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HomeMy WebLinkAbout0010 PEN LANE - Health 10 Pen Lane_ Centerville P == 193 207 Owiford, NO. 1521/3 ORA 10% 0 J� -\ COMMONWEALTH H OF 1VIASSACHirJS ,,T'I'� a��s , g !U€Y�v t ARNSTABLE ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS > DEPARTMENT OF ENVIRONMM-11 Mdj1, ItfbN DIMSION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Q Owner's Name:`? ( p F 1 Owner's Address: " ®� RCEL Date of Inspection IT Name of Inspeo please print) f Company Name Mailing Address: / q� Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was'performed a. P P p based on my training and experience m the ro er.function and p p p maintenance of on site sewage disposal systems. I am g p y a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: l�Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature - tt g 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 sharzd system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 611512000 page ] Page 2 of l l OFFICIAL-INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION (continued) Property Address: t!) `D 1 Owner: ' Date of Inspection: S 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.Anv failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass section:need to be replaced or repaired.The system, upon completion c,f the replacement or repair;as approved by the Board of Health, Will pass: Answer yes,no or not determined(Y,N AID)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 pipes)or due to a broken, settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is.removed distribution box,is.leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or 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: 2 Nee 3 of 11 OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: A Owner: / Date of Inspection: 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 surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within E Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a.priyate 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 DE11 certified.laboratory, for coliform bacteria and volatile organic compounds indicates that the well is tee from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to nr 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address:,�) -V,,,a, Y41A-e Own g,WAI Date of Inspection: — �C3G� D. System Failure.Criteria applicable to all systems: You must indicate."yes"or"no."to each of the following for all inspections: Yes N9 a/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of ef-uent to the surface of the ground or surface waters due to an overloaded or clogged.SAS or cesspool _ Static liquid levelin the di_tribution box above outlet invert due to.an overloaded or clogged SAS or ` cesspool. V� Liquid depth in cesspool is less than.6" below invert or available volume is less than'/z day flow i/, 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 l water supply. Any portion of a cesspool er 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 coliform bacteria.and volatile organic compounds indicates that the well is free from pollution from that facility and the presence-of ammonia nitrogen.and nitrate nitrogen is equal to or less than-5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) (Yes/No):The system fails. I have determined that one-or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health.to determine what will be necessary to:correct the failure. E. Large Systems: To be considered a large system the system must serve a.facility with.a.design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes . no the system,is.within 400 feet of a.surface drinking water supply the system is within 200 feet of a tributary to a surface.drinkirig 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 faded under Section D shall upgrade the system in accordance with 31.0 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 5 , Paee 5 of 1 l OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B t CHECKLIST Property Address: •/Q W 1A �6_4(_o Owner:T Date of Inspection: .: , Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes —o Pumping information was provided by the owner, occupant,or Board of Health 'Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ZHave 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?(I they were not available note as N/A) V _ Was the facility or dwelling inspected for signs of sewage backup _ Was the site inspected for signs of break out? 4 VZ _ Were all system components, excluding the SAS, located on site ? _ Were the septic tank manholes uncovered, opened,and the ir__erior 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 owne-)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing information. For example, a plan.at the Board of Health. _ ..Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 • a 9aa' Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: A- Owner: Date of Inspection: 5 � / LOW CONDITIONS RESIDENTIAL V Number of bedrooms(desig115.203 N.imber of bedrooms(actual): 3 DESIGN flow based on 310 fo example: 11.0 a d x#of bedrooms ( P bP ) Number of current residents: Does residence have.a garbage grinder°(yes or no):Al(J Is laundry on a separate sewage system(yps or no): yes separate inspection required) Laundry system inspected(ye or no);,, Seasonal use: (yes or no): r� Water meter readings, ifiav4labble(last 2 ;dears usage (gpd)): d!