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0816 PHINNEY'S LANE - Health (2)
616 Phinney's Lane Centerville P A - 251 106 i 2543 tr • I . a MT V OF 6ARij'SrABLF 0 Pj, 1: 9 12 28 05 �.... �:.. DATE / / PROPERTY ADDRESS 816 Phinneys Lane Centerville MA 02632 On the above date, the septic system at the address above was Inspected. J This system consists of the following: _- 1.1 1-1500 gaiion ze/21-ic tank., 2., 1- Diz; zigution Box., 3., 2- 500 gaiion ieacf iag cham9e zz Based on inspection, I certify the following conditions: 4" Thiz .ia a T-iUe Pave 3epZ .ic zyztem., 5.- Septic zy,3tem i,3 inp/zopea woizking o zde/z at the /2zezent time.. SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc Address: P. O. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 JOSEPH P. MACOMBER & SON,. INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 • r , COMMONWEALTH OF MASSACHUSETTS _. EXECUTIVE OFFICE'OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL IN SPECTION FORM-.NO T FOR VOLUNTARY ASSE SSMENTS SUBSURFA CE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address 816 Phinne s Lane Centerville MA 02632 Owner's Name: Richard Peckham Owner's Address: 9A Pine Ave Hyannis MA 62601 Date of Inspection: 1 2/2 8/0 5 Name of Inspector: (please print) Ralf rt A Paol"in Company Name: g, P- Macomflea 9 .Son Inc. Mailing Address: i3ox 02632 Cen eavi h e, ¢7 . Telephone Number: 5 0 8-77 5_3 3 3 8 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 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 M000). The system: XXX Passes -Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails r- Inspector's Signature: ' ! Date: The system inspector re Aof this ins ection report the.Approving Authority(Board of Health or shall submit a copy P P 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. Titto S Tncnm4inn Fnrm 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 816 phi nnPyG Tana CA-ntervi.11aNA 02622 Owner: Ri r-hash paekham Date of Inspection: 1 2/2 8/0 5 Inspection Sum`mary: .Check A,B,C,D or.E/ALWAY�veomplete,all of Section.D A. System Passes:YES No I have not found any information which indicates'that any of the failure criteria described in 110 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: zp.et.ie 3u,3tem Liz in Raopea woak.inuo zde/t at the /22eZent / ;Lime B. System Conditionally Passes: NO 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. NO 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: N-0 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: NO The system required.pumpingmore 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: 816 Phinneys Lane \ Centerville MA 02632 Owner:. Richard Peckham Date of Inspection: 1 2/2 8/0 5 C. Further Evaluation is Required by the Board of Health: i NO 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: no Cesspool or privy is within 50 feet of a surface water no 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: no The system has aseptic 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. no The'system has a septic tank and SAS and the.SAS is within a Zone 1 of a.public water,supply. no The system has a septic tank and.SA&and the SAS is within 50 feet of a private water supply well. no The system has a septic.tank and SAS and the SAS is less than 100 feet but 50 feet or more frorh a private water supply well".Method used to determine distance v.taua e "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 . r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION(continued) Property Address: 816 Phinneys Lane Cent-Prvi 1 1 P MA- n2632 Owner: Ri eharr3 pPnkham Date of Inspection: 1 2.4 2 A.10.5 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 -T. 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'%-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. X Any portion.of a cesspool or privy is within a Zone 1 of a:public well. X Any.portion of a cesspool or privy is within.50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system.passes if the well water.