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HomeMy WebLinkAbout0326 PRINCE HINCKLEY ROAD - Health 326 PRINCE gINE1,� C-VILLE A=171-171-296 lip } n Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection "Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the I computer, r,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on 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: 7 a Q ® Passes ❑ Conditionally Passes ❑ Fail-s ❑ Needs Further Evaluation by the Local Approving Authority Co ee� 10/08/2009 1 IniKector'19'sibnMe Date e ! r-- M The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under , the same or different conditions of use. [A 0 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Se a Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes";"no"or"not determined" (Y, N,ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will ass inspection if the existing tank is replaced with a complyingse tic tank as approved b the P P 9 P P PP Y Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): The system required um in more than 4 times a year due to broken or obstructedpipe(s). The ❑ y r r y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR _ 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. 0 ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis. and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No ,000 :17 Water meter readings, if available (last 2 years usage (gpd)): 2002007:1 ,000 Detail: 2007:47gpd 2008:33gpd Sump pump? ❑ Yes ® No Last date of occupancy: 10/08/2009 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 0 t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is Centerville Ma. 02632 10/08/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.no signs of hydraulic failure.Water level was 4' below invert at time of inspection.Stain line is 3' below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 333 Prince Hinckley Rd.. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code . Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately La 5nt � a t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M , 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 22' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150'feet of SAS) ® Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 333 Prince Hinckley Rd. Property Address Dan Riley Owner Owner's Name information is required for Centerville Ma. 02632 10/08/2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LbCATION SEWAGE#'Z�� ` l'CL,AGE e e'vT ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. Pj SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (size) NO.OF BEDROOMS 3 OWNER �9JC.6 PERMIT DATE: '''�f��� COMPLIANCE DATE: - Igor 0J 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) i Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet FURNISHED BY Sill FBp�� 4t 81, rq� ' �r S3' o y U � - 6/0 1 TOWN OF BARNSTABL '-EOCATION d 1OWL4 SEWAGE # VILLAGE Chi tfi'1 v��� ASSESSOR'S MAP &1 1T 1 a2 cl� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER a PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by E FC4 Fo"I� c D Qc 3�� o No. . 00 Fee �©V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer! PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for Migpo2;a16pgtem Cottgtruction Verna Application for a Permit to Construct O Repair(41--u�pgrade Abandon O ❑ Complete System D Individual Components Location Address or Lot No. 3�� �I✓cC�/�/NC�CF Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1,71 17/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3 '�iot� /�?/�J•l'1��✓ -e f a 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(min.required) 3 gpd Design flow provided gpd Plan Date �"�'-i Number of sheets Revision Date Title Size of Septic Tank • Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this B o 1M.K Si ed Date Application Approved by Date ) Application Disapproved by: Date for the following reasons Permit No. �� 10 Date Issued r�...�� ., __ . ,".. ..vl #. .. ..•l�w..Y�'r.N __ _i YY..•.."..r....1.. Pn� � � vl'ir ' �Na! Fee /O V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpplication for �Dioogal �&pgtpm Con0ruction Permit 4� Application for a Perniit to Construct( ) Repair(�UpgradeAbandon( ) ❑ Complete System U Individual Components Location Address or Lot No.3 ct� �'�CCr"/��NC�Ca�� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 171 17,1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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(min.required) .j` gpd Design flow provided �ZP gpd Plan Date J<_"47 Number of sheets 1-01 Revision Date Title Size of Septic Tank Type of S.A.S. ✓�`�p Description of Soil — Nature of Repairs or Alterations(Answer when applicable L J Date last inspected: Agreement: The undersigned agrees to ensure the construction and rfiain4enance 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 Certificate of ' Compliance has been issued by this B 41d Wlh.o� Si �eed�, --� Date Application Approved by Date 3 2' Application Disapproved by: Date for the following odris p 7 / ll� l 7 Permit No. /�C Date Issued .......... --- i r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (' ) Upgraded ( )" N Abandoned( )by 07�>_v Z at '. '� has been constructed in accordance J with the provisi ns of'Frtle�S a,dgtlad".for Disposal System Construction Permit No. c�-`�"-�� "`!