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HomeMy WebLinkAbout0010 PEEP TOAD ROAD - Health 10 Peep Toad Road Centerville A= 173 — 058 0 *Pendafle< �Esse/te 4210113 ORA M ' N., ' o TOWN�OF BARNSTABLE 6d' 0- LOCATION V ����(a SEWAGE # VILLAGE �� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER 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) Feet Furnished by p IA � g a AA a� AR A,C P. 40 �t �A 63� y� y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 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:When filling out forms A. General Information on the computer, use only the tab 1. Inspector. Y move Your key to �J �Y cursor-do not Sean M Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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 sewage disposal systems. 1 am a DEP approved system inspector pursuant to,tection 95.340 of Title 5(310 CMR 16.000).The system s 4` ® Passes ❑ Conditionally Passes ❑ Fails 7 r r ❑ Needs Further Evaluation by the Local Approving Authority o 8/10/2011 Inspector's Signature --- 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. ' A ' �115 A t5ins-091U9 Title 5 Official Inspection Form:Subsurface a Di sposal System• age 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E J 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: The dwelling located at 10 Peep Toad Rd. Centerville Ma. is served by a 1000 gallon septic tank, d- box and 2 500 gallon drywells. The s.a.s.was repaired in 2008,the septic tank is original. 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•09/08 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 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name required fo is Centerville Ma 02632 8/10/2011 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 Boars!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-D9= Title 6 Official Inspection Forth: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 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is Centerville Ma 02632 8/10/2011 required for every page. Cityrrown 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 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%day flow t5ins-09108 Title 5 Otfiaal trwedion Form Subwrtace Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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•09/08 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 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. CityRown State Zip Code Date of Inspedion 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 gpd t5ins•09108 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 r� 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. CityfTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date CommerciaUlndustrial 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-09MB Title 5 Official Inspection Form:Subsurface Disposal Sewage spore System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 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/Altemative 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•09M Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. City(rown state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: tank is original 1977, s.a.s repaired in 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 1 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 Gallons Sludge depth: 3" t5ins•09108 Title 5 Official Inspection Fomr.Subsurface Savage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 3' 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 10" How were dimensions determined? opened covers and took measurements 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 should be cleaned soon and again every 2 years as maintenance. Outlet tee intact and in good condition.Water level at bottom of outlet invert, tank was not leaking and was structurally sound. Outlet cover is on riser. 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-09108 ride 5 Official Inspection Forth: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 10 Peep Toad Rd. Property Address Edward Clough Owner owner's Name information is required for every Centerville Ma 02632 8/10/2011 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete El 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•09108 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 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. City/Town 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 0ff 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 was structurally sound and not leaking. Water flow was even to both outlets. No solids carryover. 