HomeMy WebLinkAbout0228 PHINNEY'S LANE - Health (2) 228 PHINNEY'S LANE, CENTERVILLE _
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Commonwealth Of Massachusetts
Executive Office Of Environmental Affairs
Department Of Environmental Protection
TITLE 5
Official Inspection Form -Not For Voluntary Assessments
Subsurface Sewage Disposal System Form
Part A
Certification Q
Property Address:228 Phinney's Lane Centerville Ma.02632 �/�/
Owners Name:John&Anne Erikson
Owners Address:228 Phinney's Lane Centerville Ma.02632
Date of Inspection: 11/12/2005
Name of Inspector(please print)Sean M.Jones
Company Name: S.M.Jones Title V Septic Inspectors
Mailing Address:74 Beldan Ln.
Centerville Ma.02632
Telephone Number: 508-778-4597 ,
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the i rmation¢ orte-
below is true,accurate and complete as of the time of the inspection.The inspection was perforQbased on 2ny .
training and experience in the proper function and maintenance of on site sewage disposal syste I am a%�P >
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The sys�
-20
c„
X Passes o
r*c
Conditionally Passes j
Needs further evaluation by the Local Approving Authority
ils
Inspectors Signature Date: 11 d d
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
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.
Page 1
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(cowmum)
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner:John&Anne Erikson
Date of Inspection: 11/12/2005
Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
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 the 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 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION CoNTMED
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner:John&Anne Erikson
Date of Inspection: 11/12/2005
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 310CMR 15.303(1)(b)that the
System functioning in a manner that protects the public health,safety and the environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
Surface water supplyor 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 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner:John&Anne Erikson
Date of Inspection: 11/12/2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
T _X_ Any portion of cesspool or privy is within Zone l of a public well.
_X_ Any portion of cesspool or privy is within 50 feet of a private water supply well.
X_ Any portion of 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 pp,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
X_ (Yes/No)The system fails.I have determined that one or more of the above 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:N/A
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:
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 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
CM15.304.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner:John&Anne Erikson
Date of Inspection: 11/12/2005
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X _ Pumping information was provided by the owner,occupant,or Board of Health
X_ Were any of system components pumped out in the previous two weeks?
X_ _ Has the system received normal flows in the previous two week period?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
I
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
X_ Was the site ins p ected for signs of break out?
X _ Were all system components,excluding SAS,located on site?
_X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_X — Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
X_ _ Existing information.For example,a plan at the Board of Health. --AS-BUILT
X_ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of
distance
Is unacceptable)[310 CMR 15.302(3)(b))
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner:John&Anne Erikson
Date of Inspection: 11/12/2005
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 report required]
Laundry system inspected(yes or no):—
N/A-Seasonal use:(yes or no)NO_
Water meter readings,if available(last 2 years usage(gpd): 2003=219gpd,2004=430gpd firtst 6 months
2005=233apd
Sump pump(yes or no): NO_
Last date of occupancy/use:_CURRENT
COMMERCIAL/INDUSTRIAL N/A
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:
Was system pumped as part of the inspection(yes or no):—NO—
If yes,volume pumped: gallons--How was this quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X 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 the 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: 1998,As-built,install
ep rmit
Were sewerage odors detected when arriving at the site(yes or no): NO_
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner: John&Anne Erikson
Date of Inspection: 11/12/2005
BUILDING SEWER(locate on site plan)
Depth below grade:_2`
Materials of construction: cast iron_X_40 PVC other(explain):
Distance from private water supply well or suction line:_N/A
Comments(on condition of joints,venting,evidence of leakage,etc.):
No sites of leakage,joints appeared to be good.
SEPTIC TANK: X_(locate on site plan)
Depth below grade:_1`_
Material of construction:_X_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: 1500 GALLONS
Sludge depth:_10"
Distance from top of sludge to bottom of outlet tee or baffle:_3`
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle:_4"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: Opened covers,took measurements
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
Inlet and Outlet were intact and in good condition,tank was structurally sound liquid levels were at the correct
levels,no signs of leakage.
GREASE TRAP: N/A—(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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner: John&Anne Erikson
Date of Inspection: 11/12/2005
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grader
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: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
Leakage into or out of box,etc.):
D-Box was in good shape level and with only one outlet,flow was even No solids carryover,box was not
leaking-Cover down 2 feet.
PUMP CHAMBER: N/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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner:John&Anne Erikson
Date of Inspection: 11/12/2005
SOIL ABSORPTION SYSTEM(SAS)_X (locate on site plan,excavation not required)
If SAS not located explain why:.