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates.that the well is free from pollution from4hat 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 fort.] NO (Yes/No)The system fails.I have determined that one or more of the above failure.:criteria exist as described in 310 CNJR 15.303,therefore the system fails.The system owner uld 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 1.0,00.0 gpd to 15,000. gpd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area @nterhn 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 n "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 s,'hAll 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: 81 6 Phinneys Lane 75en ervi a MA 02632 owner: Richar —Peckham Date of Inspection: 12 2 87 0 5 Check if the following have been done.You must indicate`yes..or'to"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 the system components pumped out in the previous two weeks? X _ Has the system received normal.flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out Were all system components,excluding the SAS,located on site? X Were the septic tank manholes uncovered;opened,and the interior of the tank inspected for the condition of the_baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes X— — Existing information.For example,a plan at.Ehe Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL�SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 816 Phinneys _.Lane Centerville MA 02632 Owner: Richard Peckham Date of Inspection: 1 2/2 8/0 5 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 330 DESIGN flow based on 310 CNIR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no):a o Is laundry on a separate sewage system(yes or no):n o [if yes separate inspection required]. Laundry system inspected(yes or no):n o Seasonal use-(yes or no):no 2 0 0 4=81, 0 0:0.ga a e o n s q a=2 21., 91 Water meter readings,if available(last 2 years usage(gpd)):2 0 0 5=3 7, 0 0 0 ga.Q.Q o n z G 10 D=.101.,3 6 Sump Pump(yes or no): n_ Last date of occupancy: unknown COMMERCIA4ar6uSTRIAL N/A Type of estabiint: Design flow(based on 310 CMR 15.203): end 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: N14 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, 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 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: .inst¢teed he/2t 03 Were sewage odors detected when arriving at the site.(yes or no): no 6 Page 7ofll OFFICIAL INSPECTION FORM-NOT FOR-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 6 Phinnevs Lane Centerville MA 02632 Owner: Richard Peckham Date of Inspection:1 2 28 0-9 i BUILDING SEWER(locate on site plan) I Depth below grade: 3' Materials of construction:_cast iron -X 40 PVC_other(explain): Distance from private water supply well or suction line:2 0 f Comments(on condition of joints,venting,evidence of leakage,etc.): ,IO.i.tn.b a2aea2 f.iah# , »vnILI fhnniirrh hnPiwo )wa SEPTIC TANKN a-3 (locate on site planj 15 0 0 ga i i o n Depth below grade: 10 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: 10' 6"X5 8."X4' 10" Sludge depth:_.b a a c e Distance from top of sludge to bottom of outlet tee or baffle: to a c e Scum thickness: ;t 2 a c e Distance from top of scum to top of outlet tee or baffle:t2 a c e Distance from bottom of scum to bottom of outlet tee or baffle:t/ta ee How were dimensions determined: e rz g.i n e e 2 cl 2 a tt)n p iP a.n,6 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): eum tees ate eaee., 7anx 7z zlAuctaAaZ72y zounc GREASE TRAP:O(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.): qaeaze taap .i-6 not /zaezent 7 Page 8of11 OFFICCIAL:INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 h ph i ane CentPrvi11P MA .02632 Owner: Richard Peckham Date of Inspection: 1 2.12 8.10 TIGHT or HOLDING TANK: n o(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.): Tight oa hoid.ing tankza 2e no.t pAe sent DISTRIBUTION BOX: ye-s (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 lage into or out of box,etc.): Box .e6 .2eve e.- Kaa Z No .so i-id ca/t/ty ove2 o z eeka e .cn oa ou OA gox'� PUMP CHAMBER:no (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of punip chamber, condition of pumps and appurtenances,etc.): l umRchamgeit .ins rzot R2et,ent 8 Page 9 of 11 OFFICIAL.INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS — SUBSURFACE SEWAGE.DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 81 6 Phinnevs Lane Centerville MA 02632 Owner: Richard Peckham Date of Inspection: 1 ./2 8/0 5 SOIL ABSORPTION SYSTEM(SAS): .(locate on site plan,excavation not required) If SAS not located explain why: Located .see 12age 70., i Type leaching pits,number: X leaching chambers,number: 2 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.): Sandy -eoam., No 6ign,6 o-� pia lze o2 poad.ing.- So.i-ez aite day.