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HomeMy WebLinkAbout0068 OLD FARM ROAD - Health 68 OLD FARM RD, CENTERVILLE A= 251-006 �^ r' t No. 42101/3 ORA a q ESSELT E 10� O Q O O 7 mil/ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information � 1. Inspector: � . Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification r 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evalu 'on by the Local Approving Authority 6-16-10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. t5insp official document 03/08 Title 5 Official Inspection Farm:Subsurface S age Disposal System•Page 1 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments q,y 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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.tgbutary to a surface water supply. El 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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. e 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 '/2 day flow ❑, ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes ' No t ❑ ® 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 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 16 v • r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Delinisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 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)] t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings,.if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 4-2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 I Commonwealth of Massachusetts N r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: ' Source of information: N/A 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) ❑ i, Innovative/Alteir ative 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): Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving,at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 32" 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24"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: 1500 gal Sludge depth: 12' Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness 1 6" Distance from top of scum.to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts N - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not-for Voluntary Assessments ,M 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town 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.): Tank is in good condition with baffles installed and no sign of leakage. ` 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 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): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 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.): Good condition with water at working level and no sign of back-up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 16 o Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O.Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-60'x4'x2' ❑ 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.): Leach trench was video inspected and no signs of failure were found. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): t5insp official document•03/08 True 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA 02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. L3 G 05 f -� - 53 6 -F -- 33 f t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Old Farm Rd Property Address Bank Owned (Contact Landscape Cod LLC P.O. Box 442 Dennisport, MA .02639) Owner Owner's Name information is required for every Centerville MA 02632 6-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10 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: pate ® 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: Original design plans on file show no groundwater at 12'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 BORTOLOTTI CONSTRUCTION I NC. ASSESSORS MAP NO' `1 �/ ` PpRCELNO• 0 30' �.SIIHS,VR?ACE SEWAGE,..DI'SPOSAL SYSTE?( Z-9BPECTZON POR?t 1►3dross ,oZ•(property /` Ovner,Rs�nfilie 7, _ ¢ate' oL�Zrispsc.tion; PART 'A . CHECKLIST Check if. the tollowi.nq, have been done: . PumpYnq.information. was. requested of the owner, vcc;,Uparit , :nd P Health:: . . _ None::of the system components. .have baen pumped for at least t�.o A nd 'the systam has :been receiving no; a1 Flow rates during that peii`od. c. Zga• :volumes of: vhter; have. rant .been introduced into the systam :raCd3ltly i-or:'as part .of .this inspection. . y l►s built .plans have .b.een obtained And, exam .ned . Note it they ) I a�rai.Yabl•i'..vth �N/A. _The: ft i dLliiy:•or-:dwelling was. inspected for signs of sewage �Ths a•ite `;as... Inupected :,for signs of breakout : Ail System .components ,: excluding the SAS , have been lncace ' The septie'.tank manholes were uncovered, opened, and the inter , (,- the septic tank vas inspected.. for ,condition of baffles or tees , 7aatarlal'. of .'constrtiietion, dimensions, depth of liquid , depth o sludge, d:aptn of. Scum. y The tits .,and .location:.of the . SAS on the site has been determined : o e List nq.