(') � dated Installer , pf / (� Designer #bedroo s _� Approved design flow 3 gpd The issuance of this permit shall not be construed as a guarantee that the system will f�unc`tiio� as" de��igned. Date Al-6 6 ? Inspector _ .. v --------- / -- ---- No. A) ( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 'Eligpogal �&pgtem Construction 'Permit Permission is hereby granted to Construct ( ) Repair (� Upgrade ( ) Abandon ( ) System located at c� ��"G E` /�����y �b• C�,ci 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 it. Date Approv(d by y Town Of Barnstable' Regulatory Services Thomas F.Ceiler,Director • sARP3S`FAiBEE. + a Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644. Fax: 508-790-6304 Installer &Designer Certification Form Date: ' f� Designer: y 7, �"74 Installer: Address: . +6M. LIB Address: was issued a permit to install a (date) (installer) septic system at HIWAI based on a design drawn wn by _T)IW(_V Ik dated (designer) certify that the septic system referenced above was installed substantially, according'.to design, which may include mini- approved changes such as lat�rll relocation d thIe &�tribution box and/or septic tank. s , I C.erti, &at the septic system referenced above was instal wd with major.,char eater � (i e.. greater that 2Q' lateral relocation of the SAS or any ve.Ttical relocation of y component of the Sept,a :)but in accordance with State&Local°Regulations. Plan revisioxa or certified as4bnt`l3y designer to folleva: 0H QF M,y . may. (Installer s Signature) B• n MASON `9 No 106 . ` ., �Q►3TE¢� (13esigner's Signature) ( {zx s Stamp Here) PLEASE RETURN TO IBAR 4STABLE PUBLIC E[EALTR DIVISION. CERTJ[I~'ICATE. OF CQMIPLIANCE MVIL.I. NO ISSUER INTIL BOTH THIS FORM ANn BUILT CARD ARE RECED BY THE BAR STABLE PUBLIC IAET�DI ][SI� THANK YOU. ----�— Q:Health/Septic/Designer Certification Form Town of Barnstable P# • cl, Department of Regulatory Services Public Health Division'2 �tll e� 6 a�� 200 Main Street,Hyannis MA 02601 Date Date Scheduled Time Fee Pd. Soil Suitability Assessment or S7W_Ze • .f Disposal Performed.By: Witnessed By: LOCATION& GENERAL INFO �r [OcAddress RMATION � —/ �/.✓G 6 111 ` Owner's Name d.4M`-x.0, Address J.1 t ��/���°����� s Map/ParceL �%� _171 a�- Engineer's Name,k.*0 4/�� NSTRUCTION REPAIR 4'� Telephone'I', Slopes(R6) 0Z Surface Stones Distances from: Open Water Body possible Wet Area —_ft Drinking Water Well i ----ft Drainage Way, --___ft , Property Line 6 ft Other 1---- ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity y to holes) -------------------- C!' D \ Parent material(geologic)- �r,; �I1 Depth to Bedrock �1 W Depth to Groundwater. Standing Water in Hole: Weeping.from Pit Fpce Estimated Seasonal High Groundwater_ G 0 1139W T_g7 _ Method Used: DETERMINATION FOR SEASONAL HIGH WATER'I'ABj,E Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: in. Depth to soil mottles: in. Index Well# g index Well level .. (n. Groundwater Adjustment _ ft. Readin ,Date: _ Ad. Actor Ad•fltw dwater Level PERCOLATION TEST Observation Hole# 1 l Time at 91, — Depth of Perc . Time at 6" Start Pre-soak Time @ Time,(9"•6") End Pre-soak. Rate Min.%ch Site Suitability Assessment: Site Passed Site-Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-----------. �**If percolation test is to be conducted within 100'of wetland,you must,first notify,the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC 5 r S DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis en % rave 6-/o lb DEEP OBSERVATION HOLE LOG Hole,# Depth from Soil Horizon' Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, a Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. onsi ten Flood Insurance Rate Map: ,/ Above 500 year flood boundary No_ Yes v_'__ Within 500 year boundary No V' Yes Within 100 year flood boundary No Yes:. Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us material exist in all areas observed throughout the area proposed for the soil absorption system. If not,what the depth of naturally occurring per sous material?��.._:.