— ���Dn n�0�, �aIX &&9,L/ Sump pump(yes orno): ' ' ° � � Last date of occupancy: '^' COMMERCIAL/INDUSTRIAL/ Type of establishment: Design. flow(based on 310 CMR 15.203) gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of.occupancy/use: OTHER.(describe): GENERAL INFORMATION Pumping Records P g Source of information. t' .Was system pumped asp rt of the nsp_c ion(yes or no):_ If yes, volume pumped: gallons --How was quantity-Ifumped determined? Reason for pumping: TY OF SYSTEM Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,zttach 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 ofrthe DEP approval _Other(describe): A (r�ximate age of all components, d e installed(if known and source of information: t�l" Were.sewage.odors:detected when arriving at the site(yes or n)/11 6 Page 7 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(coftinued) Property Address:<</j/ ' / id Owner:�� Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC other(explain):. . Distance from private water supply well or.suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: -cate on site plan) Depth below trade:CQZLf Material of construction: !/concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliaice(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: 7, Distance from top of sludge to bottom of outlet tee or baffle: �s Scum thickness: d Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: — How were dimensions determined: K2&41 0 r ld&9.U,44M001 Comments(on pumping recommeXdation , inlet and outlet tee or baffle ca-�dition, structural integrity, liquid levels related to outlet yyinvert, evidence of leakage,etc.): KAn / We V t GREASE TR _(locate on site plan) Depth bel w grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page8ofll OFFICIAL INSPECTION FORM NOT FOR.YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: , Owner)zinzahn, ' /� 1 Date of Inspection: COO S p �r� TIGHT or HOLDING TANI ;tank must be pumped at time of inspection)(locate on..site plan) Depth below grade: �� '' Material of construction: concrete metal fiberglass_polyethylene o.ther(explain);. Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and floEt switches, etc.): I N BOX:Zof resent must.be o ened locate on site lahDISTRIBUT O p p )( plan) ) Depth of liquid level above outlet invert j �J Comments(note if box is level and distribution to outletscetlual, any evidence of solids carryover,.any evidence of I agave into or our of box, et .): PUMP CHAMBER-A (locate on site.plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition.of pump chamber, condition of pumps and appurtenances,etc.): 8 Pace 9 of l l ` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ale Owner: Date of Inspection: Glb SOIL ABSORPTION SYSTEM (SAS): /(locate on site plan,excavation not required) If SAS not located explain why: TYPe j eaching pits,number:_ leaching chambers,number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow,cesspool,number: innovative/alternative system' Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, CESSPOO� (cesspool must be pumped as part of inspection)(ocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool:' Materials of construction: Indication of.groundwater inflow(yes or no): Comments(note condition-of soil,signs of hydraulic failure, level of ponEding,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 ponying, condition of vegetation, etc.): 9 Paoe 10 of 11 OFFICIAL INSPECTION-FORM —NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /) ill j liax�,.e Owner Date of Inspection: 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 1,00 feet. Locate where public water supply enters the building. 1 1 1 t I ►u 10 is � - j Pace 11 of l l f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cmtinued) Property Address: Owner: Date of Inspection: ,d()O,j SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers (attach documentation) ✓ Accessed USGS database-explain: You must describe how you established the high ground water elevatioi: l 1 Permit Plumber: Date: Completed by: v HIGH GR;)UND-WATER LEVEL COMPUTATION i Site Location: el � Lot No. . i Owner. /Ct� G� 5/ Address: Contractor: /` f�JL� l�yj� Address: Notes: ✓�liY/. �Yl �/%�l - STEP 1 Measure depth to water table / l ' to nearest 1/10 IL. ............................................_..... Date _.Zl l�J`✓ �� month./day/year STEP 2 Using Water-Level Range ?one and Index Well Map locat_ site and determine: A Appropriate index we-I............................ C Water-level ranae zone. .......... ............................' STEP 3 Using monthly report "Current Water Resources Conditicns" determine current depth to / water level for index well ........................... �l[® 1 7��I month/year STEP 4 Using Table.of Water-leve Adjustments Lor index well (STEP 2A), current depth i to water level.for index vuell (STEP 3), and water-level zone (STEP 2B) determine water-14ve1 adjustment ............:. �f .............. STEP 5 Estimate'depth to high water by subtracting the water- level adjustment (STEP 4; from measured depth to -water level at site (STEP 1) ...... ....:............. t 7 Figur& 13.--Reproducible computation Torn. 15 i .......+�+a.�.T�,•,_.. .om:.... .al.,�,,".— _�.....__�w.._w.-.._. ......�.—..._........