` nforimation. or approximated by n)n-intrusive methods I The facility- owner. (and _occupants, .if different from owner ; ,.provided'-:with information on the.:. proper inaia-itenance of SSDs . RECEIVE® .APR 1 8 NEALTH DEPT. OF `f SUBSURFACE.-SEWAGE DISPOSAL, SYSTEM INSPECTION FO" PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number..of .bedrooms `number 'of current residents garbage grinder„ yes or no 8 .laundry." connected. to system, yes or no 86aAgn43;. -Uxe-:` ves or no If nonresid'entia-1 ca1culated flow: Water meter readings, if available: C UI�TL'h/ East .date of occupancy GENERAL INFORMATION Pumping records and. source of information: A Pi --- :System pumped' as., part of inspection, yes or no if ,yes, volume pumped Reason.'.for .pumping: Type o:; . system Septic: tank/distribution box/soil-absorption system 'Single; cesspool, .Overf2ow.. cesspool Privy Shared system ; (yes or no) (if yes, attach previous inspection records; if any) Other`.(expla'in) Approximate -age' of all components. Date installed, if known . Source o-- informs ions n 36 S.Sewage odors detected when arrivi ng at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:. (locate- on site plan) depth below .grade:_ material of:. construction: concrete metal FRP other (explain ) dimensions.: ---" aiuc ge aeprh distance:.from top of sludge to bottom of outlet tee or baffle 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 Comments: (recommendation f or. pumping, condition _ of inlet and outlet tees or baffle depth of; liquid level. `in. relation-to outlet invert, structural integrity , evidence .of�.leakage, °recommendations for repairs, etc. ) DISTRIBUTION ;BOX:, ' (1bcate:,9m.,.site -plan) depth of, liquid level above outlet invert Comments:.:. (note' if. ;level .and distribution is equal, evidence of solids carryover , evidence of leakage into or .out :of box, recommendation for repairs , etc . ) PUHP CHAMBER (locate on site plan) pumps .in working order, yes:ror no Comments: (note condition of , pump chamber, condition of pumps and appurtenances , recommendations for maintenance, or repairs, etc. ) SUBSDRYACE ` SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM IWFORKXTION continued SOIL ABSORPTION SYSTEM (SAS) : (locate; on.:.4ite plan, if. possible; excavation not required , but may be approx'isnated �by non-intrusive methods) .If not determined -to be present, explain: �.pe. leaching:;pits+.and number leachingchambers and number leaehinq`galeries and-number. leaching-`trenches, number,. length aeachin lields, numbelk , dimensions overf number low: e-eas ool ` Comments` (note condition .of soil, .signs of. hydraulic failure, level of ponding , condition ot 'vegetation, recommendations for maintenance or repairs , etc . ) .CESSPOOLS (locate on :site plan) : v Jn number and configuration (eCX') depth topof liquid to inlet : invert r depth o! solids Gayer; — depth oft scumslaysr 'dimer►siona o! cesspool,..: --- - sat�riahs, ot; n costruct'ion Y indication o groundwater. inflo�+ (cesspool must be pumped as parto!'?;inspection) Comments (note::conditfon of soil, .signs of hydraulic failure, level of ponding , cW dition of,.vegetat ion;'. ecormendations for maintenance or repairs , etc . ) _ ^� r� f, 02&OC PRIVY . ; (locate ©nsite. plan) Wixaterials ;:.of construction depth of.- solids - .Comments: (note' condition. of soil, signs of hydraulic failure, level of ponding, condition of: vegetation, recommendations for maintenance or repairs , etc . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF- SEWAGE - DISPOSAL SYSTEM: •:include ties :to at least two permanent references landmarks or benchmark , locate all wells within 100 ' ---------------- S� DEPTH TO GROUNDWATER depth to groundwater method of -determination or ..approximation: SOBSURFACE .SEWAQE. DISP.0SAL SYSTEM INSPECTION FO M PART FAILURE''CRITERIA Indicate yes, .no, or. not determined (Y, N, or ND) . Describe basis of determination in. all hstances. If ".not determined" , explain why not) i Backup -of. sewage. into facility? Discharge or ponding of effluent to the . surface of the ground or surface..waters? Static. liquid level in the distribution box above outlet invert? / y Liquid depth .