�. Certification I certify that on f (date)I have passed the soil evaluator examination approved by the Department of Envir ment 1 Protection and that the above analysis was performed by me consistent with . the required training,exper' e d ex erience described in 3 10 CMR 15.017. Date Signat ' fl Q:\SEpTIOPERCFORM.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION " ^ F n = �t .. t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Q Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 F—) Owner's Name: MRS.GREGORY Owner's Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Date of Inspection: 2/2/01 1 RECEIVED Name of Inspector: (please print) JOHN GRACI r Company Name: SEPTIC INSPECTIONS FEB 1 6 20 01 Mailing Address: :--P.O.'BOX 2119 TEATICKET,MA.02536 TOWN OF BARNSIABLE { u Telephone Number: 508-564-6813 FAX 508-564-7270 HEALTH DEPT. 1 F•.,: 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 t 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: X Passes _ Conditionally,Passes _ Needs Furth Evaluation by the Local Approving Authority _ Fails Inspector's Signature: Date: 2/2/01 The system inspector shall submi 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 r, THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. u.. ****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. `' r,u f , i Title 5 lncnPrtinn rnrin h/I Snnnn �' 1 R,. Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �i,.CERTIFICATION (continued) Property Address: 326 PRINCE HINKL.EY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date of Inspection: 2/2/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any informatiowwhich 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: ,S x THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. 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. n/a 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/a n/a Observation of sewage backup or'break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ .broken pipe(s)are replaced _ "obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required 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 pipes)are replaced _obstruction is removed ND explain: n/a Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS 3' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Fu , CERTIFICATION(continued) Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date of Inspection: 2/2/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further,e valuation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functionirig;in a manner that protects the public health,safety and environment: _ The system has a septic tank'and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface'water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. a _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicate'sihat 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: n/a '' Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date of Inspection: 2/2/01 D. System Failure Criteria applicable to all systems: >, You must indicate"yes"or"no'to each of the following for alLinspections: 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 ''/Z 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 nLa. ${ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water"supply. X Any portion of a cesspool or privy is within a Zone I of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy.is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) _ (Yes/No)The system fWh. 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 r`=t necessary to correct the failure. E. Large Systems: s To be considered a large system the's stem must serve a facility with a design flow of 10 000 d to 15 000 d. g Y Y Y g gP gP 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) 4 L, s 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(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water suppfy well If you have answered"yes"to`ahy" uestion in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system tins 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. c d i' Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date of Inspection: 2/2/01 i' 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 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? r �. X _ Was the site inspected for signs of break out`? f X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] l. }i 5 Page 6 of. 11 , s OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS _ w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date of Inspection: 2/2/01 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: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL s ' Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records f Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons-- How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.-Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 15 YEARS OLD Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date of Inspection: 2/2/01 BUILDING SEWER(locate on site plan) Depth below grade: 14" Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC Distance from private water supply well or suction line: n/a '� Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:8" Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7"W Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 1" Distance from top of scum to top of outlet tee,or baffle: 6" Distance from bottom of scum to bottom'of outlet tee or baffle: n/a f How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related . to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING , EVERY TWO YEARS. r GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_meial_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc`.)':;; n/a ��r r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM MSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date of Inspection: 2/2/01 TIGHT or HOLDING TANK: (tank must:be pumped at time of inspection)(loc;ate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(expl tin): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a 4 DISTRIBUTION BOX: X(if present;must be opened)(locate on site plan) Depth of liquid level above outlet invert:.LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a • s R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date of Inspection: 2/2/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system .:Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD Y OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 3' OF WATER IN IT. CESSPOOLS: (cesspool must be:pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 is Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date of Inspection: 2/2/01 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. 6CL g. p C O 4A qj� AC S� cc 1 d j �n i Page 11.of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 326 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Owner: MRS.GREGORY Date or Inspection: 2/2/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavato'rs,?installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established ihe'high ground water elevation: USGS MAPS AND CHARTS- 12+FEET ,u r l ` . r 4 LOCATION ` 4EWAGE PERMIT NO. ' L A% IL VILLAGE Ila I� I N S T A LLER'S NAME & ADDRESS 6 U I L D E R OR OWNER r --'et J k a4r iP DA T E P ERMIT ISSYfD` ` DATE COMPLIANCE ISSUED �� , � % ' ��� y��� ���� � ��, f No. l.:"•�1...... FEE........... ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH .......O F...... .............................. ...... 0"..................................... Appliratiun for Di"uutti Works T uBtrnrtiun runat Application is hereby made for a Permit to Construct ( ) or Repair (\.,)��an Individual Sewage Disposal SyS . --_.... .. ............................................... ............... .................................... ml� 4� �S4 � a-_..•••••- Location-Ad ress _, ^o Lot No. ..............4!` ............._................................. ................_.__. ............................ ..... -........ .. 2wne — Address ................................................................................................ ...............••• ------------- ........................................... Installer Address d Type of Building Size Lot........1'd_/.&4WSq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder (/)a Other—Type e of Building ............................ No. of persons.......... Showers — yp g p ( ) Cafeteria ( ) Other fixtures --------------------------------- - Design Flow....... . ].5.....................gallons per person per day. Total daily flow------------------- ..........gallons. 04 Septic Tank—Liquid capaci .N'4..gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No.j_ ------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of, Test Pit.................... Depth to ground water....................... P4 ••-•••••-•••-•------•-----••••......................••••--...................----......••---.................................................................. 0 Description of Soil........................................................................................................................................................................ x w x -----------------------..............................................................................................................•-----•-•••••••------•--•----•----••••.....