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-091W Title 5 Official Inspection Forth: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 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ® leaching chambers number. 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S.a.s. was found to be functioning as intended, no sign of past hydraulic overloading. Cover is on riser. 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•09108 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 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. Cityfrown 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•0908 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 10 Peep Toad Rd. Property Address Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. Cityfrown state Zip Code Date of Inspection D. System Information (coot.) 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 1 0 A TAJVX A-2 20 13-2 29..6" !> c 3 3s' t� 3 �'a---- D-Y 3 it o y Mine•09108 Tide 5 Official Mspec ion Form Subsurface Sewage Disposal System•Page 15 of 17 -44 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Peep Toad Rd. Property Address .Edward Clough Owner Owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. CitylTown 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: 20+ 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: 11/5/2007 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: design plan on file at Town of Barnstable health dept. dated 11/5/2007 shows no groundwater was encountered at 168"and system in designed to have 5'+of seperation between bottom of s.a.s and adjusted high groundwater elevation. I Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Peep Toad Rd. Property Address Edward Clough Owner owner's Name information is required for every Centerville Ma 02632 8/10/2011 page. Cityrrown 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-09= Title 5 official inspection Form:subsurface sewage Disposal system-Page 17 of 17 TOWN OF BARNSTABLE LOCATION 7!MAJ�, 7-OA D SEWAGE VILLAGE C9Ull L JE ASSESSOR'S MAP&PARCEL /7: INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 1 LEACHING FACILITY:(type)�-SW 6ALLoA) CAAWirip(size) NO. OF BEDROOMS OWNER TR FD t''5 WZ VV)Atk IMP O j4A N u 0,q;t, PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) � . Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ;G v Set 68 3s" Da AC C 3 s 3 a 3 � J 1 Q� Z -- 1 No. - -— v THE COMMONWEALTH OF SS GHUSETTS--- : Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for �Digponl 6potem Con0tructiou Permit Application for a Permit to Construct( ) Repair(w-f Upgrade(V/Abandon( ) El-Complete System ❑Individual Components Location Address or Lot No D -I r4 O d O is Name,Address;and Tel.No. ce Assessor's Map/Par #J�" Cirtff-tf2 VIE D/ Insta-l�ejr's Name,flddre, nd Tel.No. De i ner's Name, dres and Tel ids14"5 f 7CCAIIAT'/f?/& I�f- UGtJ��s Type of Building: `Z ES [b E0L Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria_L.) Other Fixtures Design Flow(min.required) 3 3 O gpd Design flow provided gpd Plan Date " (0 07 Number of sheets Revision Date Title S 17-F Yz SAL) Size of Septic Tank G-A L Y/pe of S.A.S. Description of Soil t 4 / Natur of Repairs or 1 erations(An er when applicable) C` (� ohe -10 J Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir mental Code and not to place the system in operation until a Certificate of Compliance has been issued by this o Health. Signed 0 0 ate Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued '�---------------- -- ------ -- V/ y '� �r'e ..\ :.l" r+ ..t'.'r'... . �j,(./()/�,�''•'� /f[/fi^.y •7 (j�h q /�'/�., 9'..f '�..`. .,.+.„. o. Fee THE COMMONWEALTH OF SSACHUSETTS Entered in computer: if-4 yPUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS Yes Z[Vplication for �igpo al *pgtem Con0truction Permit Application for a Permit to Construct O Repair(t/j Upgrade( Abandon O .Complete System ❑Individual Components Location Address or Lot No#)'0 j�p�`+p p �!G O q Owner's N�e,Add s;���o. � Assessor's Map/Paro Instal er's Name,f C esi ner lddres d Tel.No. D 's Name, dress and Tel.N s3v,�/t�sced,� iv6 Vl 9J rv,�osor. ��25 o 15 33 - yoc WA )_' 13 a-re. F Type of Building: `(Z Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder.(--4_ Other Type of Building No.of Persons Showers( ) Cafeteria_(,_.) Other Fixtures Design Flow(min.required) 3 3 U gpd Design flow provided gpd Plan Date 07 Number of sheets Revision Date Title S I"`l" -4- Size of Septic Tank LT4/pe of S.A.S. Description of Soil 5 . t✓ Nature of Repairs or 1 erations(Ans er when applicable) . 42 one - - o � 0h ed^ G Date last inspected: �r Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro mental Code and not to place the system in operation until a Certificate of Compliance has been issued by this o Health. Signed Date Application Approved by Z / ' Date 2-Idle 24 � � w Application Disapproved by: Date" for the following reasons v lt Permit No. _ ._ ,,Date Issued. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS ` y Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( '�`�1((Repair epaired r �.Up'iadedti`( � ) Abandoned( )by I� S' at f V7 ha been c structed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. D dated . Installer t Designer #bedrooms �j Approved des'gn,flow 3 O gpd The issuance of this permi shall not be construed as a guarantee that the systc:,r will functio s d sig d. Date (� Inspector \ -------------------------------------------- No Feel HE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS =igpogor *pgtem �o gtruction Permit Permission is hereby granted to Con ruct (n ) Repair ( grade ) Abandon ( ) System located at 6 N� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction st b com leted within three years of the date of thi e t. Date Approved by Town Of Barnstable Regulatory Services Thomas F.Geiler,Director + B NMBLE, s a Public Health Division ArF p a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: 3 2 009 #� Designer: �>4vl 1] y400" i Installer:"�UQ. 4( cp Address: . b l b 4*-1OVO(u'I Address: 6*-4 C)L.,)I U,4 _ on was issued a permit to install a (date) (installer) p septic system at 1 n ,TW It)tD PT160 based on a design drawn by (address) dated . L (designer) a ],eertify that the septic system referenced above was installed substantially according'to , .he design, which may include minor.approved-changes such as latgr relocation of the distribution box and/or septic tank- . ,. I cerW,that the septic system referenced above was installed with'-Major,changes.(j',e, greater tfi-E 10' lateral relocation of the SAS or any vertical ceiooati in of any component of the septie,�systern)but in accordance with State&L•ocA Regedlations. Plan revisiorx or certified as-but by designer to follow. tH`DMgs �V1U �c (Installer's Signature) NIASON o.1066 X. SgNI TAR�P� 'V (l3 er s Signature) ( er's Staip Here) PLEASE RETURN TO BARNSTA PUBLIC.HEALTH DIVISION 1k . 0ZRTIFIC TE OF CONLP ,IANCE WILL N®5FiE SSUED°UIVTII�'BOT$°- IFf}IIMANIEV '_ BUELTCARD ARE RECEIVED WM EBAM S`l�A$LlE PUBLIC SEE LTH D�SI01�T THANK YOU. =f Q Healtii/Septic/Designer Certificalion'Form a` f ,}� COMMONWEALTH OF MASSACHUSETTS ' \ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION w tl ✓ • `j TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ' r¢' PART A CERTIFICATION s .3 Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 Owner's Name: RICHARD SENOSKI Owner's Address: 3413 MAIN ST.BARNSTABLE MA.02630 Ilcii.j Date of Inspection: 4/6/01 RECEIVED Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 APR 19 2001 ' {; Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF BARNS]ABLE } HEALTH DEPT. CERTIFICATION STATEMENT I certify that I have personally in the sewage disposal system at this address and that the information reported below is s 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 systemr inspector pursuant to Section 15:340.of Title 5(310 CMR 15.000).' The system: '4,A, X Passes _ Conditionall ,Pas es _ Needs Furth luation by the Local Approving Authority t ,$ Fails }-;;Y.. Inspector's Signature: Date: 4/6/01 ;; EMI" , The system inspector shall submit a cop 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 4 1 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 ,'' ;` THE SYSTEM PASSES TITLE V INPECTION.HOWEVER,THE POOL SHOULD BE 20'FROM LEACH PIT, CURRENTLY THE PIT IS Y FROM POOL.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE, A **** This report only describes, 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. n j i•a S. . flrt' . Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �' f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) a Property Address: 10 PEEP TOAb.RD CENTERVILLE,MA 02632 Owner: RICHARD SENOSKI Date of Inspection: 4/6/01 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: { THE SYSTEM PASSES TITLE V INPECTION.HOWEVER,THE POOL SHOULD BE 20, FROM LEACH PIT, CURRENTLY THE PIT IS Y FROM POOL.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG „t THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: �Al• _ 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,exhibitsq� 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. °'f ND explain: n/a i^.oS.dEa 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 pumpinj%re 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): I�r a _broken pipe(s)are replaced _obstruction is removed &; �t r f iti ND explain: n/a .�,, ,�;• A�" h.' i Page 3 of 11 - t 3,i; •��,!e OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) .} t, Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 Owner: RICHARD SENOSKI Date of Inspection: 4/6/01 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. •. i 1. System will pass unless Board of Health determines in accordance wi'h 310 CMR 15.303(l)(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. t P _ 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 r'. supply well". Method usedio determine distance n/a "This system passes if the vi%ell 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 m provided that no other failure criteria are triggered.A co g g . ,q PP �P gg PY of the analysis must be attached to this form. k 3. Other: n/a t�?i y "a ; F 1 t t` ti r Z Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM q, r• PART A CERTIFICATION(continued) Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 Owner: RICHARD SENOSKI Date of Inspection: 4/6/01 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 : i 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 NOMdue 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 °o less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be ',.a, 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 r R Srtn! 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. t,. 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 i 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 Wit 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 ;`''�). PI'a' Y Y ��.t .., should contact the appropriate regional office of the Department. K � l~ SJ Page 5 of I 1 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS fix" SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 Owner: RICHARD SENOSKI Date of Inspection: 4/6/01 's Check if the following have been done.You must indicate"yes"or"no"as to each of the following: i. 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? M1tE� X _ Has the system received normal flows in the previous two week period? ;"'r . _ 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)]j, a `i ' r Page 6 of 11 ;I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS f ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 ,, s: r Owner: RICHARD SENOSKI i Date of Inspection: 4/6/01 It 1;0FLOW CONDITIONS4 `, RESIDENTIAL `, 1� 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 1 ' Number of current residents:2 " 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 ;`3 Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM.R 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a •+l �. j Grease trap present(yes or no): NO :,$ Industrial waste holding tank present(yes or no):NO ` r�4^ Non-sanitary waste discharged to th�e;Title 5 system(yes or no): NO Water meter readings, if available: n/a Q:{. Last date of occupancy/use: n/a OTHER(describe): n/a ,�,,; r• . 'GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO3N 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 4 _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 a" ' _I�iV� Approximate age of all components,,date installed(if known)and source of information: 1977 Were sewage odors detected when a►'•riving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM c PART Cu i SYSTEM INFORMATION(continued) Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 Owner: RICHARD SENOSKI Date of Inspection: 4/6/01 "r ' BUILDING SEWER(locate on site plan) Depth below grade:22" Materials of construction:_cast iron X40 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.): x TOWN WATER SEPTIC TANK: X(locate on site plan) ' Depth below grade: 16" ; 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: 