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HomeMy WebLinkAbout0056 PHEASANT WAY - Health 56 Pheasant Way. Fmrly: 59 Pheasant Way Centerville A=207 - 162 029 mew �aREC�CIFpCQ llll � Z UPC 12543 a No53LOR o��Oy1•CON`J�� HASTINGS, MN l \4 ✓� i a 3 s � � s 2 r COMMONWEALTH OF NLASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1\AP PARCEL 1.Ox CZ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: hwilet — Owner's Name: , Owner's Address: RECEIVED Date of Inspection: > _ MAY 14 2004 Name of Inspector: (please print) y �- O/ � Company Name: (�. TOWN OF BARNSTABLE Mailing Address: •U HEALTH DEPT. ,4 G � Telephone Number:;��)�Q: �`7 • �!-�'� . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true; accurate and complete as of the time of the inspection. The inspection was performed based an 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 eeds Further Evaluation by the Local Approving Authority F i]s A Inspector's Signature: � Date: 411Ay 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 DEB.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 Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Q p Owner:d Aec, 424 4 e&A/A '.;' Date of Inspection: Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. lSystem Passes: V 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]'] OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: , A Owner: Date ofinspection: 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 analvsis must be attached to this form. 3. Other: - _ t Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: O)L Owner: Date of Inspection: (� D. System Failure Criteria applicable to all systems: You must indicate"yes or"no"to each of the following for all inspections: Yes N _ 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 y 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 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times.pumpedv 111 J111 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.. f 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 drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone IL 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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address- —A Owner: Date of Inspection. Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _Lz-- Pumping,information was provided by the owner, occupant, or Board of Health f�V✓ere.any of the system components pumped out in the previous two weeks? _ Has the system received normal flows in the previous two week period? v/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) V _ Was the facility.or dwelling inspected for signs of sewage back up t_ Was the site inspected for signs of break out? V _ 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? VWas.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 Page 6 of 1 I OFFICIAL INSPECTION-FORM—NOT FOR. VOLUNTARY ASSESSMENTS SUBSU][tI+A.CE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: %V FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310.CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: 0 Does residence.have a garbage grinder(yes or.no): Is:laundry on a separate sewage system (yes or no); �(�lif yes separate inspection required) Laundry system inspected(yes or no):�v Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd)): -I// 000 0 -` %0 Sump pump(yes or no): ,,0��✓ Last date of occupancy: A" COMMERCIALANDUSTRIAL Type of establishment: v4QY Design flow(based on 310 CMR 15.203): gpd Basis of design-flow('seats/persons/sgft,etc.): Grease trap present(yes orpo):_ 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: Was system.pumped as part of the inspection( s or no): If yes, volume pumped: gallons--How was quaritity pumped determined? Reason'for pumping: TYP�R 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 copyof the DEP.approval _Other'(describe): App ox'mate age of all components, date installed(if known)and source of information Were s age odors detected when arriving at the site(yes or no)J� — 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: Owner: Ae Date of Inspection: BUILDING SEWER(locate on site plan)/)tO— 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: locate on site plan) —( P ) Depth below Grade: / Material of construction: '_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list aae:_ Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of certif cate) Dimensions: x ` X Sludge depth: Distance from top Pf sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Z- Distance from bottom of scum to bPations. outlet tee_or baffle: How were dimensions determined:Comments(on pumping recommen let and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of leakage,etc.) V i� +r i A/wO 0/ use. GREASE TRAP (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 Page 8 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT or HOLDING TANKK (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): y 