- :: ege•ta.t.ion .iz no2ma e., CESSPOOLS: no (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.): cezzpooiz ate not /?2e,6ent PRIVY: no (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.): PlLivy i,6 no•t /zee,6ent 9 Page 10 of I I IfF 1AL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUILSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C: .SYSTEM INFORMATION(continued) Property Address: 81 6 Phinnevs Lane Centerville MA 02632 Owner: Richard Peckham Date of Inspection: 1�$f 0 S w SI,CETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks:Locate all wells within 100 feet. Locate where public water supply enters the building. 1 10 r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM INFORMATION(continued) Property Address: .81 6 Phinneys Lane Centerville MA 02632 Owner: Richard Peckham Date of Inspection: 12 2 8/0 5 SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: g Obtained from system design plans on record-If checked,date of design plan reviewed: ye.6 Observed site(abutting property/observation hole within ISO feet of SAS) w �e h Checked with local Board of Health-explain: R u c p t 2 d no Checked:with local excavators,installers-(attach documentation) zez Accessed USGS database=explain•t;6P r f owno aaanisto9 ie.,ma.,u!s '—, You must describe how you established the high ground water elevation: 11.sed. : Ca e Cod Comm.ih.ion 1date2 7aaie Coritou2h. And Fugue Uatea Su/piY GJe22 /zeal �aoteet ion a/teah map., SeTt 1995 ldatea 2ehomceh 0•44f./ce cage cod comm-Lion,- • Leaching Pit 'eet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical.separation distance between the bottom 1 0 of the leaching pit and the adjusted groundwater table is/6 feet. r 11 •t. , B'N A$ BOARD OF HEALTH TOWN OF 91H)SUIZFACH SEWAGE DISPOSA4 SYSTF,M ItIgPFCTION FORM - PART D - CERTIFICATION •••41.1�T•:'57,�,1117,".Sy.*,MS,11'R11,f1 TIf7rIf�7Z7�.t•ITl'ipA1P'rJ11,IM rrwwmw- -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED , STREET ADDRESS .816 Phinneys Lane ASSESSORS MAP, IILWK AND PARCEL # OWNER' s NAME Richard Peck PART` D - CH1?TIFICATX0N NAME OF INSPECTOR Rogeat na.o$*ni COMPANY NAME be h l'•' Rgcomlz,1' Son Inc t3ox 66 Cen�ezv•ie1e Saab' 02632 COMPANY ADDRESS -- Tovn or city. Stake LIP Str��Ft _ FAX (• 508• )190 1578 COMPANY TELEPHONE ( 508. 1 77.5 ' 3338 A CERTIFICATION STATEMENT I "certify that. I have personally .inspected ..the sewage dispose► system at this address and that the information reported �e�tiangwascperformed and and any • omplete as of the time a:..f .in spection.• Tn . F recommendations regard.ing- upgrade , .ma•intenance , and repair .are eon$istent with my trainii.;g and experience in th8 proper function and maintenance of on- site sewage disposal systems Check one; Systeoi PASSED The inspection which •I have •conducted has .,nat found any information wi�ich indicates that the system .fails to adejuately protect .publi.c health or the enviropment as defined in .310 CMR. 15'.30.3, Any failure criteria Dot evaluated are as stated in the FAILURE CRITERIA section of this. form. System FAILED* The inspection which I have •co•n ted • has found that the system fails to Protect the public health and the environment in ac4ord•ance with Title 6 , 310 CMR 15 . 303, and as . specifically noted on PART, C -► . FAILURE CRITERIA of this insectio form Inspector Signature - Date One Copy of tins cert.i,f i.cat•i•ofi must be provided :to , the .OWNER, the. DUYER - a here a�Pl i.aa-blo) and th* B9ARD OV HSAL!ill * if the inapect� on FAILEn., the owner .ox operator ahall . upgre►de'the system• within o•ne year of the da�t•e of the in�a•pection, unless. allowed 'or- regui;red __ n"e%vi Aad in 110 CMR 16 , 305 1 TOWN OF BARNSTABLE LOCATION`-I' P I-11 r e Y�S L- ,4h'(? SEWAGE # 2 6®,- VILLAGE- C e N 7l e R V I-1 L ASSESSOR'S MAP&LOTS L INSTALLER'S NAME&PHONE NO. 7 P n A c o A4 6 e ie r- s a*' SEPTIC TANK CAPACITY 'LEACHING FACILITY: (type) Pif Y tV ell S (size) YO.OF BEDROOMS 13 BUILDER OR OWNER PERMTTDATE: �/— 16---10 COMPLIANCE DATE: 1 y 6 " 03 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 IV r (� TOWN OF BARNSTABLE LOCATION 9�IAIAJ e=''Y'S G-,4AIe SEWAGE # A 0 03— VILLAGE C e it/f'e g V/L L e ASSESSOR'S MAP & LOT § '-' INSTALLER'S NAME&PHONE NO. P /Y!A co 446 a /Q i- s oA,, SEPTIC TANK CAPACITY __�S 0 .0 LEACHING FAciLrrY: (type) _01f v w a L! s (size) A NO.OF BEDROOMS .� BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: I AI ` 63 � 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 . t i \ ! �q , ev 1 No. I Feel 55 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Digozal *pgtem Construction Permit Application for a Permit to Construct( )Repair(V�Upgrade( )Abandon( )XE Complete System ❑Individual Components Location Address or Lot N P h t n n e y,3 Lane Owner's Name,Address and Tel.No. Cent 2 �� P1u�s�, a J©� Same Bzian aohnz.ton Assessor s Map�arce�' l Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No.5 0 8=2 7 3—0 3 7 7 a. %. MacomPe2 & Son Inc. aC Cng.ineeAing 2854 Caangeaay Box 66 Cente2v.ii e, P1aa,s. 02632 jEaz.t Waaeham Na,3z. 02538 Type of Building: Dwelling XX 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 1500 Type of S.A.S.2-5 001,3 Description of Soil Loamy Sand to medium coa/z,6e zand. Nature of Repairs or Alterations(Answer when applicable)Om i t t.i n g c e,6,3 R o o i.6. I n.6.t a e e i n g - 1500 gaiion zept_is tank 1-Dlzta ilu.t.ion Aox & 2-500 gn.P.Pan ieach.ing chamge/zz. 25 'X13'X2' 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 Ay this Bo d o e I Sig Date 9115?03 Application Approved by Date 01 1 Application Disapproved f the following reasons Permit No. -;X905 v-4 6 Date Issued / [ R No. 3 I + . Fee("5 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in a mp er: Yes JJJJ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppfication for Miopoml *pgtem Con5tructiou Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( )XTI Complete System ❑Individual Components LocationtAddress or Lot N 1 h.i n n e y-3 Lane Owner's Name,Address and Tel.No. R Cents P azeQer, ('lase. Same Bltian a,ahnbton Assessors a Installer's Name,Address,and Tel.No. 5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No.5 0 8 a 2 7 3—0 3 7 7 �. /. Nacomgea R Son Inc. ;C Eng.inee/ting 2854 Caangeaay /Box 66 Centzaviiie, Naee. 02632 East ldaaeham Mahe. 02538 Type of Building: Dwelling X y 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 I"` J( Revision Date ' Title Size of Septic Tanks 1500 Type of S.A.S.2-500'.6 Description of Soil Loamy .sand to medium coaaee hand. Nature of Repairs or Alterations(Answer when applicable)OM i t t i n g c e e e/a o 0 2 e. I n e t a.PQ.i n g 1-1500 gai.Eon eept.ic tank 9-IB-ieta.igut.ion eox &' 2-500 oa.Pion -geach.ing chamr?eae. 25'X93'X2' - 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 Bo d of e 1 Sig ed Date 9/1 5?0 3 4 Application Approved by Date q 15j, Application Disapproved f the following reasons Permit No. POO 3— Date Issued q 1 e, THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 'ertifirate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )UpgradedXX* Abandoned( )by 1. B• Nacomgea R Son Inc. at 830 Ph.inneye Lane Cente4v iiie, Mahe. has been constructed in Vccordance with the provisions of Title 5 and the for Disposal System Construction Permit No.7-40n3-4/ I dated Installer ;, B• Nacom9ea 8 Son Inc,. Designer X Engineea.ing t The issuance of this ermit shall not be construed as a guarantee that the system wil nc i n s ned,�� Date ©5� Inspector 4 No. 3 1✓I Fee $5 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligpozal bpztem Congtrurtton Permit Permission is hereby granted to Construct( )Repair( )Upgrade( X�Abandon( ) Systemlocatedat 830 Bh.inneys Lane Cente/zv.i.22e, flaee. 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 Mis"per. it. Date:__����� 3 Approved by _� SEWAGE INSPECTIONS' LOCATION'° Phinney.6 Lane DATE 8/15/03 VILLAGE Centeaviiie, Ala-6,3. ASSESSOR'S MAP do LOT •INSAECTORl0.6e/2h P. NacomPe2 a/z. SEPTIC TANK CAPACITY None 6 'X8' ce,6,3/2oo g & 1- 1000 .12,..t LEACHING FACILITY: (type) Both (size) 250,0 yaieon,3 NO. OF BEDROOMS BUILDER OR OWNER Anne Johnston -OWNER MAILING ADDRESS . 71 Pine -4/Lden COIL-.ve Oe,3t Bo ezton 01583 Naz,6. ti s 3 o P111xlw ers, Z ,q,,.e r OAT E :8/15103 PROPERTY A 0 0 R E S T#� Ph.inne y,s LjYfie RECEIVE® CentealJ.i.P.Pe, N a.s.s. 3 2003 "02632 — ————————————— TOWN OFBARNSTABLE HEALTH DEPT. On the above date, I inspected the septic systerr�r:at the above address, Tnis system consl.sts of the following: MAP 1. 1-6 'X8 ' P.Pock cea,6/2ooP. PARCEL, , '3(AO ?. 1- 1000 ga.P Pon /2aeca.6t Peaeh.ing /2.it. LOT 2® Baseo on my inspection, I certify the lollowing conditions: 3. 7h.iz ih not a t.it.Pe ;ive 6e/2t ie �y-stem. 4. 7hi,6 .i.a a eewage zyztem. 7hat ha-6 had a 1000 ga.Pion paecazt Peach.ing /z.it added to the exizting ce.6.6/2ooP. 5. The beaching /2.it i,s /2aeeent.Py day. 6. The Peaching pit wah .inzta.P2ed 1112184 7. The .3ewage .6y.6tem .ie in /zaopea woaking oadea at the /7a heni' time. 8. Que.at.ion ih .il the 3yztem i,6 Paage enough to and.P a /oua Pedaoom ome. S LG NAT U R 9. 