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HomeMy WebLinkAbout0072 ROLLING HITCH ROAD - Health 72 Rolling Hitch Road Centerville P A = 192 064 IIII �RECYC(goC UPC 12543 w' M-13LQ `bsrco '� NASM109,MN i i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is Centerville MA 02632 _ required for every .. /ecatioLA page. City/Town State Zip Code Date of 1 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:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not A. Riker JAI{ use the return Name of Inspector key. R.L.C. —v Company Name P.O. Box 726 Company Address South Yarmouth MA 02664 City/Town State Zip Code 508-776-6460 S14590 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date -/Cl 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. t5ins-11/10 Title 5 Official InspnFo : urface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Rolling Hitch Road ' Property Address Nowak S. Owner Owner's Name information is ll entervie MA 02632 e required for every C ��� bo page. Cityrrown State Zip Code Date of I sped on B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: On inspection of system there were no obvious signs of failure observed. System was issued a certificate of compliance for a installation dated 04/12/2004. System was approved for four bedrooms with engineer's letter on file dated 04/13/2004. 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 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. ❑ Y ❑ N ❑ ND(Explain below): ` 1 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every Centerville MA 02632 page. Citylrown State Zip Code Date of nspe ion 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 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 ❑ 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•11110 Title 5 Official inspection Foam:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy< 72 Rolling Hitch Road Property Address .Nowak S. Owner Owner's Name information is Centerville MA 02632 ,� ff VZL4 required for every ' page. Cityrrown State Zip Code Da ection B. Certification (coot.) 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 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 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is Centerville MA 02632 required for every i s page. Citylrown State Zip Code D to 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. ❑ ® 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 0 g , QO 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 r ❑ ❑ 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every Centerville MA 02632 r, page. CityfTown State Zip Code Dpfte 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): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 GPD t5ins-11l10 Title 5 Official Inspection Fond: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 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's(dame information is required for every Centerville MA 02632 page. Cityrrown State Zip Code b#fe of Inspection D. System Information Description: Property was a foreclosure with last date of occupancy unknow. Unable to contact previous owners. Number of current residents: 0 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2011= 1 GPD 2010= 176 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unk.Date Commerciallindustrial 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy< 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every Centerville MA 02632 q / page. Cityrrown State Zip Code D e of spection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: not required at time of inspection 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•11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I , Commonwealth of Massachusetts Title 5 Official Inspection Form II� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every Centerville MA 02632 1 ®hInspection page. Cityrrown State Zip Code to D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Installed in 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: ®cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Interior piping had no indications of leakage observed.There is a in-ground sewage pump for basement bathroom. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) 1500 gallon H10 concrete tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1 IT 5'6"W 66" H Sludge depth: 10" t5ins-11/10 Title 5 Official Inspection Form: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 yy� 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every Centerville MA 02632 012 page. Cityrrown State Zip Code u to Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" 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 How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet cover has paver pation over cover with outlet cover 12"below grade with 12" riser installed.PVC tee s in place with gas baffle on outlet. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'� 72 Rolling Hitch Road Property Address Nowak S. Owner Owners Name information is Centerville MA 02632 required for every VO4 201?_ page. City/Town State Zip Code dite df 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.): -regular pumping is recommended 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Dis posal sposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every keinspection Centerville MA 02632 012 page. Cityrrown State Zip Code D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert equal to two outlets 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.): No evidence of carry over or leakage out of distribution box. 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y�< 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every Centerville MA 02632 1 /2012 . page. City/Town State Zip Code ClaZe of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: U500 gallon w/4'stone ❑ 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.): , no indication of effluent present above area S.A.S. Soils above stone were free of staining with no standing water in bottom of chamber inspected with riser. 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 t5ins-11/10 Title 5 Official Inspection Forth: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 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every Centerville MA 02632 6 . / 03 page. Cityrrown State Zip Code Date 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-11H0 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 72 Rolling Hitch Road. Property Address Nowak S. Owner Owner's Name information is Centerville MA 02632 required for every � /2012 page. Cityrrown State Zip Code bite 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 I ?d �S = 58 ° 3 5 = -3 33' q yi 37 t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 Codimonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every Centerville MA 02632 DD�� /2012 �� page. City/Town State Zip Code to of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12+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 2004 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Soil test data on file 03/29/2004 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file at Board of Health indicated water was not observed at 144" . Installation was issued a C.O.C. with engineered plan on file. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts _ W Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Rolling Hitch Road Property Address Nowak S. Owner Owner's Name information is required for every Centerville MA 02632 01/2012_ page. Citylrown State Zip Code D to 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION ` ill re N xD SEWAGE # � `X`f7 VILLAGE ��'� ASSESSOR'S MAP & LOT �� 'el INSTALLER'S NAME&PHONE NO. V��� C �� �� ✓'� a� SEPTIC TANK CAPACITY LEACHING FACILITY: (type)/eiG <) (size) NO.OF BEDROOMS �` c.�%`a �,��i* �,� •�,, ; BUILDER OR OWNER .�`C��� '�� PERMIT DATE: ""E"�COMPLIANCE DATE: Separation Distance Between Maximum Adjusted Groundwate�Tab a and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) : Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by. ��' 7 C 73, CP e_ TOWN OF BARNSTABLE LOCATION mac' r"' 41,rCR ,?D SEWAGE # VILLAGE ' e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ' LEACHING FACILITY: (type)/=il Eel NO. OF BEDROOMSiw �' Tf`>st c./.ir•�. t�%�.f' ' BUILDER OR OWNER PERMITDATE: 'mom`�'' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) f Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Adz E; 6 C3 No. Fee 6(79 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ^ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes 2pplication for 33i5po5a1 *pgtem Construction Permit Application for a Permit to Construct( . )Repair( Upgrade(I-)Abandon( ) O Complete System O Individual Components Location Address or Lot No. 7.D. !/[o«/y9 �{/G�� Q Owner's N�m�e,Address and Tel.No. Assessor's Map/Parcel i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. `Tfjy .�C�oGsv� s' o-70 7 �,a'P/.o 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 S��'�"�.�e�-.►� �� gallons per day. Calculated daily flow y y� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank is-ao 9aZ- Type of S.A.S. /3X 3� C of 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 Certifi- cate of Compliance has been issue y is oard of Health. Signed Date Application Approved by Date Application Disapproved f r the following reaso s Permit No. Date Issued Fee -THE CO�AIOIONWEEAAL`-TH OF MAS§ACHUSETTS Entered in computer: "�'�''_,,�"•.- Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS F�M 11ppricatfon for Mtzpooal *pttem Construction Permit Application fora Permit to Construct r pp� -, , ( . )Repair( l�Upgrade(Abandon( ) O Complete System 0 Individual Components Location Address or Lot No.-7Z /Co Zl/y9 4 C AQ Owner's Name,Address and Tel.No. Assessor's Map/Parcel •-. Installer's Name,Address;and Tel.No. 6 r Designer's Name,Address and Tel.No. O 7O 7 t -D.,+' -/,o /Jj d Jo, S Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No,of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow__S��tv.P o0,+1 S'3 d� gallons per day. Calculated daily flow gallons. Plan Date _T 3P o Si Number of sheets Revision Date t Title Size of Septic Tank Type of S.A.S. i3X 3A"'X,Z Description of Soil; t , Nature of Repairs or Alterations(Answer`when applicable) Date last inspected:. ' Agreement: ! The undersigned agrees to ens a the construction and maintenance of the afore described on-site sewage disposal system fk 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 y„ is.Board of Health. Signed y7 A"I j tv fig ,,i,—,. Date �'` Application Approved by r t:. Date . Application Disapproved for the following reaso s / A a--' ` / Permit No. Date Issued - ---.----=--------------------------------- ST ���°'�°`� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSEWS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( l�Upgraded( ) Abandoned( )by �i�ia cc.Ovc�`UF at >Z iP o,e L 1,✓, �yi rn,4e oP _has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N( dated Installer(-'fi m -e Designer rVAI o(QP The issuance of this pg tshall n t be c nstrued as a guarantee that T' asyste wll n�onasdesigei.Date Inspector . r ---------------------------- — No. Fee `1— v r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Migogal *pztem Congtructfon Permit Permission is hereby granted to Construct( )Repair( 4)'Upgrade O)Abandon( ) System located at --> .•22�c<<�r�q /f►riTG,S/ ?!� C c�`�✓T. 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 7/6 be om feted within three years of the date of this pe Date: "'7 I Approved by z _4 Town of Barnstable Regulatory Services Thomas F.Geiler,Director `"� Public Health Division Thomas McKean,']Ii►rector 200 Main Street,Hyannis,MA 02601 Fax: 508-790-6304 Office: 508-862-4644 Installer& )esigner Certification Form Date: Designer: ��b/d d ,r Installer: Address: � . Address: 7/f' � on was issued a permit to install a _ (date) (installer) �11TG / ,,5- based on a-design awn y._ septic system at (address) G� .�.d�v.1J •�3• ,�(f'��✓ dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank- I certify that the septic system referenced above was installed with major changes (i.e. greater than 10, lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. ees i gner Signature) (Affix Designer s:-Starrip Here) PL E RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL- NOT BE ISSUED UNTIL BOTH—THIS, FOB AND AS- BUIL.T CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.. Q:Hea1dYScptic/Desi9ner Certification Form I Commonwealth of Massachusetts Executive Office of Environmental Affairs -+ 9 Department of Environmental Protection '/&N VAlK r F.Weld to lob, q Cox* or Argeo Paul Celluccl y� hS oF� u.Gommor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` ' QCERTIFICATION Property Address: 7 2 /A�'I ' Address of Owner. Date of Inspection: g 7 (If different) Name of Inspector. Company Name,Address d Telephone Number. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: +� Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: �/ Date: �-_ /S— 9 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional_off_ice_of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Boatel of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-S500 A iJ Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: { Owner. (� Date of Inspection: 4B]SYSTEM CONDITIONALLY PASSES (continued) _ acSewage,backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) o%due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF.A,PPROPF.Y.kTE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PR6T-E--CT THE a LM'—T1U N i,D SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER s (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to aor the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesapool or privy is within 50 feet of a private water supply well. Any-portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for eoliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist- the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone lI of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 � L , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Y PART B CHECKLIST Property Address: Owner. Date of Inspection: Check if the following have been done: ./Pumping information was requested of the owner, occupant, and Board of Health. =None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. t�IINx built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. 