- in cesspool <6" below invert or available volume< f low?. J_. Require& 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? AlIs .any::portion of the SAS , cesspool or privy: below. •tha high groundwater elevation? /V within 50 feet of a surface water? with;in.. 100: feet of a surface water supply or tributary to a surface-. watery; supply? Al within .a Zone I of a public well? ­4L' within 50 feet of a bordering vegetated wetland or salt marsh (cesspools andprivies only, not the SAS) ? ,; within 50 feet of a private water supply well? -`=#— 1.0s.s. -.than .100 . feet.'but greater than 50 feet from a private water supply ;well,..:with no acceptable water quality analysis? If the well has;been..:analyzed to--.be. acceptable, attach copy of well water analys for .c61, .form bacteria, volatile organic compounds , ammonia nitrogen and.:nitrate nitrogen. r; SUBSURFACE, SEWAGE DISPOSAL SYSTEM INSPECTION FOR?4 PART . D CERTIFICATION of Inspector�U�� Namen Company Name 30r'4&1 Company Address ��S (Jcee(oy�?Od Cgrtificat-ion S'_:atc e: I certify. that .I ' have 'personally inspected the sewage disposal system at: this .addrssd;and-that the 'information reported is true, accurate and compl4ite` as 'ot the time o! inspection. The inspection was performed and any recommstdatl'ons.. regarding .upgrade, maintenance and repair are consis tent;.-ith my. training and experience in the proper function and manitenannce of- can-site sewage disposal systems . Check one: I have:"not found any information which indicates that the system f<, to adequately protect public health or the environment as defined r. 310 CMR 15. 303. Any failure criteria not evaluated are as stated e-FAILURE CRITERIA section of this form. Z . have,;,-::determined that the system fails to protect public health the environment as defined in 310 CMR 15 . 303 . The basis for this' determinatfon' `is provided in the. FAILURE CRITERIA section of this f Orin*. Inspector.' s. Signature / I Date Original.: to ,system owner copies= to: Buyer (if applicable) Approving: authority . Town of Barnstable . Department of Health, Safety, and Environmental Services • tanRNgrABM I NAM. Health Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health May 31, 1995 TO: M. Durfee 68 Old Farm Road Centerville, MA 02632 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 68 Old Farm Road, Centerville was inspected on April 11, 1995 by Robert Bortolotti a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Sewage effluent overflowing onto ground from cesspool. • No riser provided. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE B ARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health 2 / ASSESSORS N11AP NO: PARCEL NO:f 0� [Installer letter] TO: I ►• r 9—z (Date) r2d c.cn G3Z ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. twas The septic system owned by you located at � 01.k I'� inspected on nj II M5 by 006ef F f or-I ' a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TIT (310 CMR 15.00 due to the following: a due arm C 00 You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable } Fri$............. .............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABL.E Appliration for Uhnp Sal Workii Tomitrmr#ion Urrmit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: G ..a0 �./1�iK .�....4+� ---------•.•... ---� -/�►.r F/1�✓1..l�-------------------------------------•---....-------- ---......... -------- - ... t-- Loc tion-Address or Lot o. ...f--------------------------------------------•------•-----•-•--- -••------••--•-•-•---•• ......•...---•--•-•-------.sue t t..�— ......--- Owner Address a C9�m t�O.7 CL ��� / /y(/� `�7 UN 7 w5�---------- -----g Ca - --`� g' y .....•-•�- Installer _ .__.. ._._. � Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.-.-------- ..........----------- ...Expansion Attic ( ) Garbage Grinder AJd aOther—Type of Building ............................ No.. of persons-_----_-_------__----..---- Showers ( ) — Cafeteria ( ) dOther fixtures . -- -------- -------------------------------------------- ------------ W Design Flow..................--_-__---__gallons per person per day. Total daily flow.............-7.73.0................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width------------- -- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.............------- Total leaching area....................sq. ft. Seepage Pit No------------ ------ Diameter.................... Depth below inlet-------------------- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------- ----------------------------------------------------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...................... r14 Test Pit No. 2................minutes per inch Depth of Test Pit-----------.