7hiz .i.3 the aer,Pon /oa the eond.it.ionaP - ----- - -- -- - /?a-3h• Name , ._ P . -Macomber_Jr . _--- �ompany : �g�g�h Pam_ M�S4m�2�� d_ Son, Inc . ...... ...... _Ce-nS L'-Lam,_ �J a - _Q.Z6 3 2- 0 0 6 6 ? ^,one : _ _508_• 775_ ) ) 38 -- - - - --- TmjS CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks•Cesspools•Lsachllelds Pumped & Installed Town Sewer Connections P 0 Box 66 Centerville. MA 02632.0066 )15.3338 175.6412 ' 1 . -ti COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 830 Phinney.6 LaN£ en e/zvi e, Nazz. Owner's Name:Anne Zohnz on Owner's Address: / 7 Pine qi d e n D/z ive e,6 Z Z3 oy on, a 777U 1583 Date of Inspection: 8175103 Name of Inspector: (lease print) ao,6e/2h l. (1acom&e2 a/z, Company Name:a• l • 17acom ea on Inc. Mailing Address: o x 66 e&Z e/z v 71 T e, a.s 6. 02632 Telephone Number: 5 0 8- 7 7 5-3 3 3 8 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 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: casses onditionally Passes eeds Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: eo�-4. 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. 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:830 Ph.inney.6 Lane en t eILv.e e, Ma.6.6. Owner: Anne ao n,6 on Date of Inspection: 8/"15777— Inspection Summary: Check A,B,C,D or E�//ALWAYS complete all of Section D A. System Passes: r!�� �7a�G�Cj' A0 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: at fho nno,tonf fimo 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. &-Vl—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: 't� 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 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 830 Ph.inneyh Lane Cen.te2ui-Pe e. Na.ah. Owner: Rnne gohn.64on Date of Inspection: 8/7 5/0 3 r.;.. C. Further Evaluation is Required by the Board of Health: �7Conditions 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(l)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 7hi.6 i3 /ou/z Ped2oom hou,3e. Ii- hah a 6 'X8' P.Pock ceah/?oo.P and a 1000 ga.P.Pon /22ecaet Peaching 1?.i.t a.a an ovelz�-eow. 7h.i-6 ih .in queht.ion. Do noit )eee.P it i,6 .Pa2ge enough )?o/z a lout gedltoom home. Pi.t wah cnhtaPPed in aanuaay 1984 Pelcmit # 84- 17 . 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 Zo\ne'l 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. /VO The system has a septic tank and SAS and the SAS is less than 10,E feet but 5 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: 7h.ia .ia a hew m The .6yh.tem eon,6.i,6t,6 o,,' one h 'XR' P.Pnrk reAA.Pool) with a 1000 ga.P.Pon R2eca.6.t .Peach.ing pit as an n„on_ 7ho nit �� nnv svnfJ�y day he houAo -.6 ubed �6aa.6o1-za(.(, The 6ewage zy.6tem ie .in 122o/?elt wo2king o2dea at the /zee,6ent time. 3 Page 4 of 1 1 , OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION(continued) Property Add ress:830 Phinney,6 Lane en e2v.c e, Owner:Anne 1ohn�s#.on Date of Inspection: 8115103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No� _ _✓✓ ackup 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. esspool . .1 squid depth in cesspool is less than 6"below invert or available volume is less than '1A day flow _ �/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 6. y 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. rl-t yportion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 c py of the an lysis must be attached to this form.] /WW 5 Q14Y y-04)r4 AAV (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 4the system is within 200 feet of a tributary to a surface drinking water supply P the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:830 Ph inney.6 Lune en T eay.c 11 e, Owner: Anne o 76 on Date of Inspection: —$7=3 Check if the following have been done. You must indicate s"or"no"as to each of the following: Yes No / ' _ 1/ Pumping information was provided by the owner, occupant, or Board of Health YWere any of the system components pumped out in the previous two weeks _L 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 pan of this inspection ? --k/*)_ Were as built plans of the system obtained and examined?(lf they were not available note as N/A) Y_ 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,-s*luding the SAS, located on site ? r AJG� 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 ? z_ 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 —o / Existing information. For example, a plan at the Board of Health. l/ Determined in the field(if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) S Page 6 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C T SYSTEM INFORMATION PropertyAddress:830 Phinney.a Lane en eay.i e, a,3.3. Owner:Anne 7ohn,6t orz ^T Date of Inspeetlon: 8/15/03 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design):it Number of bedrooms(actual): �D�J DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x it of bedrooms): Number of current residents: 1_ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system,(yes or no):otf [if yes separate inspection required) Laundry system inspected es,or no):Z&5 Seasonal use: (yes or no): 2001=24 U00 Water meter readings, if available (last 2 years usage(gpd)): ga P eons=6 5. 