-•••-••-•-•----•----••- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•••---------•••---•-••••••••••-•••...-•••-•-••-••--•-•-•-----•••............................................•••-•••••••••••••-•-•-•.....••••--••••••-•---•--............._..........--•••----••- Agreement: Th ndersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the P. ei oljs of TITLE 5 of the State Sanitary Code—The undersigne urther agrees not to place the system in ope pvretd o ompliance has been is ed by the b and health. Signed A PPY ...... ::. ......................=..... ......--............._..... ;. .l� ...�.................. Date Appfor the f ollowin reasons:-----•-----------------•---------•--------------------••----•-----------------•----------- ................. -•-•................•----.......---------...........----------...................---......................--•--•--•---------------...------•-•---•-----------------------------------------•••••-•-----•- Date PermitNo......................................................... Issued....................................................... Date 7 c � x No.r..........I..... FEs.... -........ THE COMMONWEALTH iOF MASSACHUSETTS' BOARD OF , H E AL,T H 3 .........OF . ... ,.tea rj z<I l ApplirFatioaa for Dhipw3aliVorkri Toaautrartion p0mit Application is hereby made for a Permit to Construct.. ( ) or Repair ( ) an Individual Sewage Disposal,: System at: .. ..... # �,�n�! Location.Address j / //} (/+ or Lot No ........................ --ty;.��f�..C<:.^......................................... .....�....... �^1 u5�'s`:B'�. �................................................ 3� Owner Address F Wt ............................................•.. ............ �'- ._...... Installer Address 5 ¢ Size Lot Type of Building q __--•_ '�Fri_Y_.: S feet Dwelling—No. of Bedrooms.............. ? ._.:_ ....._Expansi'on Attic ( ) Garbage Grinder Other—Type of Building ............. . No. of ersons" YP g -._ ._,..._ P ............................. Showers'.( ) — Cafeteria. ( ) ^ 0.' Other fixtures ................................................ �._.. .... Design Flow . .°� .,� gallons per person per day.-Total Total Bally flow .. ..._. gallons WSeptic Tank Liquid capacrt����'°rt..gallons Length ___-. Width Diameter Depth................ Disposal Trench—'�To Width......... ._.:Total Length"_ ` _ Total leaching area....................sq. ft. x' VA Seepage Pit No.j.!� .� ''..... Diameter.................... Depth below inlet ............... Total leaching area... .....sq. ft.' Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by....................... .......... Date............................... Test Pit No. I.......... .....minutes per inch Depth of Test Pert----- Depth to ground water........................ r-T Test Pit No. 2_______________minutes per inch Depth;of Test Pit__._ ........._.. Depth to ground''water...... ................. -•---------------------------------- ------ ......-----------•. . ...............-•----........-••---•-•-•.............•--..............--.. -- O. Description of Soil, -----------••- x, U ------ ------------------------------------------------------------------•-----•---------- W ---- -------------------------- --•---- ---- • ------------- UNature of Repairs or Alterations—.Answer when applicable . _._...... _._................. ........ ...................................................-------------••-•-••-•-----•--••-------- ....... -----•--•--•......-- --••--------------.. •... ---•-- •-_. .......... w Agreement: Th.-Indersigned,agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the pro •�ons of TITLE ' 5 of the State Sanitary Code ' The undersigned„further agrees not to place the system in i. X operatio nt- aeC' rtih of mpliance has been issued by the board of Health: r y � �`/ , Signed . . ----- ------;� . ----...-•-• ----•- . ., � ate' pplicati proved By.. ....- -- �. -----•_-•---- i Date ; APPI. tion Disapproved for the f ollowin `rea' ons:...-- •----- ----------------•-... ----...-•-••.........--•---•---•----------..-- •----------•---• Date i ` Permit No......................................................... Issued....................................................... Date THE COMMONWEALTH;OF MASSACHUSETTS BOARD OF'.HEALTH "y OF.............: .... .... ................ Trrtif iratr of faout li�tn �e THI IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( r Repaired ( ) y.. ✓ / ) ss ler * at........../.