-------- Depth to ground water....................... C4 -------------------.................... ....................................................................................................... 0 Description of Soil........................... _......._ t✓s� x ...•----••••••-----•----•-••---------------------•-•-...---------•••---............--------•----••••-...........••--- U .................-....................................................................................................................................................................................... ., W U Nature of Repairs or Alterations—An wer when applicable.--_� .aT' '4-4-- 4- 1 Jul.__ _ _ _. - �-------------- r yJ .. a.4s,---•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s b en '"ssu the board of health. Signed .............. . ---- li/yG r� Dale f Application.Approved _......... --- ._..._ /7 _/,/ _...................._.........--'---.................. Dare Application Disapproved for the following rearon.r: ......._....._....._.._. .. - --------- ---------------------- --------------- ________ .... ....... .. ._..................._....._..._..__............._....._.. .. ...... ........ are Permit No. Issued ---- ............... .. Dace - No lam `/,#,/l 3a I ic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iration fOr Dhi-pw3al Workri 'T rigttitrurtinn Permit Application is hereby made for a Permit to Corrst*uct ( ) or Repair (p<) an Individual Sewage Disposal System at (1-9 G U0 �Lwt kl)A-•D Location-Address � or Lot ......................c��1 1 :D tJ/l�c-----------�...-----ram s -�J�c..a�--c�-----� ;----- ^J/ L ....................... ... W Owner Address CG rJ,ST" c- (Q)�] -7(p AQt�.,/� �►/� yt/I 1�.l S --•-----------------------•-------.....•...--------...------�-----•-•-------•--. •••... ---------- may.--------------•--- 14 Installer ' Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............ --------------------___-Expansion Attic ( ) Garbage Grinder () J aOther—Type of Building ............................ No. of persons.......--------------------- Showers ( ) — Cafeteria ( ) d Other fixtures........... ------------------------------------------- W Design Flow...................�. _ '.......gallons per person per day. Total daily flow............. 3_Q_.-------------------------- --------------gallons. WSeptic:Tank—Liquid capacitv............gallons Length---------------- Width.__.______---._ Diameter..._._--_--_--_ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length._--_-__-.____-___- Total leaching area....................sq. ft. Seepage Pit No.._-._-_-_---.-._.-- Diameter------------------- Depth below inlet.................... Total leachingarea..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- -------------------•--._....-•---------------•------------...._._ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------______-..-_-_ Depth to grounds water........................ 40 Test Pit No. 2................minutes per inch Depth of Test Pit-_..____---_..-____- Depth to ground water......................... ................•---....-----....----•--•-•---•---•------•-••--••-•-•-•--•---•--•---••-•-••-•-••••••......................................................... D Description of Soil........................... ......... x •-•----•..... .................................... U ----------------------------------------------------•----------•--------------------------------...----------...-----------------------------....-----------------------------------•--................ W U Nature of Repairs or Alterations—Answer when applicable__tN_�S 1 4-L __.�..._..�- ti ------------- Agreement: The undersigned agrees to install the aforedescribed Individual..Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hVlas bD7 en -- .ssued by the board of health. Signed ----------- k -------- ( ------------------- ------ Dace ....-..�. Application.Approved B, _' ;-..�� . h'..,-f'.------,-------.... */`/f-' . ---------- ----------------- ---------- Dve Application Disapproved for the following reasons- -------------------------__._............. .... ... _.. .......- ...... ................. . ..................._..... .. ........._....... . �•�--^ / / •—^""'!Dare Permit No. �t.� ---- / ----------------------- Issued --.-�,� .� t A Dace __,� .��.--Y- ��1�v m.-:>_-.���.�-.� •-�������.�..—..:�.-.n-gym a_ :...�..�. ,.�.,..�.�..