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Home My WebLink About0065 MILLSTONE WAY - Health f 5 11 f rlsto—ne Way Centerville P == 251 010 OPWdefleAor 752 V ORA 10"/o P2 I� //y� / TOWN OF BARNSTABLE 1 LOCATION 6 5- A�/5 70.VA al4y SEWAGE # VILLAGE Cc�✓IF2 /r�/� ASSESSOR'S MAP& LOTIS ®` 0 INSTALLER'S NAME&PHONE NO. ASEPTIC TANK CAPACITY d-0,90 t /� '.EACHING FACILITY: (typee /0®p (size) .t7.OF BEDROOMS-_ BUILDER OR OWNERZ-,c,6JA' ye ke2---�,,V7X PERMTTDATE: .3,0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 r &AaA6 r `lea Do a3 ' /a C' 33 ` J).) 2y. - 3ql i COMMONWEALTH OF MASSACHUSETI`S — - _EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - = DEPARTMENT OF ENVIRONMENTAL PROTECTION - - DECEIVE® --- - MAR -2 9 2005 TOWN OF BARNSTABLE - -- TnLE•5• HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PANT A CERTIFICATION R **JJ Property Address: 4C 130�.'a� Ct w7 CAL rr/l/e �W.. ._- Owner's Name: 2 s.�s�.v Tyr" d Owner's Address: Date ofTnspection: /o /o S" o f ] may, ;AP Name of Inspector. (please print)a,-41 y.✓—C10e-"- ,0•��o d40 Company Name: Mailing Address:_D ox i y'op -V Telephone Number: S-o7-7 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 fimction and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15—W of Title 5(310 CMR1S,000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector I 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 ****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. s •Page 2 of 1 I 4 OFFICIAL INSPECMON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACESKV�AOF DISPOSAL SYSTEMINSPECT- IONFORM - PART A - - CERTMCATION(continued) Property Address: 0i S CF VfA4 de le— Date of inspection: Inspection Summary: Check A,B,C,D or E[ALWAYS complete an 9 fSec6Oa D =S)stemes: found any information which indicates that any of the failure criteria described in 310 CNM 15303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: IL 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 replaceme orrepair,as approved by the Board of Health,will pass. i Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is I d over 20 ye old*or the septic tank(whether metal.or not)is structurally unsound,exhibits sub al infi on or ltratioa ar tank fad t immin=System will pass.inspertian&the existing tank is replaced a comp ' tic tank as approved by the Board of Health. *A metal septic-tank will ass inspection s stsuctunally sound,not leaking and if a Certificate of Comp indicates that the tank is >; s than 20 old vailable_ ND explain: Observation of s e bac or break oin cr higft level in the.distribution=.due to brok t or obstructed pipe(s)or.dne t a bro settled ormneven distribution box.System will pass.inspection if(with approval of Board of Heal ): broken pipe(s)-are replaced obstruction is removed. distribution box is leul3 orr.regiaced. . ND explain: The system required pumping more than 4 times'a year due to.broken.or obstructed pipe(s).The-systern will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 'Page 3 of 1] OFFICIAL INSPECTION-FORM NOT=FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM. . PART A- - CERTIFICATION_(continued) _ Property Address: 6 s s Owner:L-Iit le- A-1TF _ Date of Inspection: le C. Further Evaluation is Required by the Board of Health: Conditions exist whit quire evaluation by the Board of Health in order to determine if the system is fading to protect public health, fe or the environment 1. System will pass unl ar Health.determines in accordance with 310 CMR 15.303(l)(b)that the system is not fun ning in a ma er which will protect public health,safety and the environment: _ Cessp or privy is within 50 feet o surface water ool or privy is within 50 feet of a b Bening vegetated wetland or a salt marsh 2. System will fail unless the Board of Health,(and ablic Water Supplier,if any)determines that the system is functioning in a manner that protects the ublic health,safety and environment:: _ The syst has a septic tank and soil abs 'on system(SAS)and the SAS is within 100 feet of a surface water su ly or tributary to a surface ter supply. _ The system has tic tank and S and e eP the SAS's within t ithin a Zone l of a public water supply. _ The system has a septt k an AS and the SAS is within 50 feet of a private water supply well. } P PP Y _ The system'has a septic d SAS and the SAS is less than 100 feet but 50 feet or more froth a private water supply well-,*. tho d to determine distance "This system passes if th ell water an sis,performed at a DEP certified laboratory,for colifor baL eria and volatile or m c compounds in "sates that the well is free from pollution from that facility and the presence of amm ' nitrogen and nitrate 'trogen is equal to or less than 5 ppm,provided that no other fail=criteria are trio ered.A copy