76 Cj/ D Sump pump(yes or no):.4.)6 = ga.2 eon.6=73. 98 GI)D Last date of occupancy: COMMERCIAL NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _ d Basis of design flow(seatslpersons/sgft,etc.): Grease trap present(yes or no):4& lndusrrial waste holding tank present(yes or no):�! Non-sanitary waste discharged to the Title 5 system (yes or no):4 ) Water meter readings, if available: Last date of occupancy/use: �¢ OTHER(describe): T T GENERAL INFORMATION Pumping Records Source of information:None ava i-Qag.Pe Was system pumped as pan f the inspection(yes or no): 4D If yes, volume pumped: gallons •• How was quantity pumped determined.) Reason for pumping: Ty'PE OF SYSTEM Septic tank,distribution box, soil absorption system 7 Singlc cesspool 1 Ovcrflow-Gsi6Pce4 40 Privy 4CSSharcd system(yes or no)(if yes, attach previous inspection records, if any) -,�Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained fiom system owner) /(PTight tank _Attach a copy of the DEP approval ��her(describe): App x�te age f a.,cgrriponents, date in lle(iff known)and ur f info ation �1 Were sewage odors detected when arriving at the site(yes or no): 100 6 i Page 7 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 830 Ph inney.3 Lane en e2vi1-0e, 17ahh. Owned rzne ao n Date of Inspections 8115103 Cast .t2on to 4" i.ite BUILDING SEWER(locate on site plan) R Pa'6t.tC fl'iRe & )e.i.t.t Singh /J"I thaough out the hewage Depth below grade:� h yatem. Materials of construction: cast iron td0 PVC 1 ther(explain): Distance from private water supply well or suction line: _le i f. Comments (on condition of joints, venting, evidence of leakage, etc.): 10, ntz aR/2eaa Lighl. Nn e),)rJenre, n.4 Poaknao The zyhtem -iz vented th2ough the zoos venth. SEPTIC TANK. Rlocate on site.plan) Depth below grade: Material of construction: ,4concreteIJAmetaI�berglass,2i polyethylene o'Aother(explain) A?,4 If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no):JA(attach a copy of certificate) Dimensions: ZA _ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: _Z2± Distance from top of scum to top of outlet tee or battle: Distance from bottom of scum to bottom of outlet tee or baffle: W How were dimensions determined: _ /l 14 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): Svnf it fnnk !A nnf 'p,;oAont GREASE TRAX"locate on site plan,) Depth below grade:/ Material of construction.4kconcrete,9�qmetaY4fy fiberglasx polyethylenesother (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: 4114 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): rnvrzAg fnrin i A nnf na¢QeR f II Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM 'INFORMATION(continued) Property Address830 Phinneyh Lane Cen e2U.i e. ash. Ownert4nne lohnhton Date of Inspection:817 5/0 3 TIGHT or HOLDING'/TANKtke' a.nk must be pumped at time of inspection)(locate on site plan) Depth below grade: .7/1 Material of construction: concrete.,�mctalJZA fiberglass,,polyethylene i:�/4other(cxplain): Dimensions: Capacity: eallons Design Flow: allons/day Alarm present(yes or no): Alum level: _ Alarm in working order(yes or no):/� Date of last pumping: AM Comments (condition of alarm and float switches, etc.): 7-iqh1t o2 tank.6 aae no �2e6en DISTRIBUTION BOX (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_ 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.): / At i U ion Sox i,6 not R2e.3ent PUMP CHAMBER4��locate on site plan) Pumps in working order(yes or no): 104 Alarms in working order(yes or no):_,�2� Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): l�umn �h�im0on i,l nnf no�onf 8 Page 10 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress:830 Phinneyh Lane Cen.te2v e, ( a.6.6. Owner: Anne John.6 ton Date of Inspection: 8/15/0 3 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. R yle � t .z 10 ' LOCATIO.�I�O SEWA .CE PERMI�TN Q. j VILLAGE lyLnE Q - I INSTA LLE 'S NAME i A-DDRESS r Q /e) .6 e U I L D E R 0 OWNER DATE PERMIT 1SS.UED 9 � DATE COMPLIANCE ISSUED // i C� 4 4 � j Page 11 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:830 Phinneye Lane CenteR,y.(. 'ee, Mahe. Owner: Anne 'ohneton Date of Inspection: _811 5/0 3 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: yLcS Obtained from system design plans on record- If checked, date of design plan reviewed:8/15 ( In co/z 2 e c t .,ULSObserved site(abutting property/observation hole within 150 feet of SAS) u,�6 Checked with local Board of Health-explain:A e gu.i P t ca,, cd ( in co 22 e c.t Checked with local excavators, installers- (attach documentation) =SAccessed USGS database-explain:htt/?.