1000G L 8 6 H 7 W 4 10 Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:32" i .a•, Scum thickness: 1 Distance from top of scum to top of outlet tee or baffle: 24" f $ Distance from bottom of scum to bottom of outlet tee or baffle: n/a j ;4 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SEPTIC SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a z 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 recommendat Ions, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t s 4 a .x to outlet invert,evidence of leakage,etc.): l� n/a . .y a 1 L Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 Owner: RICHARD SENOSKI Date of Inspection: 4/6/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) { �y Depth below grade: n/a Material of construction:_concrete_me`al_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons k'.i: 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.): THE DISTRIBUTION BOX IS:STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site,.plan) cyh r Y''I Pumps in working order(yes or no):`NO Alarms in working order(yes or no):NO :y Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a a 'A!, IJ R Y Page 9 of 11 9 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ',` PART C SYSTEM INFORMATION(continued) Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 Owner: RICHARD SENOSKI Date of Inspection: 4/6/01 ' 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 0 leaching trenches, number, length: n/a n/a s leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a <!, innovative/alternative system ' 4 Type/name of technology: ' n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.HAS NOT HAD MORE THAN Y OF WATER IN IT.THE PIT IS 3'TO POOL. 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 +F Comments(note condition of soil,sins of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a h . , Q L Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 Owner: RICHARD SENOSKI Date of Inspection: 4/6/01 i. SKETCH OF SEWAGE DISPOSAL SYSTEM t t 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. its• A �jac�- t- t OCCL 'a;u C ti L • .. s ��-t I,A.1 ri q�''Y,} .�I1k7f,t a1q .µ4 .. AP y'- go 43 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 PEEP TOAD RD CENTERVILLE,MA 02632 Owner: RICHARD SENOSKI Date of Inspection: 4/6/01 - SITE EXAM _Slope _Surface 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 NO 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 exdavators,installers-(attach documentation) YES Accessed USGS database-explain: n/a t• You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET t ,dXF.' Tit , i -LVqO , T ION SEWAGE PE RMIT NO. A� yet PILLAGE INSTA,LLER'S NAME & ADDRESS B UI'LDE R OR OWNER DATE PERMIT ISSUEED DAT E COMPLIANCE ISSUED �� �,� �r Gt}A r \1 CS' A No.••--•••_.. FEE...../ `.. THE COMMONWEALTH OF MASSACHUSETTS BOARD. O HEALTH _... ... I ---OF............ � - ..:,.. --------------------- Application -fur Uhipuuttl Worko Tunutrurtiuu VPrmiit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewag sposal System at o©<y il ---------•----------------------"=-.o-----t Q�lG 44 L --Lca` ��� or Lot No. Owner i' S Address .. �1��.lr------------------------------------ Installer Address Q Type of Building Size Lot_. __ ....Sq. feet U g _....Expansion Attic (� ) Garbage Grinder (Q®) Dwelling o. of Bedrooms_._______:__es�c-�................... aOther—Type of Building ---------------------------- No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ....................................................... W Design Flow-------- ...........................gallons per person per day. Total daily flow___________-,a:��---0.q--------------gallons. WSeptic Tank 4—Liquid capacity1Qo9---gallons Length---------------- Width----------- Diameter-----.---------- Depth---------------- x Disposal Trench—No- ____________________ Width-----_: ---- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------------I------- Diameter.../.400....... Depth below 'nlet--- _ _____ ____ Total leaching area................._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) / G Percolation Test Results Performed by-------------------------------------------------------------------------- Date_----_--_------------------------------ ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_-_--..----._.-..-_--- rXq Test Pit No. 2................minutes per inch Depth of Test Pit-----_.-.