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�«�on t Comments(note if bok is level and distributio"outlets equal, any evidence of solids carryover,any evidence of --leakage into or out of boy, .): ` -Ale Yaw PUMP CHAMBE!y 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 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: P4 c Owner: Date of Inspection: SOIL ABSORPTION SYS EM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type Ieaching pits,number:_ aching 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; �i CESSPOOLS%/ esspool 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 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.): 9 Page 10 of I 1 OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Ad/dress: Owner Y 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 100 feet. Locate where public water supply enters the building. 10 r Page I 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: v� A Owner Date of Inspection: 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: Necked with local excavators, installers-(attach documentation) Accessed USGS database=explain: You must describe how you established the high ground water elevation: V } 3- INER NMI , ; Permit Number: Date d'i * w1-2 5 i} � at; 4 � Completed � by: T/ h HIGH GROUND-WATER LEVEL COMPUTATION _. 4: •f " ks its Site Location:��/7//w� WIt V Lot No. HIS S Owner: Address: 'ANI5F Contractor: Address: — i� '� r :Notes: x� STEP 1 Measure depth to water table to nearest 1/1oft. ................................. . ... .Date 1/ month/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: Appropriate index well.................................................... B Water-level range zone ......................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to Q �y water level for index well ........................... 6(� month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) F4 determine water-level adjustment ...................................................:...................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) ( from measured depth to water levelat site (STEP 1) ............................................................................................................. ` Figure 13.--Reproducible computation form. 15 l Town of Barnstable o� BARNSPABLE, - Board of Health i : A�0 P.O. Box 534� an Hynis MA 02601 rED MA'S Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Wayne Miller,M.D. Sumner Kaufman M.S.P.H. November 21, 2003 Mr. Stetson Hall 28 Rambler Road Osterville, MA 02655 RE: 59 Pheasant Way, Centerville A= 207-162 Dear Mr. Hall: You are granted variances on behalf of your client, Helen Weinman, to construct a replacement onsite sewage disposal system at 59 Pheasant Way, Centerville, Massachusetts. The local Board of Health variances granted are as follows: PART Vill, SECTION 1.00: To construct a soil absorption system 81 feet away from the edge of a wetland, in lieu of the required minimum setback distance of one-hundred (100) feet. PART VIII, SECTION 1.00: To install a septic tank 64 feet away from the edge of a wetland, in lieu of the required minimum setback distance of one-hundred (100) feet. PART VIII, SECTION 1.00: To design a future reserve area 77 feet away from the edge of a wetland, in lieu of the required minimum setback distance of one-hundred (100) feet. The variances are granted with the following conditions: (1) No more than four (4) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to four (4) bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (3) The registered sanitarian shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the engineered plans dated October 3, 2003. HallWeinman These variances are ranted because thephysical g constraints restrict the location of a proposed replacement septic system due to the close proximity of the two wetlands in the area. Sincerely yours, Wayne Miller, M.D., Chairman Board of Health HallWeinman IV. Grease Trap Variance Request— New Food Establishment: Granted Patricia Mitrokostas, Nibbles and Sips, Unit A, 211 Route 149 Marstons Mills- With Multiple pre-packaged take home entrees, cookies, bagels, buns, and breads are Conditions proposed to be heated, an under-the-sink grease interceptor is proposed. (1) No cooking or grilling of food will be allowed. Only store-bought"pre-made" cookies, bagels, buns, and bread may be heated. (2) Only disposable single service paper, plastic, and other disposable dishes and utensils are authorized. (3)An under-the-sink grease interceptor shall be installed in accordance with the State Plumbing Code. (4)The under- the-sink grease interceptor shall be cleaned monthly. (5)This variance decision letter shall be posted on the wall adjacent to the food service permit for future viewing of health inspectors during inspections. (6) In the event that this business is sold or