of the anal must be attached to this form. 3. Other Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS : SUBSURFACE SEWAGE DISPOSAL.SVSTEMIWECTION FORM -- PART A_. . _ -- CERTIFICATION(con) Property Address. Cj 5 A,l/sro•✓c a/a y Owner: 7 r Date of Inspection• s o D. System Failure Criteria applicable to all systems: You mast indicate`�+es".ar"nb"to each of the following for all inspections Yes No = _ _:;"JB ackup 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 overloadtd or clogged SAS or cesspool Static liquid level in the distribution box above outiefinvert-dueto an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6mbelow invertor available-volume is Iessthan%Z day flow — �Required pumping more than 4 times in the last year NOT due to clod or obstructed pipe(s).Number . of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation.. 7,Any portion of cesspool or privy is within 100 feerof a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 ofa public well. Any portion of a cesspool or privy is within-50 feet of a private water supply:well. Any portion ofa cesspool or privy is lessthaa 100 feet but greater than 50 feet from a private water supply well with no acceptable water-qualityanalysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for eolsform bacteria.and volatile-3r-gamic componads indicates that the welds free from pollution from that facility and the presence.of ammonia nitrogen and nitrate nitrogen is equal to or less thm:5 per,prwAded-dint no other failure criteresia are triggered.A copy of the analysis-must brz=cha ta-this#orin.1 (Yes1No)The system fails:l-have determined that am or.more of the above failure rriteria exist as described in 310 CMR 15303,therefore the-system fSik.The system owner.should contact the Board of Health to determine wharwill be necessary to correct the failure. E. Large Systems _ s To be considered a large system the systen scre&&facility whk a des gn1low of 10,000 gpd to 15,000 g Yon must indicate either to each of ollow _ (The following criteria apply ems m n to the criteria above) yes no the system iso e drinlang water supply — the system isf a 3utary to a surface drinking water supply _ the system is ogen s are (Interim Wellhead Protection Area—IW'PA)or a mapped Zone II off-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 CIvfR 15304.The system owner should contact the appropriate regional office of the Department. r ;page 5 of 11 - OFFICIAL INSPECTION FORM*-NOT FORNOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM.INSPECTION-FORM - PART B --- ;_;_�__�_CHECKLIST Property Address: /7, //s r o ✓ - /m r - Owner:LuGi Date of Inspection• ion „mac - Check if the following have been done.You must indicate"yes".or"no"as to each of the following: Yes o 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) Z_ Was the facility or dwelling inspected for signs of sewage backup ? _ Was the site inspected for signs of breakout? 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'vf 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 P P P The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no t L _ Existing information.For example,a plan a the Board of Health. _ _ Determined in the field(if any of the failure criteria related io Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 r OFFICIAL INSPECTION FORM-NOT.FOR YO .UNTAR ASSESSMENTS SUBSURFACE SEWAGE-DISPO&4L-SY INSPECTION FORM- SYSTEM INFORMATION Property Address: !/S Tv�✓� �/� Owner: A soa,* .V re; Date of Inspection: /o FLOW CONDITIONS RESIDENTIAL _ Number of bedrooms(design): Number ofbedroams{.actual): DESIGN flow based on 310 CMR 15203(far example:I I0 gpd x 1 ofbedmoms): 33 6 Number of current residents: � Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system{yes or no). yes separate-inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no):.(/ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIALIMUSTRIAL Type of establishment Design flow(based on"0 C 5203): avd Basis of design w(seats/ /sgft,etc.): Grease nap pres t es or ) _ Industrial waste h din resent(yes or no):_ Non-sanitary waste d to the Title 5 system(yes or no): Water meter read' a able: Last date of occupancy/use- OTHER(describe): - GENERAL INFOHM'ATION Pumping Records Source of information: Gv n,-E 2 `Pas system pumped-as part of the inspection(yes or-no): !!✓ Ifyes,volume pumped:_gallons—I3ow.was quantity.pumpecfdetrrminedT Reason for pumping- TYPE-OF SYSIEM tic tank,distribution boa,soil absorption system _Single-cesspool _ Overflow cesspoor. Privy _Shared system-(yes or-no)(if yes,atta &,,if any)- _Innovative/Alternative technology.Attach-zzopy ofthe 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: /,Vs7 *//,eO q-3o -2 o Were sewage odors detected when arriving at the site(yes or no):&:f - " . Piage7ofII OFFICIAL INSPEMON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACt'SIEWAG'*EDiSP.OSAL-SYSTEAI INSPECTION FORM _- _ PARS'C -. SYSTEM INFORMATION(continued) Property Address- t/S �i/�_V ro Y Owuer:L Date of Inspection:_ D BUILDING SEWER(locate on site plan) - Depth below grade: 3 1 ?