�,.....+o�'.� .....—�...�.�M.-.-.._......._tea..�:� -.......�:'.1��.:.......... ...... M!1!'tNj %"r..._....__........ / 77 i G/ TOWN OF BARNSTABLE LOCATION _lD �i;rl I4h/ SEWAGE # 3Z 8 VILLAGE-.___-6y7gr0y lam ASSESSOR'S MAP & LOT LrTSTALLER'S NAME&PHONE NO._rO S - y2d!97.3 8 Los 1 L/gojr o's SEPTIC TANK CAPACITY /000 -LEACHING FACELrrY: (type) _ (size) aO G NO,OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE 2-S D -O'L COMPL CE DATE: I 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 fa ility) Feet Furnished by ,. __ -_`: p�/< .. .,S �� �s ^V U; �� f� 0 N.. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migoar *pe;tem Construction Permit Application for a Permit to Construct(,air( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. > Owner's Name, Name,Address and Tel.� Assessor's Map/Parcel cao rli?rv1`��� ���v�h a� C 4d,/ 1173 -- ;W Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. gi 6,►.� 6L1, . l Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7'v�STIsG� / ox Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed -c Date Application Approved by Date Z Application Disapproved for the following reasons of Permit No. 2 Cj_�,2. '32 ——— Date Issued TOWN OF BARNSTABLE LOCATION 1D /'2//I ZA4 r SEWAGE # 1 X2- 312 8 VILLAGE ��� ,o ASSESSOR'S MAP& LOT193 -2 e7 LNSTALLER'S NAME&PHONE NO. -SD 8 — y20 SEPTIC TANK CAPACITY /DOO LEACHING FACILITY: (type) (size) /BO O -NO.OF BEDROOMS 3 BUILDER OR OWNER PERNIITDATE': :f-S D ^O 1. COMPL CE DATE: 7- 2• 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 fa ility) Feet Furnished by i I i �r �s c s t No. ., a , Fee JOi THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: j Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Zigpogar *p5tem Congtrurti.on Permit Application for a Permit to Construct( air( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /O P1;Aj 4ly,wzJ Owner's Name,Address and Tel.'10.� c rf,r vi%1i: �TLiorti ray Assessor's Map/Parcel , lq3 — 207 za l;:Fo Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: j Dwelling No.of Bedrooms ? Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date � Title t Size of Septic Tank 1 Type of S.A.S. Description of Soil l �f { Nature of Repairs or Alterations(Answer when applicable) 2"h 57011 l&EIel 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed -c Date Application Approved by ci . 1:1Date Application)hisapproved for the following reasons k Permit No. Date Issued C'S THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certiftcate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed(Gam-Repaired ( )Upgraded( ) Abandoned( )by .l.eS-c"04 �� it/•✓►U� at NN has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 1 ab Ll 2 . Installer Designer The issuance of this Vemut shall not be construed as a guarantee that the syste ti d igned. Date O 2 Inspector No. J C SLSG2 �J — .c / Fee i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi5po5al *pgtem ctCongtrurtton permit Y Permission is hereby granted to Construct( )Repair( )Upgrade( y)Abandon System located at m p/=N L yAm �rti 7-IV-V1l,/i and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pernit. Date: Approved by`�� A COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF RECEIVED DEPARTMENT OF ENVIRONMENTAL PROTEC ION ally 2 0 2002 Q,� - e TOWN Or BARNyl ABLE `7��`-�'" r HEALTH DEPT. S1 t0-1 4- TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 Pen Lane Centerville, MA Owner's Name: Thornton Cody Owner's Address: Same Date of Inspection: July 22, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 193 Mailing Address: P.O. Box 49 Parcel:207 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes ✓ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: July 25, 2002 The system inspector shall subm' copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 No:.. .?Ay... Fss..........................d . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH _ Town .......OF.......Barnstable -- -- -- ---------------------------------------•------------------•- Alip ira#ilan for Uhipvii al Work,5 Tomitrnrtiun ramit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal �,jf System at: Lot # 22 Pen Lane Centerville /� -----....... ---------------- •••••-rus--...------•--------------.---..._...... ..-. ---•.----------- Loc ion-Ad ress o Lot No. Suffolk Realty ' P.O. Box 30 Centerville - .. -•------'•--------------------•--••••-•'-•-- --•-............---------•---------•--.....----••-•----•--•-•---....................... �1 Kevin Hickey Owner Address Carriage Lane:...... arnstable a -•-•-- ..................... Installer Address 18 ,290 8 '290 d Type of Building Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms_.....three...................--.Expansion Attic ( ) Gazbage Grinder r(o ) per4 Other—Type of Building ..caP-e.............. No. of persons......2................... Showers ( 2) — Cafeteria (nq Other fixtures ............................... . . W Design Flow...........110.........................gallons per person per day. Total daily flow............AU...-_33Q...........gallons. WSeptic Tank—Liquid capacityl OQO_gallons Length 8._-6_'_..___ Width.......5...... Diameter................ Depth....5.4':..-. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--___--1.......... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box �c ) Dosing tank ( ) 9 Percolation Test Results Performed by.._--.