transferred, both the current licensee and the owner have the duty to inform any and all potential purchasers of the existence of these variances and the fact the Board has explicitly made them non-transferable. (7) This variance may be revoked anytime unsanitary conditions are observed. V. New Variance Requests- Septic System Setbacks: Granted A. John Churchill, Jr., P.E. representing Justine Rioux and Anne Somerset, 72 Glen With Road, Hyannisport-Three variances requested regarding setbacks to property line Conditions and retaining wall, proposed repair of a failed system. (1)The engineered plans shall be revised to show a land surveyor stamped plan and shall be submitted to the Public Health Division Office prior to obtaining a disposal works construction permit. (2) No more than three bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (3) The applicant shall record a properly worded deed restriction,signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to three bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (4) The land surveyor shall stake the soil absorption location prior to the installation of the soil absorption system. (5) The professional engineer shall supervise the construction of, the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the engineered plans. Granted B. Stetson Hall representing Helen Weinman- 59 Pheasant Way, Centerville, three With variances requested regarding setback to wetland, house addition and renovation. Conditions (1) No more than four bedrooms maximum are authorized at this property. Dens,study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2)The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to four bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (3)The registered sanitarian shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial 0mpliance with the engineered plans dated October 3, 2003. VI. Multiple Bedrooms: Approved A. Craig Condinho- Mill Pond Crossing, 164 Route 149 Marstons Mills, 4,800 square feet of office space plus 5-2 bedroom units proposed on 35,382 square feet of land. FEB 2 6 1997 BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 0264 TGNHOF�® eL� 508-771-9399 508428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO ' �` ` PART A CERTIFICATION Property Address: Date of Inspection: 1 9 Inspector's ame: Owne ' N e and Ad ress: CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Passes Needs Further Ev tion By he Local Aproving Authority Fails Inspector's Signature: Date:__ The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY- A)SYS PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM-R 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If i not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 - T 1 VIA- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four 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 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 the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 WELL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVHtONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year N-01 due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if tJie following have been done: _� ping information was requested of the owner,occupant,and Board of Health. one of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been troduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. `The facility or dwelling was inspected for signs of sewage back-up. _Lz'Fhe system does not receive non-sanitary or industrial waste flow. _LLfhe site was inspected for signs of breakout. _I�AII system components,excluding the Soil Absorption System, have been located on site. ✓T a septic tank manholes were uncovered,opened,and the interior.of the septic tank was in- spected for condition of baffles or tees,material of construction, dimensions,depth of liquid, ,depth of sludge,depth of scum. he size and location of the Soil Absorption System on the site has been determined based on ,existing information or approximated by non-intrusive methods. -3 .,r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C _ SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL* Design Flow: lions Number of Bedrooms:-3— Numbcr of Current Residents. Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readings,if availa�: Last Date of Occupancy: COM_M .R AL./INDUST 1AL.: Type of Establishment: Design Flow: aallons/day Grease Trap Present: (yes or no)__ Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of infonnati n: a System Pumped as part of inspection:_ If yes, olume pumped: hallons Reason for pumping: TYPE 9F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): APPRO TE AGE o all components,da i tailed(if known)and source of information: SewaKodors detected w e arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: r� Depth below grade: Material of Construction: ►/ concrete metal FRP Other (explain) — Dimisions: Sludge Depth: '` Scum Thickness:_ ` Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees�or b ep,depth of liquid level in relation utlet in ert,s ctu ri 1 mte ,evidence of leakage, etc-Z22 / GREASE TRAP: l Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:—concrete—metal—FRP—Other(explain) Dimensions: Capacity: Gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if nd dis 'bu 'on is qual,evi e f solids carryover evidence of leakage into or ou of box,a .) , CL PUMP CRAMBER:_ Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) 5- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Wi ,�Leaching umber: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Co ents: (note condition of soil,signs of hyd ulic f i ure level of pon mg,condition of vegetation, etc.) 36" A-0AC O.T6Q CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: (� Materials of construction: Dimensions: Depth of Solids: Comments; (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) S1 XTCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. c�Q CC 731.bS._v� 3qi $' DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method opetermination or ppro 'mation: ��� �l`/f��'�! 1,16-5 J4 -7- TOWN F BARNSTABLE LOCATION SEWAGE # — " 97 VILLk.GE ASSESSOR'S MAP:� LO ZOP NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER ORiOWNj� PERMTTDATE: 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 �� ® 40 A,�V,r UOR'S MAP NO. PARCEL LCATION SEWAGE PERMIT NO. ,,,,e 0 Lo a � - 5' VILLAGE ��.� � ►( � may. e I N S T A LLER'S NAME i ADDRESS S U I L D E R OR OWNER F� DATE PERMIT ISSUED �J/&5z' DATE COMPLIANCE ISSUED EI � ?ecx� a� v t A. .............. . Fxs.... ..®.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ©ut1 .. oF.......... 5' a..................... Appliratiun for Diupuual Workii Towitrnr#iun Prrinit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst • �lt4t Via...-------•................ Lo Address or Lot No. . .................................................. ner A. Address................................ Installer Address Type of Building Size Lot... -0-AA 1------Sq. feet �-, Dwelling—No. of Bedrooms.......3.................................Expansion Attic 00) Garbage Grinder aOther—Type of Building .........................�.. No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------•------------.....------------------------------------------------.....-•--••-------------•------.........--.. W Design Flow.........15 .........................gallons per person per day. Total daily flow----- ..........................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (V� Dosing tank ( ) a Percolation Test Results Performed by. .. . _ 1��(.�..13!�1�...................... Date... �........... Test Pit No. 1....4_Z.....minutes per inch Depth of Test Pit----- Depth to ground water____._.__.-....------- 44 Test Pit No. 2...G2.....minutes per inch Depth of Test Pit...... Depth to ground water...'7._.-�...._... .......................... --- ---- ---- O Description of Soil ?4 ---...... � ...� ! 1n�Me�6(� cx., w U Nature of Repairs or Altera ' — wer when applicable............................................................................................ -- . ...-----••----•---..-•.............................................................................................................................................................................L.._. Agreement: t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 5 of the State Sanitary Code—The undersigned further agrees not to place the systerp in a r tion nt' er fi to of Compliance be ue o rd of health. Signedc. `Sa _...'Za ' CDaffy Application Approv d By--•• . -•---•-. ...... ....._.. =. .-. ?..`"-? Date Application Disapproved for t e following reasons---------------••---------------------------------------•-----------............................................ ..................•-••--•............---...-••-••-••-••------......-•--------•--••-------.......•-------•-•-----------------------••-------•-------------------•------••----------------•--•-----•.----- Date c�- Permit No.......•�---e`er--•��--�------------------------ Issued_............... `-6---r e-5---•---•--- Date j 7 No...... `�_�. '--� Fes$...? ..v�.... THE COMMONWEALTH OF MASSACHUSETTS �....� BOARD OF HEALTH 4.0ratiou lof Uhipmal Works Tuustrurtiuu lieruti# Application is hereby made for a Permit to Construct ( K) or Repair ( } an Individual Sewage Disposal SystgnA: d"r+ess �VC�_ k4c � or Lot No d .............................................. " Owner Address a .................... ......................... .. ......... ......... ..:...:......... ~ Installer Address tt UType of Building Size Lot_`0.-140-1.......Sq. feet I—I Dwelling—No. of Bedrooms......��,.?'.----------------------------------Expansion Attic �16) Garbage Grinder a Other-T e of Building a YP ------------•----------�-•• No. of persons____________________________ Showers ( ) — Cafeteria ( ) Other fixtures -----••-----•. ; W Design Flow...._....5.15 ......