-�" I_g-.. - l,f.d�a.O.....V', r ....................................... . . ... has been installed in accordance with the provisions of TLF 5 of he State Sanitary Co as ` escribed in the, application for Disposal Works Construction Perm T �'��� __..._._... dated/ /�,.:�............. THE'.ISSUANCE OF`TNIS�"CERTIFICATE, SHALL NOT BE CONSM91),.A�S A GUARANTEE THAT THE SYSTEW WI L F,UNCTION SATISFACTORY DATE �� { . •-------- •------•-•-----•-•--- ------. Inspector-- --- -------- -------- -------- -------- - --------- ? THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF =HEALTH :a .<s ...............................oF.......... ... .... . = S No.. FEE•: ................. Ui�Omt ork Ia1 u x.y:n rrutt# +# Permission is he � grantedr .. ..---- •-••--••----•-•-- •... ... ... �., ' R-2---•- ---•- -to Constru e a ( ) ivld Se` ge Dis s stem Sheet �, as shown on the application for Disposal Vl'orks Construction Permit N 'r....-_____... Dated------------------------------------ �. . ....•. --- ----•----- ••-- --- ------------- ••---•-- f Board of Health DATE....__.... - k FORA 12$5 A M. SULKIN, INC BOSTON L SINGL>= °FAMII-Y ;5 BCOROOM IJD GARB��GE �jWND�2 Lo - 110 A 3 - Z30G.Pp g8•oo fT p fat t_�( F� ln/ ' - , " 5EPT1G TA►JK -% 330x15o'/• r A956:P. U$1✓ l000 GAL. 015Po5AL PIT uSE ' Ivo0 GAL. i 5%Pr-WALL AV-SA. z %,o s.ti 1 S.F X �.•5 z9 137`! G.P� -- �'iT 1 �fP ': 5 Q � BOTTOM rAgF-A r • �o S.F. ,t�A�f k� �o S.F X. loo -ToA1- pE.�16N * '�25 (,.PD• 2 PAP T -TOTAL. T>A I t-Y Fl,-oW .. 33o G,Po. /5 �$ f. PaZCOLATION GZATEI I'�IN ZAn1 oP-LE5514 ��••-� i ••` 1f. !'ovA/DA7'/DAI ` .. b .,N OF ALAIy RICHARD W. I I Z' ABAX. JONES ' � c ,I u ER No.224048 STEpQ` ` ,Ss.i y �r 20 ► I 57 TOP FWD- 100u lN�• FA i '31JiGK► D 1 ST. I N V G° S¢8 r TANK LEAG11 i' PIT INV. INV, is WA;NGD S .. 6TvNG GERTtFtGD PLcT Pl-A-W PRUF1LG Loc4•T ►oN �VIU.L3 �`` ; Ii�Lr f No. CALE t �AT � ' "IrZ1' ,i• rl p P L.P,t�I RE F E IZE►� GE �I 1 GER?�FY 'BRAT TNT �oUl,'►-)alloiA SNowN � NE 2EOI,1 GOMPI-`(5 1nitTN"tNE �,1 o�L%W� I �y A►�D S6-rev&cX R.6gqv� I�rZ,�.EMENT� dT -(ca W N p F �31�(�iTA�C.(� A,N� I S NO"�" ..�. L D 11J 1-1'6 G o o D OCATE WIT r i . DA.T E 1-12- 614LBAxTEcz.e tiYE INC. _EG I SZ 1=26•D'%.A"D S u�.Y Tins PL&.N 15 ^4OrT aN6r D o►d AN os�l-E2vILLE • MAss• i II INS-T-R�MENT V ZVey �--rHE o NoT i3E u5EDTo OE'TE.Rl�t>.1� t_.oT -INE.�j APPLICArIT �LAIJ MALL ` SORS MAP:.ASSES , TEST HOLE LOGS PARCEL: Q U. '— �WA4661 FLOODZONE. SOIL EVALUATo .� NOTES: WITNESS V_ L REFERENCE: DATE:w a Z PERCOLAT I a RATE: G '�'Nt 1 1) The installation shall comply with Title V and Town of Barnstable Board of Health c=7c. Regulations. Z J �✓ r I ti . - 2) The installer shall verify the location of utilities, sewer inverts and septic components nor to Po P _ : installation and setting base elevations. TN 1 TH 2 g 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8 r foot.The first two feet out of the - i l� �., d-box to The leaching shall be level. g l 3 4) This plan is not to be utilized for property line determination nor an other r "1 P P Pent Y purpose other than lfl h r '1 the proposed system installation. 5 All ► , � ) septic components must meet Title V specifications.... r? b '� � � 6) Parking shall not be constructed over H 10 septic components. .$1 7 The property is bound r LOCATION MAP .0 - Mr.t>lJ1 ) P PertY bounded property property�� o corners and ro Imes. 8) The property owner shall review designconsiderations to approve of total design flow and PP l� ,i number of bedrooms to be considered for design. Receipt of payment for the plan and �13 c� _ installation based on the plan shall be deemed approval of the design flow by the owner, 9) The existing leaching or cesspools shall be pumped and filled with material r Title V - abandonment procedures. Those within the proposed SAS shall be removed aloe with , along contaminated soil and laced with clean washed sand r Title V specs. replaced per rr, r 10) System components to be 10 feet from water brie. Sewer Imes crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. 0 Q' 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such., 12) The installer is to take caution m excavation around the gas line if applicable. SEPTIC SYSTEM DES I GN If 1-4/9 FLOW ES�"I MATE .. � BEDROOMS AT D cAL/DAYlBEDRooM• ✓IV GAL/DAY �' jrc,Sy bQG✓ RF.CAR.t SEPTIC �.3 0 GAL/DAY x 2 DAYS GAL 3 E -. USE IOO� GALLON SEPTIC TAN X.i✓Tl K W� ti QF = /� �SORPT1ON SYSTEM � s` o�' DAVIDAj y t7 UU MASO v, �C '�5T �✓' N N y 9 0.1066 y 1 W c�7 (JUw� /STeRE �raa►A .a l roo _i SIDE AREA. X I .�— y.,_ (�,. BOTTOM AREA: Z I?J 0�� = `�,'' �� ,.� , 07 5 I C SYSTEM SECTION . I / G , W, All Id 6MllU r r-i �o (�q 8 n O -� 0 GAL M �! ► --T S — Sa SEPT I T , 8 ETC TAW 8 SITE AND SEWAGE -PLAN LOCAT i ON : 32 �`IC HIWC� �� ILVILI.E , M� a PREPARED FOR : i Oyu G �� a � � a 0 o - - SCALE: W DAV I D B . MASON ZS DATE: 3 b o _ DBC ENVIRONMENYAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA W _ t508) 833- 2177