// .town. 6a2ne.ta&_PP_. ma. ue. You must describe how you established the high ground water elevation: sed Gah2etu � t'odeP. 12116194 aond watea eievai_ione move eea .t?eveP. tied: Oneezvat_.on wei2 data. une 1992 sed: LLSGS , 7echnicai ' guiiet.in 92-000- 1 Piate 2 Annuai ,z— 6 o y2oun wate2 p pva cone 2anua2u 1992 ---'—'—"- n Leaching �. Pit ;eet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method. Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 y,•Rnr+.—n-r��.-+r-ern:a.n•nTfrn..rawrre*w R1.•++�.r�r�*e.•rRn mrR ` �e 1 TOWN OF ,6 BOARD OF HEALTH SUBSURFACE SFWAQF OISPO.SA4 SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••T'9•T••.••.'.—T.1I T.�.�1T�1•TI'.1.1�1 TR]•{9f T111R''—t't r'IT11 i1TWrTv"V W"W MWIM""wWww7 TA -TYPE OR PRINT CI.EAALY- PROPERTY INSPECTED STREET ADDRESS830 Phinneyh Lane Cente2U•iiie' plaza. ASSESSORS MAP , BLOCK AND PARCEL # `` OWNER' s NAMEAnne aohnatblz PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J P Macomber & S o H Inc".` COMPANY ADDRESSBox 66 Centerville Mass . 02632 Strvvt Town or City 9taty LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , �I Check one : . System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have con vcted has found that the system fails to protect the j-)ublic health and the environment in accordance with Title 5 , 3.10 CMR 15 - 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date �l ne copy of this certification must be provided to the OWNER, the BUYER ( Where applicable ) and the I30ARD OF HEAL'I'll, If the inspection FAILED, the owner or""operator shall u within one year of the date of the inspection, unless allowed dortrequiredm otherwise as provided in 3.10 ChIR 16 . 306 . partd .doc 301-0° 22-0° U N JAL Dili D � rii n i o _-4 �i s 001 r 100 rn D £z Z . o m — o N 5i_On 101-01 O Z m o - F O � d� � u k n m.U� • 24'-0° 1 Q L p C7 PROJECT: m 816 PNINNEY'S LANE FINE LI E ARGHITEGTU�L DESIGN CENTERVILLE, MA 8 WEST BAY ROAD OSTER_ VILLE, MA 02055 9 w KITCHEN REMODEL PHONE: 508-4.20-123ro TOP OF FOUNDATION - 100.87' 5" DIA. OUTLET(S) FINISH GRADE OVER CHAMBERS = 99.20' - 98.80' GENERAL NOTES REMOVABLE COVER SLOPE @ 2% MIN. OVER SYSTEM 1. UNLESS OTHERWISE NOTED ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE OVER TANK EL.= 4"SCHEDULE 40 PVC MIN SLOPE 1% 3/4"TO 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE ' FINISH GRADE OVER D-BOX=99.1 O METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE FINISHED GRADE 98.75' - 98.50' @FOUNDATION = 99.36' 2"OF 1/8"TO 1/2" DOUBLE WASHED STONE ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES. . .� -� � TOP OF SAS = " 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD 20" MIN. ACCESS COVER PROVIDE RISER OVER OUTLET 96.33' PLACE RISERS ON ALL CHAMBERS OF HEALTH AND THE DESIGN ENGINEER. (3 TYPICAL) TO WITHIN 6 OF GRADE 36"MAX. 9"MIN. TO 6 OF FINISHED GRADE 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL \\\ 95.50' 36"MAX.I BREAKOUT EL - 96.00' BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED.4. TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE LESS THAN 1 MIN.SLOPE t% g" 3" 2�'DROP MIN. F 9„ PROVIDE WATERTIGHT ELEVATION =96.00' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS 3 DROP MAX. JOINTS (TYP.) A 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF 10' 4" PVC IN FROM 1(=ED>> O o00 O oo THE LINER IS NOT LESS THANoTHE BREAKOUT ELEVATION. 14" 96.29' SEPTIC TANK 4 PVC OUT TO o OO5. SLOPE ALL SOLID PIPE AT 1.0 /o MINIMUM. 96.50' LEACHING FACILITY T o o g. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. 12" oo 7. LOCAL BOARD OF HEALTH TO BE NOTIFIED PRIOR TO BACK FILLING WHEN _ OUTLET TEE 95.75' MIN. 95.58' 2 o> �p 0 0� SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS NOT TO (CONTRACTUr-, 48" f o0 000 � � � � � oo BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH. TO VERIFY) �6„CRUSHED STONE o0 0 0 8. ELEVATIONS BASED ON ASSUMED DATUM OF 100.00 MSL OBTAINED 22' ZABEL FILTER tw OVER MECHANICALLY - MODEL#A1801 HIP COMPACTED BASE FROM A NAIL IN A TREE AS SHOWN ON PLAN. 19.4' (GAS BAFFLE ON 25. 4. ' 4. ' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION s 6" CRUSHED STONE BOTTOM) 5 OUTLET DISTRIBUTION BOX (Typ ) THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE OVER MECHANICALLY TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV.= <87.95' 12.9' AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY COMPACTED BASE �,` BASE. FIRST TWO FEET OF OUTLET 93.50 DISCREPANCIES TO THE DESIGN ENGINEER. PROPOSED 1500 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. 2- 500 GAL. CHAMBERS 5'MIN. 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE LENGTH 10.5' WIDTH 5.66' DEPTH 5.58' CROSS SECTION VIEW I STRUCTURES SHALL BE MADE WATERTIGHT. TYPICAL CHAMBER PROFILE C HAM B E I I ETA I LS CHAMBER END VIEW 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR S E P IC TANK PROFILE DISTRIBUTION BOX DETAIL ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH NOT TO SCALE NOT TO SCALE NOT TO SCALE DETERMINATION FROM APPROPRIATE AUTHORITY. -- - ` 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS •♦ Shalt Pond TEST PIT DATA LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE vvk�s � 1 THEY SHALL WITHSTAND H-20 LOADING. / N •r • • , 34 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND r •�,►� • o AGENT: NOT WITNESSED FINES. G� 40 OV � o SOIL EVALUATOR: Samuel Philos Jensen 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND T Z / VV (40,F � � � � I DATE: September 11, 2003 UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF �'R/V,qT • U • .\ • >►Q TEST PIT#: 1 LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN v /� T\ F) • COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN • ELEV TOP: 98.45' ACCORDANCE WITH 310 CMR 15.255(3). � / / �F C i . • . �\ s m� \ • , • :�� .o• ELEV WATER: <87.95' 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. J / J99 ���� * PERC RATE: <2 Min./In. Q �� . ✓.- F� C�alsland • ••rr 16. PROPOSED PROJECT IS LOCATED WITHIN: 10�o O / / • DEPTH OF PERC= 34"-52" ASSESSORS MAP 251 PARCEL 106 uller ; . • • `� ��2 500 � � 41 f «+ � � • � • , TEXTURAL CLASS: 1 17. OWNER OF RECORD: JOHNSTON, BRIAN E. &ANNE P. Q • // / ��5 \ 7 • •• +• • r • M ' / 0 98.45' ADDRESS: 71 PINE ARDEN DR. !.41 \ r 4n • • ' • • • Sandy Loam 10YR 4/2 W. BOYLSTON, MA 01583 a INSTALL TWO, 500-GALLON lit �. • • ' • ; ; • /� A Massive; Friable FEMA FLOOD ZONE C CHAMBERS i• • 'Q ' • . • 3►� 8" Sandy Loam 10YR 6/8 97.78 AS SHOWN ON COMMUNITY PANEL# 250001 0005 C Izz1 �itt4 % ��� . • B Massive; Friable 18 PLAN REFERENCE: lr . • • 1. LAND COURT PLAN 30367-A o �� . . ; • . . • C Perc. 19. DEED REFERENCE: 25.0' j f : \� r •` � ' : ! 1. CERTIFICATE 100964 / C JAL rv) • • J# • '`l '1 ` 52" II 1 20. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. ,,C Fp 0�� ; • • L,,� • f( • �_. • ' M-C Sand 2.5Y 7/4 21. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY �/1'j� O • J . .�o� .�`" + Loose; Single Grain FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY F 1 • • ll; f/ • • 10-20% Gray., Cobbles _ O = 0 0 �` . F • FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. : DISTRIBUTION BOX --- . ''--_-_-__:._• LOCUS PLAN No Standing Water, Weeping, Mottling EiTiC B.M. Observed MAP 251 Nail in Oak SCALE: 1"= 1000' Elev. = 100.00' 126" 87.95' Assumed DESIGN DATA LEGEND PARCEL 106 GARAGE ` ' 10,778 S.F.± (ON SLAB) 1 NUMBER OF BEDROOMS: 3 DESIGN FLOW: 110 GPD/BDRM -- 50 - - EXISTING CONTOUR TOTAL DESIGN FLOW: 330 GPD / F� COL N ' DESIGN FLOW X 200 % = 660 GPD 50 PROPOSED SPOT GRADES PROPOSED 1500-GALLON USE NEW 1500 GALLON SEPTIC TANK E � PROPOSED CONTOUR SEPTIC TANK E/T/C EXISTING OVERHEAD UTILITIES INSTALL TWO 500-GALLON CHAMBERS W ---- EXISTING WATERLINE / \ C #8309 / WOOD DECK EXISTING �' SIDEWALL CAPACITY GAS EXISTING GASLINE 3-BEDROOM / DWELLING 79¢� / \ 4, \X ++ TEST PIT LOCATION (LENGTH +WIDTH)(2 SIDES)(EFF. HEIGHT)(.74 GPD/SQ.FT.)=GPD MAP 251 It (25'+ 12.9')(2)(2')(.74 GAL/SQ.FT.)- 112.2 GAL. LEACHING/DAY C' TOP OF FOUNDATION Q PROPOSED 1500 GALLON SEPTIC TANK EL. = 100.87' TP ' PARCEL 150 BOTTOM CAPACITY I N/F NYMAN (LENGTH)(WIDTH)(.74 GPD/SQ.FT.)= GPD 4"SOLID SCHEDULE 40 PVC PIPE CONCRETE PATIO ' (25')(12.9')(.74 GAUSQ.FT.)= 238.7 GAL. LEACHING/DAY / 98.45 ' TOTALS: El DISTRIBUTION BOX 1 DO 500 GAL. LEACHING CHAMBER TOTAL LEACHING AREA 474.1 SQ.FT. J TOTAL LEACHING CAPACITY 350.9 GPD REV. DATE BY APP'D. DESCRIPTION PROPOSED SEPTIC SYSTEM UPGRADE a PREPARED FOR: - CP ' BRIAN & ANNE JOHNSTON EXISTING CESSPOOL TO LOCATED AT BE PUMPED AND FILLED a WITH GLEAN SANDl-g36'PHINNEY'S LANE � � - MAP 251 �� RESERVED FOR BOARD OF HEALTH USE CENTERVILLE, MASS. PARCEL 107 \ MAP 251 SCALE: 1 INCH = 10 FT. DATE: SEPTEMBER 13, 2003 0 5 10 20 40 FEET N/F ROOD U ���RL' PARCEL 105 ILL - PREPARED BY: JR. JC ENGINEERING, INC. ~� N/F LORRAIN �t NoC�vlea7 2854 CRANBERRY HIGHWAY -)N .,ry` , EAST WAREHAM, MA 02538 SITE PLAN 508.273.0377 SCALE: 1" = 10' Drawn By: SJ Designed By:SJ Chedced By-JLC JOB No.541