---.-Ronald•Giffor----•------d ---------------------- Date'T6r25-78................ ,`4� Test Pit No. 1..........2---minutes per inch Depth of Test Pit-----144".... Depth to ground water------4--mix-.-. (T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.----_---_--_-_--_----. 1:4 •-••--••'•••--------....•---•--•--••-•-------••---•-••••----••••-•••--•-----•-•..................•'-'--'-----•-'-••-'-'•'--•-••---'-••..........•••.......... 0 Description of Soil....................................................0`a-3 0'°•--•-Loam- .&.._subsoil--••-•-- x 30"-54 Medium sand-•&-••light--gravel--.••-_-__.---. v .............................................. ........•'•-•'-••-'------'••.........---"'-.........•----...•... 54"-144" Medium find sand ------------------- ----•---.....-----------...------------------------------......---------------------------------...--•-••...----'----•.-----•--•--• ••'-----•-.. ...............•----'---'---_.... 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 ilTIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the oar iea t � ----. •-•------Signed _�.^ ' .................. `C Date 7F ApplicationApproved By.......... ,f.......................................................•---------------•-------- ............ ' �-"-------------- Date Application Disapproved for the following reasons------------------------------•------•----------------------------------------------------------------------"''- "---...••-------•--•-••--'-'-'•.....--•------•-••--•---••----•-••---•-•••••-•--••--'--••...-----•-•--•••----'--••••----'---'••--'---•••--------••••-----•••-•--•-•----------------------------------''- Date Permit No........ G/ Issued-........`.-�� 7 `1 Date . k THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town........................OF.....-Harnstabl e - ------------------------•---•-------..........------------------ Appliration for BbopwiFal Workii Tonitrurtion "amit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at`c -4 , Lot # 22 Pen Lane Centerville .......•....................•---•-•-•--.....................-------•---••---------•.....----•---- ..._..--•---••-•-••••---••---•----------...---••--•---------•-------------•------................. Lo ion-A dress Lot o. Suffolk Realty rust P.O. Box 308 ten erville -------------------•.._._.. - ......... ....-...-.....-.---------------------•------•-- ------------•--------•-•--•----------------------------------------------- ..------- Owner,; Address W Kevin Hickey Carriage Laney Barnstable a ••-•-•--•-------------•••--•••. ................._---......------ -------------- ------- Installer Address d Type of Building Size Lot...18.t 290 q . S feet aDwelling—No. of Bedrooms-------three......................Expansion Attic ( ) GZbage Grindertl(O ) p., Other—Type of Building .Cc1Pe............... No. of persons......2_................... Showers (2 ) — Cafeteria (no) a' Other fixtures .................................. W Design Flow..........110.........................gallons per person per day. Total daily flow............00....... . 0............gallons. WSeptic Tank—Liquid capacit3l-000._gallons Length$---E2....... Width------5 Diameter________________ Depth.... 4....... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-._-__1_...__..... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ) Dosing tank ( ) '-' Percolation Test Results Performed by.............................................................21a Gifford ............. Date.10-25--78................ aTest Pit No. I.........2....minutes per inch Depth of Test Pit....144....... Depth to ground water ___4___MiTX Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---•••••-•••----•-----------•------•••••-•••-•-•--•••••------••....................•---•••....----••........................................................ Description of Soil....................................................OA_-30........... OaRI-_&-_-subsoil.--____.. x 3011-541, Medium sand � light...gr'.avel ... 54 -144'. Medium find sand UNature 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 TIT p 5 of the State Sanitary Code— The undersigned further agrees-not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...l�.~< �. >1..-1 -------:�Y_------�._l _ �..�.•........... Application Approved By.......... .' !r iF Date Application Disapproved for the following reasons:------•----------------------------------------------------------------------------------------••-......--••--•. 5 Date - Permit No. 7. Issue3....... .....................................ate Date THE"COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....Town.........................OF......Barnstable........................-......... (9rrtifiratr of Tompfiaanr�e r r THIS IS TO CERTIFY, T niCthe Individual Sewage Disposal System constructed (X) or Repaired ( ) by... Kevin Hicke ....-•......................•----------•-------------------•--............................-•--•---•---....------•---...............----•---•----•-- Lot # 22 Pe ane Centerville,Inr 02632 has been installe in accordance with the provisions of TITI."; 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------1?,X!�...................... dated.--. .`_. .. ._-____-___.___-.-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. ....