---_______- Depth to ground water__.__._________.-_-_.._. rx .............. ------------------ -----•---- tion of Soil-------- �.. x P - 2 O Description - , c., ------------ ••---•----------------------•---•---•••-----•-•-•-•-•--•-••-•--•-•-•••-----•-------------------------------•---- ' 1---------------------------------------- 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 Article \I of the State Sanitary Code - The undeVeees not to place the system in operation until a Certificate of Complianceneas bee ssu d b e pc PY G// g .. //�� Date: Application Approved By...........-� �!P� - -•---------------- •.... Date Application Disapproved for the following reasons____________________________________-----------------•--•----------------------------••------ -------- ._,__. ---------•------------------------------------------------------------------------------------------------------•-------------------•...--•---------------••--------------------------------------•----- Date PermitNo......................................................... Issued........................................................ Date No.. ......-- FEE..........3.....:..":::.. THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALTH, lOF............. . .. :.�6.�1_f ✓�:_,.. ... ----w ...................... ApVfirtttinn -fur Uhipuiittl Workii Cnnnitrurtinn prkiit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �cacQ�c a ...-- .. -••-•••------•-----•-••-•--•-••-•••'---- Location-Ad ress Lot No. ......-- Owner --•-••Address Installer Address Q Type of Buildingo. of Bedrooms__.______.__ ..__._____ _ Size Lot...1�..2-��...Sq. feet Dwellin U g _-__-------_ Expansion Attic ( ) Garbage Grinder (4O) aOther—Type of Building .---_______________________ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures Q' -------------•--------------------------------..---•--------------------•--•---------•---------------------------------••------ W Design Flow._._....��4`_�..........................gallons per person per day. Total daily flow..............._ _?P-----.-..-.--gallons. WSeptic Tank+Liquid capacitv_rP^_�__--gallons Length---------------- Width------._........ Diameter.........------- Depth..-..----_...-. x Disposal Trench—No- -------------------• Width----------P__----- Total Length......_.___........- Total leaching area....................sq. ft. __-.. •- Seepage Pit No------------J....... Diameter...- __$___ Depth below inlet____________________ Tgt`alroleaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) r,)i . /OC --11" aPercolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------.. a Test Pit No. 1................minutes per inch Depth of Test Pit------------------- to ground water-------------------- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._._-.--.______--.--.--- Ix O Description of Soil-------- .; ! �a- f_ _�`c �'-......-- .�-- ----- 1-Z V ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------- -----------------------------------------------------------------------------------/------------------------------------------------- ........................ 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 Article XI of Sanitary Code r The undersigned fVtIertees not to place the system in operation until a Certificate of Compliance has been d bye board Signed `� f f Date Application Approved By------ ------ ;r.... . ....f `1A--- --------------------- ---- Date Application Disapproved for the following reasons--------------------------•-• •-----•-•-----•---•--•---------------------•---------------•_-.----------•--------- ----------------•--•-----•---------------'---•---•-----------•---•---•--------------•-----'---------•-------_-------------------------------------------•-----.-------------•--------------•-.--------- Date PermitNo----'--------------------------------------------------- Issued........................................................ Date <. THE COMMONWEALTH OF MASSACHUSETTS RjDK— ` BOARD OF JHEALTH '-71,1 .....OF............... ... ...r ,���.....,.-...............!. o�T �f wrrtifiratr of 01.11mphaurr THIS I T E T FY That the Individual Sewage Disposal System constructed ( or Repaired ( ) ----/--�-Eby------- -y- - -------f-f iijl} 1 /�/{t - -----------•--•---------------- has been installed in accordance with the provisions of Ai6)_ I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._'_ ______T r n-_-___ dated----_-e.