----:.•-•--.-•---_.gallons per person per day. Total<daily�how----3 ---------------------------gallons. WSeptic Tank—Liquid'capacity.....__.....gallons, Length................ Width................ Diameter................ Depth................ x Trench—No: .:::._ Width_:_:................ Total Length__.._._...._.___._._ Total leaching area.._..__.....____.._sq. ft. Disposal; Seepage Pit No-------------------- p inlet.................... Total leaching area..................sq. ft. _ Diameter......:...... ._ Depth below inl Other z Percola ionr1Test Results ) Performed bsin tank Y ` Date...12`_12-g A---•-------- - Test Pit No. 1---._:......minutes per inch Depth of Test Pit----- Depth to ground water...__:'?K'_._............ 44 Test Pit No. 2.... _.....niihutes per inch Depth of Test Pit----- '_." Depth to ground water..�__................ a -v O Description ofSoil --�"' � '-� _ -@ C'st-` �r 4.� j,E1, Q Y�k��r a ni i , ..._.... "� r� ... �"�,k1 tom= e ' ----- _ - - V Nature of Repairs or Altera swer when applicable............................................................................................... a ••• ----•------.._..•--- Agreement: The undersigned agrees to install the aforedescribed Individual'.Sewage Disposal System in acco,.rdance with the provisions of TITLE 5'of the State Sanitar Code—The undersigned further agrees not to place,the system,in o do un ' a Cer ` to of Compliance be sue .& rd of hea 1 t- Si ne ..... ....._--•+ ---- � �E Z S �,��- ....__ Application Appro d By. `3...f -pig 170 �^,. Date-------------• 1 Application Disapproved for tl�e following reasons: ----•---•---•-•-•--•--------------•-.....••--••--"--•••------------•--•-.---•---•..I...........-------- � .....................__..._____..___._.___---•-_______---__-••-______----__--____....._____..._..___....._.......... _jD ' ~ " -at e Permit N IssuL 6o....-•- ------------------ --•-. --^^-•--- Date THE COMMONWEALTH"OF4MASSACHUSETTS OARD OF EALTH (9rdifiratr of Tompliattrit THIS IS TO CERTIFY, T the Individual ag Dispos System constructed ) or Repaired ( } - atSdGf..1_. �1 t-- U��'1=•i••` •.. 1. l --ller----•-----------•-----••--••-•------....-•-••---------•---•-•--•.....................•-•----•- has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.1�_7;45................... dated_-_''�_._`�6 "19.�..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE ACTORY. -_ . .. . --•...... DATEIooI WILL FU CTIO --SATISF.---•-------•-------=---- - Inspector......................-............................................................. tf THE COMMONWEALTH OF MASSACHUSETTS _ OARD OF ALTH ......................OF.. ..................No... S:).' � FEE. - .... Disvol d u kil 1911tt ivit Vprrmit Permission is hereby granted......... ......... ........... ----•••••------•------•-.......----•••••..................••.............•-----. to Construct ( ) or� pair ')j an Indi 'dual Sewa Disposalystem at No. 1•• `�1-----•-•-- Stree as shown on the a lication for Disposal Works Construction Permit s '"-� � ..........7 9 PP P Dated ----------- ............................. 3,.� �► =` ...-------•---•--••---••._...._....-•-- �g L ,.. - Board of Health DATE= •-----{{.................................................................... ; FORM 7�Z' 5 A. M. SULKIN,.INC., BOSTON - � I i v _ u yyl 4 : • , k �. v ,n x' .. a •,mi '^ a . t. 1 0 a� '_ `.� construct r. 61 or # 63 Pheas a The COMM. Fire Departmenttinspected the new nstructed1in entaredyain#this area and ethE the (COMM.) q Way Centerville. Because �' this simple. The permit (I belie - abutters are using an altncejsllhtrygtoakeepveway Basemen � the address changes for 3-4 properties a.k.a. # 61 Pheasant Way. During construction, a k.; ' was issued for his Map 227de Parcel 143,and the land was combined with Map 227 Parcel 142, owner had t P parcel, they b All the land with the old house anduarese aon one re now all on Map 227 63 Pheasant Way when two or more buildings e .a Parcel 142 . Under the ordinance, p The others that mes for new unitized. The new addresses for theseallo #o63)onrMa# 227 Parcel e142. house (formally 61) and # 50B for the old house (formally changed are as follows: DEV LOT OLD House# NEW House# Road Name ° MAp/PARCEL Pheasant Way, Centerville 55_ 58 ., •,:, 207/161 28L 59 56 7 29 20 /162 < t t m 6 r. r a s a y �b a r w a _ : k i. a r , r t , 1, f —5>R $ _, -.. ., .. - . .. - •, •� b ' Op �q �o r.0 --- - io - •--;�X,C�"T.�, "Q fir' �j� ,/ �oz''�' �s� / P[7,_R 4 N0, 9733 sa. .. .\/ Al 119 �� ',o•� ,pow / ,��, � %�� `� �� ,, ,,�' � ��� \ I N i Z-o r3Z4�:, s X / a = 3Zo G.I-._ f Tdra L T �/G�/ ,S"ar.' G!zt.%F�- e ;.. � °� � _ i .,ram f:. �/: .r �v� ✓.c:" //C/✓, Aelcl E 1°- 2.0 Vw 13� 'f G_77 411 .B,4�l�ST.�'>f .4�1//✓- /,s ic"`��--����,-:9;��'r� .f,�-X''c,�'�,�J�=�►mil Ret,K �� ►9g� � � r 1