Type
Leaching pits.Number:
_X_Leaching chambers,number: 4 High Capacity Infiltrators
Leaching galleries,number:
Leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternitave system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Soil surrounding S.A.S.was not saturated,no sign of hydraulic failure vegetation was normal not overgrown.
CESSPOOLS: N/A (cesspools 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: N/A_(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.):
.OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner:John&Anne Erikson
Date of Inspection: 11/12/2005
SITE EXAM
Slope X
Surface water
Check cellar X
Shallow wells
Estimated depth to ground water 5'+
Please indicate-(check)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)
_X_Checked with local Board of Health-explain: Accessed TOB GIS
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by:
1) Accessing Town Of Barnstable Groundwater Map
2)Hand augering to approx.5 feet below S.A.S.with no groundwater encountered.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:228 Phinney's Lane Centerville Ma.02632
Owner:John&Anne Erikson
Date of Inspection: 11/12/2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or
Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building
Side
Phinney's
Ln.
A
B
1
TANK D-BOX SAS
A-1=25' A-2=41'6" A-3=49
B-1=17' 9-2=40' B-3=47
❑2
3
TOWN OF BARNSTABLE
LOCATION SEWAGE # .--T&
VII L'AGE' ���►�; �criXi�,"` ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC.TAh1K;CAPACITY
LEACHING FACII.TI'Y::(type) - (size)
NO. OF.BEDROOMS.. ,
BUILDER OR.:OWNER
PERMIT DATE: a `?�&d COMPLIANCE:DATE: -�
Separation Distance Between-the:
Maximum Adjusted Groundwater Tabie to the Bottom of Leaching Facility Feet
''Private Water Supply Well and Leaching Facility (Tany,wells eust ',':
on site or within 1061eet of leaching facility) Feet
Edge of Wetland and Leaching.Facility(If any wetlands exist
within 300 feet of leaching faciliy) .. Feet
Furnished by
TIP e
10
No. < r— Fee
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for Migoga[ *p5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade('Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.OaoT ,v-XA_S U, Owner's Name,Address and Tel.No.
C.avP";{ cJ
Assessor's Map/Parcel _Ool�_ ✓� V�►w
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Pm o-c"pv
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 cSA�'1 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank I M (a- s << Type of S.A.S. C., G��
Description of Soil Slut
Nature of Repairs or Alterations(Answer when applicable) 2 yvIM6AL NSdQ
d`f �v— l—l-V c.. C_n d G7
�'✓11�hP_.S -�-�'c.l u ulnae., ,._,-��
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 EnyAironmental Co a and not to place the system in operation until a Certifi-
cate of Compliance has his Bo
Signed _ Date 3d �
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. r "7 d1 Fee
�
r ; , THE COMMONWEALTH F MASSACHUSETTS Entered in computer:
Yes
;PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
1 �`
PiXtiation for Migogar *pgtem Conaruction Permit
Application for a Permit,to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System E1.1ndividual Components
Location Address or Lot No. �$
c� �w�.s ��� Owner's Name,Address and Tel.No.
�CI� esrv�� 0
Assessor's Map/Parcel ^� _ of r d V C�x(Aj
Installer's Name,Address,and Tel.No. p Designer's Name,Address and Tel.No.
-Ske vs,�__y `
Type of Building:
' Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
c Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow _3`1 I_ gallons.
Plan;;Date .Number of sheets Revision Date
Title
-'Size of Septic Tank er "ram p r,, Type of S.A.S. t .� C C. i "i _.
Description of Soil
Nature of Repairs or Alterations(Answer'when applicable) �RV�-5� �� ��08 S p��C"'�C,KL�•�f(_ ��
C-3-- 6c-e- ' vY- F�yc,4. Ccc �,L. t- Lc. ` `/.G S
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'.,of the En ' onmental Co e and not to place the system in operation until a Certifi-
cate of Compliance has hem-is•sne is Boar Realt �^
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. FT-L1d6 Date Issued 7- u ~.'.
THE COMMONWEALTH OF MASSACHUSETTS �
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded(X)
Abandoned( )by M l- Pt P l-,S I (—,- .
at CAN, n / � g 5- "-INN 0 has been constructed in accord ce
with the provisions of Title 5 and the for Disposal System-Construction Permit No. �'6 dated ,5,-,/L 9
Installer Designer
The issuance of thispe t t s> 11 not be construed as a guarantee that the system ' 1 fu'•ction as designed.