�! �Q.................. Inspector1-91 ....... . .............................................................. �r* THE COMMONWEALTH 91 MASSACHUSETTS as ""•"'tNRr$'�s P't*,� 1. BOARD OF LTH Town Barnstbie OF..................................................................................... fJG No.....2r��........ FEE.t...�`r...... Disposal or o Tonotrnrtuan rrmit Kevin ickey - A; Permission is hereby granted.............................................................................................................................................. to Construct X) or Repair ( ) an Individual Sewage Disposal System L�t # 22 PefiX Lane Centerville atNo. •... ... ... •••. •----•----- ... ---•-•-•------•--•-•---- --. Street 4 as shown on the application for Disposal Works Construction Permit No.__-7j.df. ------ Dated-- -�-'- �1�- ........... 9 # d Board of Health DATE......../�......;7— ' FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Pen Lane Centerville, MA Owner: Thornton Cody Date of Inspection: July 22, 2002 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: B. System Conditionally Passes: ✓ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ✓ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed ✓ distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Pen Lane Centerville, MA Owner: Thornton Cody Date of Inspection: July 22, 2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Pen Lane Centerville, MA Owner: Thornton Cody Date of Inspection: July 22, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Pen Lane Centerville, MA Owner: Thornton Cody Date of Inspection: July 22, 2002 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 f Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Pen Lane Centerville, MA Owner: Thornton Cody Date of Inspection: July 22, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 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)): 2001 -38,000 gals.; 1999-39,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:—Pumped on Nov. 22100 -per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Nov. 14178-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Pen Lane Centerville, 1M Owner: Thornton Cody Date of Inspection: July 22, 2002 BUILDING SEWER(locate on site plan) Depth below grade: 5' Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 4' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs ofleakage. Scum/sludge were minimal. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 f • 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 Pen Lane Centerville, MA Owner: Thornton Cody Date of Inspection: July 22, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: Gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 D-box was broken down structurally. The cement was deteriorated. The D-box needs replacement. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Pen Lane Centerville, MA Owner: Thornton Cody Date of Inspection: July 22, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'- 1000 gal. leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The pit had 4'ofwater on the bottom. The scum line was at the same level There were no signs offailure The bottom to grade was approximately 11'. The cover was approximately 2'6"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 w Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Pen Lane Centerville, MA Owner: Thornton Cody Date of Inspection: July 22, 2002 Map: 193 Parcel:207 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. � I aa- a� a A3' `�a•co Ay- 61y- Lice O y 10 Y Page 11 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Pen Lane Centerville, MA Owner: Thornton Cody Date of Inspection: July 22, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25'+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:_topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately]1. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and conditionally passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCA710Iv AL+ /YLP SEWAGE # VILLAGE ASSESSOR'S MAP & LOTJ !y',PE,r7Z*S NAME&PHONE Nj 7 71- SEPTTC TANK CAPACITY )QQQ t r LEACHING FACILITY: (type) - —(size) (.o' kl� NO.OF BEDROOMS BUILDER OR OWNER-d4AA)%, PERMTTDATE: COMPLIAN 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 1 I 0 ,r 0 TOWN OF BARNSTABLE LOCATION 10 �✓� �R/�2 SEWAGE # VILLAGE C^ "KVA ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. -SEPTIC TANK CAPACITY U� LEACHING FACILITY: (type) p (X (size) 1 UVO G� I NO. OF BEDROOMS 3 BUILDER OR OWNER 1FUrAo" CU PERMITDATE: 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 (1f any wetlands exist within 300 feet of leaching..�facihty) Feet Furnished by znsp�O 0- FUe, i ,.q Aa- Vo.(a Qa- aL '13- `�a•�° a 81- Aq- aq- Lid O y LOCATtO.N SEWAGE PERMIT NO. /L 6,' ,22 49/t/ 7 72 9 VILLAGE 62.�7j-�,t L L E I-NSTA LLER'S NAME i ADDRESS /<w/,,y /-/I BUILDER OR OWNER SurFdl-lc Rz,4LTi DATE PERMIT ISSUED DATE COMPLIANCE ISSUED s1 r -41U LOCATION SEWAGE PERMIT NO. ,C T 2 2 e-AWf- -7 g- 71 9 VILLAGE INSTA LLER'S NAME i ADDRESS �4Rl�I5ffi L 8i4,''?N B U It D E R OR OWNER CS-AITZ LKVat—LL— DA T E PERMIT ISSUED � '7 DAT E COMPLIANCE ISSUED I iS ��S G 0 7- Iz a,• � fit`;= pt ��. . r � L C? 7- 1 ' y f. 35 PE,e 7-0 kl'^J to E CO R D S TO b,,1A1 VQ TEJ �5 fq t/A /L f? r ,�j lAt.SX? 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