___-!.JS-'7_7......_.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------ 5 7--- Inspector.............. .! ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � � '~' t� ........... ....;�k-."�`,rt' . ..t..,...O F--......... . .. -.................._.................. N .--•-••• 'a............ FEE... .":........ Permission is hereby granted_.__.... _ ---------- to Con ruct ( or Repaair ( ) an I i Icival Sewage Disposal Syst yff 1 f Street t as shown on the application for Disposal Works Construction Per 't No.............. ted._ ... ..........................' _.... •---...... •-;-----�, "-�! ;----f-,;W '--- $card of Health DATE.. --�o2a --7 --------------------------_------- ` FORM 1255 HOBBS & WARREN. INC., PUBLISHERS u' r SOLD <` ORjex g Oak ROBERT • No.22l62 j? .� GIST`-%� CERTIFIED PLOT PLA.N _'* 2 V LAk ?/ 4! ' ja /G r C41 sf i C N'lE.w C M9xRu�CT ON ONLY 9� IN A80Ve Lour POINT OF A0JACEN,T � �,�$►�,�1.�'�';dl� �� � a ROAD.' SGALE DATE fl L�' E �l1YELRtNt3. .IAf I CERTIFY THAT TMEl���^ CLIENTS SHOWN ON THIS PLAN IS LOCATED E8ts `-E`RE a REfl1STER © jOB tjo_7?Oi�g 4N THE GROUND AS INDICATED AND -CIVIL {.�,y LANO� � GQNFORMS TO THE ZONING LAWS ' t..N+4t A ` BURYE'YOR � j D YE. OF `idAR1 ST 8 E , M S$a '•^T'! a I� 1 ST' x s 7' 'M�cINrS'#�• �:, ......�.'', .... _.'►yi;7 3' IB. LAND SURVEYOR, : pft pip CONCRETEMill I!® PER:'RT CONCRETE COVER " � . MUM LEVEL . .-•. . .. . 11 LAYER 411 CAST _ - "a•z 2 I/8 OF 3/811 �� PITCH - /C%6G Q r p • r ..• WASHED STONE 9 1/4" CH- SEPTIC TANK DIST. ' ° . «: . rti . . i p ° p . PER FT. JJf 8 ?X f e e • / r :.'e 1 s.R ° •, f f p p p • • i- i✓TIYLp.1 .e o° l4U— ° 1 • • •, s WASHED STONE • 1 . o . ..• ° PRECAST ` SEEPAGE 1 •• a • • too e PIT OR EQUIV. INVERT ELEI/ATIMS, . _ e T. olA. �V1fE AT #L ��'�° FT. IO FT. DtQ►. 0 (SEE Ti�EtIL/�Tt F (NN) ` :.Itt►L>t'f TAM 7. , r FT. }t) WATER. TABLE O T(,f T C TA{ C h 3..3.FT. SECT-ON 4F L ET Msr.re��JT� I}oi! 2._33! T S GE L *L gYSTEM WTI �X �' F7 a , SCALr t14 & t tl i ET, SE3 'i4�iE PlT 7 •9 FT Til"AT1 4 FT W. TirMA _�_FT Mom OP, ICYc TES#' _ _ TOTS, _ s — -- TEST FT MY MIA 401 ibiiG• {$lfi., Atw - - - - - -- _ -- - _.: �_ _ � _ ��•� =�3 A� � art~ iM , �o t+ . -fi — - - - - _ - = ASSESSORS MAP : *17,E TEST HOLE LOGS NOTES: PARCEL : FLOOD ZONE : A/67 -16 L 4E1 SOIL EVALUATOR : �VI WITNESS : W 0- l 1) The installation shall comply with Title V and Town of Barnstable Board of \ REFERENCE : } ,,i ..� bF "I:W I) `' ��'3�q fj 1c t� pv DATE : Ilealth Regulations. 2) The installer shall verify the location of utilities, sewer inverts and septic L�L[7 --� � 2 PERCOLATION RAT : Ike I�-- , I �J ZCO f 16p components prior to installation and setting base elevations. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first 0 TH- 1 TH-2 two feet out of the d-box to the leaching shall be level. Auvr " A J( Srq,4V �,Q AA a 4) This plan is not to be utilized for property line determination nor any other Ib + '��° �o �(1.da I '1�ib purpose other than the proposed system installation. I� �.- I� 4�I��w�.. - 5) All septic components must meet Title V specifications. 5�t� U,� 1 � t� � 1 / ! 6) Parking shall not be constructed over HI septic components. tb�I?,b(� � (og,�j� ' _ lb ___11-0 _ b�'SOO 7) The property is bounded by property corners and property lines. LOCATION MAP W�I�5� 1 ____._____..-__�_ _ C L lye 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. \ 1 ' 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along;with contaminated soil and replaced with clean washed No 00 4wo' U sand per Title V specs. ---- 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the 1 \ owner to ensure such. FL')W ESTIMATE 12)The installer is to take caution in excavation around the gas line if \ ���\ I- ,`�w� �' -- �, applicable. _ 22 "y� BEDROOMS AT Ib GAL/DAY/BEDROOM - ;l GAL/DAY ) 13 The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. SEPTIC TANK GAL/DAY x 2 DAYS - tn�n GAL ° I USE ISO GALLON SEPTIC TANK(1�? I�f ll-4( SOIL ABSORPT 16N-SYSTEM SIDE AREA t �0 BOTTOM AREA: (' 1 rj � 2 �' - � ��:)••` -KEPT I C SYSTEM SECT I ON AC f..- S 4. 65,S I z of 3/g ���� l�,► y cV I0On GAL 101, Z ° ' b . SEPTIC TANK �O$►�azOj (�Ex.A 5 Wcf as _ _ - Q Ib SITE AND SEWAGE PLAN irLl LOCAT ION : �i I Ca I IEP _TDAD 2ogD C 1^47E)2V/t_C_E- m PREPARED FOR : E8E7f211')q1w.. P o SCALE : WgJE 0 DAV i D B . MASON FS DATE : DBC ENVIRONMEN AL DESIGNS w EAST SANDWICH . MA W DATE HEALTH AGENT ( 508 ) 833- 21 /'7 Z