+Materials of construction: cast iron .Z PVC other(explain): - Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SUTIC TANK-_(locate on site plan) L•epth below grade: Material of construction: concrete metal fiberglass_polyethylene _other(explaia) If tam,is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy o' certificate) Dimensions: D D D '4l'69 D V"V.4 a- S ludge depth: 2-," Distance from top of sludge to bottom of outlet tee or baffle: �/ r Sctmt thickness: o " Distance from top of scum to top of outlet tee or baffle: O ~ Distance from bottom of scum to bottom of outlet tee or baffle: o `� How were dimensions determined: r 0- l� Comments(on pumping recommendafions,inlet and outlet tee or baffle conditior,,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: (locate on site plan) t Depth below grade:_ - Material of construction:_concrete_metal o}ass olyethylene`other (E;cplam): Dimensions: S:' m thiclCIIe55: _ Distance from top of st^.tm to top of outle or b e: Distance from bottom of scam to bottom f u at tee or baffle: Date of last pumping: Comments(on pumping recommen inlet and outlet tee or baffle condition,structural integrity, as related to outlet invert, liquid 1s��eIs evidence of leakage,etc.): ASSESSOR'S MAP NO.'2 51 PARCEL (_ j LOCATION SEWAGE PERMIT NO. V I L L A G--E� �--�- I N S T A LLER'S NAME A ADDRESS B U I L D E R OR OWNER D A-l-E----P I S S U E D DAT E C0MPLIANC -ED r' 32 5 �2we-44-7 'Page a of 11 OFECU rINSPECUON FORM--NOT FOR ViDL N T ASSF.,SS1S SMSUR1�AC SEWAGE DISPOSAL SIS�11��T�E o14T ME S V-STRd INFORMAMON( am iiuetl) Property Address: G' S it/s al,4 r - - e Gr A-7 IF Owner Zvc iA_a Date of Inspection: 10 /is-/o yr 1TGM or HOLDING TANK: (taIIk must be gtnape3atfime of insge�(lo�te on site plan) Depth below grade: Ma�erial of construction: c metal fiberglass—_polyeLh}'ler e other(expIaia): _ Dumensions: Capacity: o Design F.ow onslday Alarm Pr'-�t(yes or no): Alarm leveL- Dale oflast Pumping: m ��or no): COmme�{conditi of alarm.and.float switches,etc.): �I�TRII�U'I'I�1�I 3�: (Fpresent must be opened)(locate on site plan) Depth of liquid level above outlet invert _ - C-omments(note if box is level and.distribution to outlets egnal,.any evidence of soli 3 ds carryover,any evidence of ..akage into or out of box,etc.): Gf/g f cr � 1r � LEvE � Pb-W AMBER: Aor � site gI Pumps in working order{y-kL—mS in working order(yCtn;ne�ts(note cobditiom ber edition s auil _.._ p �urtenancas,etc.): + 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: Owner. Gv�•.�i�c7 �/�5/�i3.vTt Date of Inspection:_ I;s /a je- SOIL ABSORPTION SYSTEM(SAfi): . (locate on site.planrexcavation not required) If SAS not Iocated explain why. . Type leaching pits,number. leaching chambers,number- leachiaggalieries,number leaching trenches,number,length: leachin-fields,uumber,dimensions: overflow-cesspool,number. imiovative/ahemative systems-Type/name of technology.- Comments(note-conditiotrof soil;signs of hydraulic failure,level of pondin-damp soil,condition of vegetation, etc.): A � L sty id �t�f'TN /�s s✓ f/l� ��T� CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configurV Depth—top of liquid Depth of solids layer:Depth of scum layer.Dimensions of cesspoMaterials of construc Indication of groundwater infi (yes or no): Comments(note condition of soil,simis of hydraulic failure,level of ponding,condition of vegetation,etc:): 1 PRIVY: (locate on site pl 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 11 OFFICIAI;INSPECTiON-FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SE'- AGEDISPO NSPECMN FORM PART-C SYSTEWINFORMATION(continued)- Property Address: - �'� ✓T1� 2. vG �P Owner:L-v G iA Ma /LB f�fl�✓�� v Date of Inspection: . i o ♦s as! SKETCH OF SMIAGE DISPOSAL SYSTEM- Provide a sketch of the sewage disposal.system including ties to at-least two permanent reference landmarks or benchmarks.Locate aitwelr within l00 feet:Locate where-public warm supply-enters the-building. r..3� 14 G 3 i . s a z 5",6 a & ,fig ` t Y-�G- 33 I of 11 _ . - OFFICIAL INSPECTION FORM-NOT FOR VOI,UN7ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM — PART C - SYSTEM INFOI2Il AT10N(continued). - G Property Address /N - s: � /�sT�F �� ' C � NTC2v� //-e Owner:& G i o 0 Date of IaspecfioII: o T a S1 E EXAM T Slcpe c e- Su Ttace water /vV*vE Chzck cellar 0.4t), Shaliowwells ,cioAJE Estimated depth to ground water>`,feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe bow you established the high grouted water elevation: J