Date 8 Inspector
W ^No. / (/�j ---------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mtgpool *pgtem CongtrUctton Vermtt
Permission is hereby granted to Construct( )Repair eJpgrade( )Abandon( )
System located atp-f �} • - r��,1 ��{
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 p tt.
Date: �J Approved by
l0/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
i
i
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
SAS , hereby certify that the application for disposal works
construction permit signed by me dated �„—3b-` , concerning the
property located at C et,--r- meets all of the
following criteria:
There are no wetlands located within l00 feet of the proposed leaching facility
r/• There are no private wells within 150 feet of the proposed septic system
X'There is no increase in flow and/or change in use proposed
•There are no variances requested or needed.
�/ If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater tab!e elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map) 3cx�
SIGNED : A DATE: lO"3d
LICENSED SEPTI SYSTEM.INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
0
v .
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i
S/D �
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I
3
y
TOWN OF BARNSTABLEJv
LOCATION SEWAGE # 19 V06
VILLAGE' �"��,�,s ,t ASSESSOR'S MAP & LOT -
0,6
INSTALLER'S NAME&PHONE NO. - .—, F, ' ^
SEPTIC TANK:CAPACITY 15-6 0 . UU
LEACHING FACIL=.::.('type) - (size)
NO. OF BEDROOMS
BUILDER OR OWNER 5� 4 x
PERMITDATE: ..y c� �` COMPLIANCE DATE: ,7—
Separation Distance Retweertthe:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water SupplyWell and Leaching Facility (If any wells exist '
on site or within BOO feet of leaching facility".) Feet
Edge of Wetland and Leaching:Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
FIMAY
IVE:®
Commonweafth of Massachusetts 9 1997
Executive Office of Environmental Affairs ,Cr7T.
Department of AN�i j',A'
Environmental Protection
WNOam F.Weld Trudy Coxe
Gowernor BsraMsry
Argeo Paul CNluocl David B.Struhs
LL do rwr CotnntlsMonsr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERTIFICATION
ProperiyAddeesm 228 Phinneys Ln, Centerville, MA AddeessofOwner. Leeanne Sullivan
Date of Inspection: _ Ci -*7 (If different)
Name of Inspector. V.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8)7 7 5—8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I out*that I have personally inspected the sewage disposal system at this address and that the information reported below is true,acmrste
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
ied&Further Evaluation By the Local Approving Authority
ails /�
Inspector's Signature: Date: 4
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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#hall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The origipal should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
PECTION SUMMARY:
C A,B,C,orD:
A] PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] TEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Iadica yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked structurally unsound, shows substantial infiltration or ezfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
( evised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02106 a FAX(61?)swio4g a TeNpha»(617)262-wo
%.
ice,Printed on Recytkd Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddrem 228 Phinneys Ln, Centerville, MA
Owner. Leeanne Sullivan
Date of Inspection: tl (,—Q-f
B]SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pips(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are 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 pips(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
editions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
lic health,safety and the environment.
1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
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.
9) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
AFETY AND THE ENVIRONMENT:
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 within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system end 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm.
9) O ER
(revised 11/03/95) 2
• i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 228 Phinneys Ln, Centerville, MA
owner. Leeanne Sullivan
Date of Inspection:
DJ �� 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 am. the
failure. _
_ Backup of sewage into facility or system component due to an 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the 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.
El GE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
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 Zons U of a public
water supply well)
The owns or operator of any such system shall bring the system and facility into Hill compliance with the groundwater treatment program
requireme is of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for fiuther information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
pnpwr&yAddnww 228 Phinneys Ln, Centerville, MA
owner. Le a n Sullivan
Dale of hopmUom �/—
Check if the following have been done:
✓Polumping information was requested of the owner,occupant,and Board of Health.
_v one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates .
during that period. Large volumes of water have not been introduced 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.
,✓LThe facility or dwelling was inspected for signs of sewage back-up.
/The system does not receive non-sanitary or industrial waste flow
✓The site was inspected for signs of breakout.