1C A11 system components, excluding the Soil Absorption System, have been located on the site. ��The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. size and location of the Soil Absorptions Svartem on the site has been determined base: on siting%fati=s �?r __ approximated by non-intrusive methods. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ?-x- ,� --__ z /d`c.�cJ� '�••�sa w�JP Owner. �j -► Date of Inspection: ' —P' — er-7 FLOW CONDITIONS RESIDENTIAL: Design flow: 3 3 0 sallons Number of bedrooms:_ Number of current residents: O Garbage grinder(yes or no):-A-a-i Laundry connected to system(yes or no): ,1i1/ Seasonal use(yea or no): AIV Water meter readings, if available: Last date of occupancy: COMMERCIALAND USTRIAL- Type of establishment: Design flow: gallons/day Gres"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: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: n Q off, System pumped as part of inspection. (yes or no)-/0 If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yea or no)AIV (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:- Owner. Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP_other(esplain) 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) (revised 11/03/95) 6 r e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity: eallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,_evidence of solids carryover,evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order-(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .=. PART C SYSTEM INFORMATION(continued) Property Address: ..- Owner. Date of Inspection: �— `3' Y-7 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc. CESSPOOLS: (locate on site plan) Number and configuration: t 0­1 Depth-top of liquid to inlet invert: ,.7 mac.,: b,;•-L Depth of solids layer: Depth of scum layer: Dimensions of cesspool: 0 Materials of construction: Cr,. . Indication of groundwater: inflow(cesspool must be pumped as part of inspection) - - - - 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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: Owner. Date of Inspection: — F1— o+—7 SKETCH OF SEWAGE DISPOSAL SYSTEM: iaehide ties to at least two permanent references landmarks or benchmarks ]ovate all wells within 100' r� / 0 ----------------------- 01'7 DEPTH TO GROUNDWATER Depth to groundwater.-i`(11 feet method of determination or approximation: (revised 11/03/95) 9 }Sala—t �} SI2t/m' 4 a em - — a�ie� P -Dam ' a , - f 4 �y ASSESSORS MAP : T I� - TES I HOLE LOGS -A), - PARCEL : (p NOTES: Q FLOOD ZONE: �AD (-- QL��C� ._1,, ✓.- SOIL EVALUATOR : WITNESS : r REFERENCE—T�,V- C) � ,-_g_O_I.1_� I j DATE: 1q� -I�2 2�00 PERCOLATION RATE: i) The installation shall comply with Title V and Town: of Barnstable Board of c � Health Regulations. 2) The installer shall verify the location of utilities, sewer inverts and septic TH- I TH-2 components prior to installation. QL,,' LOAD 3) All gravity septic piping to be 4 inchSch 40 PVC at 1/8" per loot. Al �� 17 4) This plan is not to be utilized for property line determination nor any other S i -.1 ti --' purpose other than the proposed system installation. '� �� / `� `�� 5) All septic components must meet Title V specifications. �� 6) Parking shall not be constructed over H10 septic components. LOCATION MAPC`-h5� 34' " '��� 7) The property is bounded by property corners and property lines as depicted. 8) The property owner shall review design considerations to approve of total P P Y � PP . � number of bedrooms to be considered for design. Receipt of payment for the C I plan and installation based on the plan shall be deemed approval of the number of bedrooms. / 9) The existing cesspool/septic components shall be pumped and backfilled per Title V Abandonment Procedures. 10)Proposed leaching is to be within 36 inches of grade or provide venting or cut grade as permitted by the Board of Health. 11)System components to be 10 feet from water line. SEPTIC SYSTEM DESIGN FLOW ESTIMATE BEDROOMS AT //0GAL/DAY/BEDROOM - 3,-aAL/DAY l - SEPTIC TANK 0 r `-��QGAL/DAY x 2 DAYS - GAL 0 © 0 0 /0 USE �50CbALLON SEPTIC TANK � �C�j°+2 _►�-c.t�� .��tt�lrj�-�L-1,•.�� 1��2.�(I T� / SOIL ABSORPTION SYSTEM � r n R. VjP SIDE AREA: 4 "4 J, BOTTOM AREA: I z � 0r� . 5Z. i.'. „. ) r� G aSEPT L" SYSTEM SECT I ON CK �-?,3 ,i -, � �2 J!,I� of► �C q it -- --- --- -fry---- � �0� \ BB// Fr� } �..�...'1 CJ`-� ✓ 1�^' I GAL SEPTIC TANK '�t'�L�rl ^I`C`,� -� �I- .�vugv Wt �t�►�- 1 .. _ . - 1 i SITE AND SEWAGE PLAN LOCATION : Z ► �{ �� �g PREPARED FOR : j t �., c 5i/. o SCALE: ��'`Z0 1 0 (Pal 7 DAV I D B . MASON ,I�t DATE: 5IL1104 Z DBC ENVIRONMENTAL DESIGNS z EAST SANDWICH . MA W DAT HEALTH AGENT ( SOS ) $33- 2 177 Z