................•-•. --•--•••-•-•-•-----•-•-•----•----••...........-•------•-------•-----•----•---••--•----•••-•-•---...._..---•--•-•---•-•-•---•-•----•••......-----••-•-••--• W --------------------------------------------------------------------------------------------------•--------------------------------------------------------•-------•----------------------------..--•-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------------------------------------------------------------------------•------•--------------------------------------------------------------------............--•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... _ . Date, Application Approved By. /j _ /'r -------- -------------------------------------------------------------------•------ f Date Application Disapproved for the following reasons:.................................................. ........................................................ ----------------------------------------•...------------..•....-----------•-------•--...-------------•----••-----•----•--•--•-••••••---•--•---•--•--•--•-------------••-•-------•--•---•-•------•------- te Permit No. _`_A ........--••••-------•----•----.... Issued a . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................:.........:............OF.........../ ...............`................f L ........................................... TntifirFatle of TompliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) .................................................................................... -- ------------------•---------------- T q i I Z'/. r 4,/ Ins>(Iler . j at...........................................`-----•-----'-•------...........--•-----•----•-------------=-••-•----•-•----...••....f , has been installed in accordance with the provisions Of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......7:21f'j:__9.`...................... dated.....��_._.��' J_ �...-•------ ---------•-•-----•-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .:..............OF.........41,4 l r'/yf�t c ............................................. No... ...._._ �...... FEE...:.............. •t cr 11ispoottl Works Tonutrudivit Vamit Permission is hereby granted....•-..../'/& t .............A/&_//e-_ • -- ---•----------------------------------------•----------.---.----.----------- to Construct ( >/) or Repair ( ) an Individual Sewage Disposal System at No............ r r /, /, ��siF/U c ri tY r- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.._ ......_.7............... --•--------------------------------------------....................................................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS r TOWN OF BARNSTABLE LOCATION SEWAGE # �a VILLAGE �ti-�. ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. i SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 4t-cco.,_t_ j2; (size) 6 XG "w NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER (J le-y DATE PERMIT ISSUED: f �� 7Z 7 7 DATE COMPLIANCE ISSUED: /Z - 7 VARIANCE GRANTED: Yes No r �S �l,00 TPNI� t ? L,O;CAT ION u5 S E AGE PERMIT NO. VI"LLAGE INSTA LLER'S NAME & ADDRESS �A.x.� B U I'L D E R OR OWNER e� J? .�, ; a DATE PERMIT ISSUED DATE COMPLIANCE ISSUED , " I 1 kip _= t