✓All system components,excluding the Soil Absorption System,have been located on the site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of ba8les or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The site and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
propertyAdarem 228 Phinneys Ln, Centerville, MA
owner. Leeanne Sullivan
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Desiv d w.12 llonsi
Number of bedrooms: --y3
Number of current rssidents�
Garbage grinder(yes or no): O -
Iiundry connected to system(,yes or no): J'�s
Sessional use(yes or no)' A o T 1995 - 412 , 000 gals
Water meter readings,if available:
494, 000 Gals
Lest of oocupam:
O ERCIAL NDUSTRIAU
Type establishment:
Des' flmv: pllonWday
G trap present: (yes or no)_
Waste Holding Tank present: (yes or no)_
No -sanitary waste discharged to the Title 5 system: (yes or no)_
W r meter readings,if available: --
Last to of occupancy:
•(Describe)
of occupancy:
GENERAL INFORMATION
PUMPING RECORDS an source of information:
System as part of inspection: (yes or no)�t s
If yes,volume Pumped: l� aallona
Reason for pumping
TYPE OF SYSTEM
-- optic tanWdistribution ba dsoil absorption system
� sine cesspool
OverIIow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)/I- �
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
propertyAddreaa 228 Phinneys Ln, Centerville, MA
Owner. Leeanne Sullivan
Date of Inspection:
S q TANK_
an site plan)
Depth w grade:
Of construction:_concrete_metal_F1tP_other(e:plain) i--
s depth.-
from
top of sludge to bottom of outlet tee or bade:
scum
Distance from top of scum to top of outlet tee or battle:
Distance bottom of scum to bottom of outlet tee or bafn
Comment
(r000mme uktion for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence if leakage,etc.)
GREAS TRAP._
(locate on site plea)
krmo
ade:
struction:_concrete_metal_FRP—other(explain)
op of scum to top of outlet tee or bade:
ottom of acum to bottom of outlet tee or battle:
on for pumping,condition of islet and outlet tees or battles,depth of liquid level in relation to outlet invert,str udueal inter,
kage,etc.)
(revised 11/03/95) 6
a �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
pmpertyAddress: 228 Phinneys Ln, Centerville, MA
owner. Leeanne Sullivan
Date of Inapection: 41—/ .
GHT OR HOLDING TAN _
( on K:
site plan)
below grade:
of oonsunction:concrete_metal_W_,othm(e:plain) '
Ca ty: aalions
now: ¢allons/day
level.-
Co
nte:
( 'tion of inlet tee,condition of alarm and float switches,etc.)
DIS BUTTON BOX:_
(locate n site plan)
Depth of liquid level above outlet invert:
nts:
( if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of boat,oft
PUM P CHAMBER_
(loca on site plan)
Pum in working order(yes or no)
b:
(note ndition of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
q �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
property Add, ,= 228 Phinneys Ln, Centerville, MA
Owner. Leeanne Sullivan
Date of Inspection: G/-/L -9 r?
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan,if possible:excavation not required,but may be approximated by non-intrueive methods)
If not determined to be present,explain:
Type:
lewb*ng per,number:_
leaching chambers,number:_
3saching palieries,number:
lesrhing trencher,number,length:
leaching fields,number,dimensions:
overflow oesspool,number: /
Comments:(emote condition ofj9il,si4w of hydglulie ure, level of ponding,condition of vegetation,etc.)
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: rb
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool: -�
Materials of construction: /d C � S
Indication of groundwater: /L o
Inflow(cesspool must be pumped as part of inspection) t=S
a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
i
elf
( on site plan)
of construction: Dimensions.
De of solids•
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddreu: 228 Phinneys Ln, Centerville, MA
Owner. Leea ne Sullivan
Date of Inspection: `r/ —01 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmark
locate aU well within 100'
DIiPTH TO GROUNDWATER
Depth to potmdwater:_LL=L�aet 1 l
method of determination or approximation: 6 W
(revised 11/03/95) 9
PAR Real Estate System General Property Inquiry Help
Parcel Id: 229 096- - Account Nog 141741 Parent:
Location: 228 PHINNEYS LANE CENT
Neighborhood: 42AC Fire Dist: CO
Devel Lot: Lot Size: . 62 Acres
Current Own: SULLIVAN, LEE ANNE TRUSTEE State Class: 101.
LADYBUG REALTY TRUST
No. Bldgs: I Area: 1920
88 NORTH ST Year Added:
HYANNIS MA 2601
Deed Date: 110193 Reference: C132025
January 1st: SULLIVAN, LEE ANNE TRUSTEE Deed MMDD: 1193 Deed Ref: C132025
Comments."
Values: Land: 321004
qXNNEY-S LANE Frntg: 190
Indexg 522 (FALMOUTH ROAD (ROUTE 28) Frntg: 255
Control Info: Last Auto Upd9 091496 Status: C Last TACS Update: 091196
Land Reviewed By: Date: 0000 Bldgs Reviewed By: Date: 0000
Tax Title: Account: Taken: Account Status: Hold Status:
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Pariel Number 229 097