- ,��.a--� "_-...,.���.-�.s..s --�-.._,:r:��-_-...-.;r-.�-. THE COMMONWEALTH OF MASSACHUSETTS r' BOARD OF HEALTH TOWN OF BARNSTABLE (11trtif irate of (ILlumplinure THIS IS TO CERTIFY hat the Individual Sewage Disposal System constructed ( ) or Repaired p ' .--T.6. `a171-1.........C.6Y_n si7C L! p ski at ........_........... ................... .. . ..4 r......_G[ p-- ----- :-/LLt✓+i1----k-'�---- has been installed in accordance with the provisions of TITI_ 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No �T' �". <°' ............... dated ., � ,�,///°? ....-. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. `�I ��- DATE......_.. .../ �� Inspector .. -'/t THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH /I,�' TOWN OF BARNSTABLE -- No. -•-•-..-•_.... FEE........................ Permission is hereby granted------------------ y577LJ�'' /.G:�_._....._... to Construct ( ) or Repair ( an Individual Sewage Disposal System at No. ��'' U p ---� ,lJ_.......--- �lZ-v._Lc_C Street as shown on the application for Disposal Works Construction Permit o---!_,',���� Dated..��................7 ... ..-----•• ----- •- . .� Board of Health P` DATE. ---------- ............ . •. ---••-------•-•-•-•-•------••..... FORM 36506 HOBBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE ©P P/®/�/ LOCA'X'1 ON I4 I���► R SEWAGE VILLAGE �e4` el-0 dZ le ASSESSOR'S MAP& LOT____ ,___ _,,, INSTA:LPR'S NAME&PHONE NO. SEPTdC TANK CAPACITY �lJZ� C1 a >> LEACHING'FACILI' ' (type) rem �� (size)+wf NO.OFBEDROOMS tUILDER OR OWNER, PERMIT®ATL7: COM1ANCE DATE: Separation Distance Between the; Maximum Adjusted,Groundwater 114ble to the Bottom of Leaching Facility EMI PrMite Water Supply Well and Leaching Facility.(if any%veils exist t on site of within 200 feet of leaching fatciuty) 3Fcgt Edge of Wedand and)_.caching Facility(If any wetkinds exist within 300 fe t f leachiq f zrAtry) � �� Ae 7 Fee /' �" a tyt� Furnished by „a„ t a p c c 05 ' IATION6? 6/UE; - �TOWN OF BARNSTABLE SEWAGE # i �� VII.LAGE UA ASSES 'S MAP &LOTo�ZS� INSTALLER'S NAME&PHONE e� SEPTIC TANK CAPACITY AW.<701160�i/Ii<4_ LEACHING FACILITY: (type) /^��%�l� �/� (size) 7 �;X •?'rD0 NO.OF BEDROOMS BUILDER PERMITDATE: 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) do Feet Furnished by 30 3a o 33, 3� i 60 F f I i �t TEST HOLE LOGS ENGINEER:__ _ i" WITNESS: -�' I�A(G fC: x DATE: a_ '`� ` � I �•� i PERC. RATE 0. S•�".o[+tom 5.� :.p A,. _ � LOCATION MAP �kr Aa aA or- t* F I.t i�( 4.o 1�Il a ybeo voa:- oeivrswmt , At~�-jc;rF ASSESSORS MAP ZS I PARCEL o �� b � � FLOOD ZONE � BUILDING ZONE: N - y' Tz \'-T S'�T ; SETBACKS: FRONT ° � 9 Ia.►.ti� 'J` I SIDE - , 4� REAR Ir NOT E e-lilOit./ 1 . DATUM IS 2. MUNICIPAL WATER IS a \ \ `g ,.;c_�;; tam - f7p�aEME►JT 1`►�oL 3. MINIMUM P!PE PITCH TO BE 1/8" PER FOOT. b \\ c'. C a t F T L\ a �-�=� �--. "t 4. DESIGN GOADING FOR ALL PRECAST UNITS .0 BE AASHO-'-�__� 5. PIPE OINTS TO BE MADE WATERTIGHT. ;� • „ 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. SEPTIC`\. FR-OFILE _ ENVIRONMENTAL CODE TITLE V. (NOT TO SCAW 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE USED FOR LOT LINE STAKING. T.O.F. AT EL ' $, PIPE FOR SEPTIC SYSTEM TO SCN. 40-4' PVC, -Wtot I trT \ '..4. .'-r.. f ��, 1ti7f. l�+:J ✓ 't t.s-_. r I`� T 4.V '.�r:.d1. 4 per. irti. `• _� ---- f-C -n_ 3 16. httN:lit3�i j �F" ..L"Jri t^ {3`tF.� , p v PS a ' •C --- Caf..� !L� e<2v cat� ra ati46-r. ---- ! ,: xr EdA4► ., (v nl t•�t 1 FOR FIiRST 2 1.1 F tRUN ____ ' ^ PROPOSED ' f � � r Q&UON SE'P71C S �q TANK (HA) _ b� ,. 6t S �T Pes� T'EE SIZES: _t N.S . _ _`� +'�• �,,I _ Le :\ U-% SLOPE) INLET DE � ;r (.-% SLOPE)A a- _% SLOPE) old �v rah++F !% -,^yv►�, {� r OUTLEr DE t ir>eTtotii _ -- SEPTIC TANK `� -_ D' BOX LEACHING p, ,_;r�r;ci A�.1 r�a1tL?�1►ie a .i yc';.k� 2 y A� J. FACILITY \ i •'e:a�� 'tea 6 t_r�f F�1C.C-p^�!A"1-':�'��� i f SITE AND SEWAGE PLAN OF -'v., e �,, 4� ���� Ft►�'s� SEPT IC DESIGN: (GARBAGE 0,sposER Is NpT a�►.o►�-1�►� i3 �1.r� ��a.�.ra � ©tL 0 &[ — `- �-3 iTAq4�' �= w� DESIGN FLOW: BEDROOMS (_',o GPD) _ Z2:s2 GPD IN THE TOWN OF: USE A GPD DESIGN FLOW SEPTIC TANK: '7 R GPD GALLONS USE A li GALLON SEPTIC TANK PREPARED FOR: - LEACHING: SIDES: (Z4) 4 GPD Zv 0 �� . Feet BOTTOM:__ )_ ) = I GPD ' — BREAKOUT_ r.a,a, TOTAL: S.F. '=�►Z GPD SCALE: t' DATE: a _� — (150%) _ FROM EL —_. — ._ �"� /(Ga.G L� rQ�h�•i� mC� .state! (?`' q` Ot v T SYSTEM IS FROM EL � 4Z� ARNE H. It I /1 ���\ i doT4n cape engineering, inc. �E OJ/►LA �� - o� ARNE A ` CIVIL ENGINEERS Not�t LAND SURVEYORS — PHONE 508-362-4541 FAX 508-362-9880 BOARD OF HKALTH DATE MA 939 main st. yarmol-1th, ma APPROVED — DATE