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HomeMy WebLinkAbout0006 SCUDDER BAY CIRCLE - Health 6 Scudder Bay Circle Centerville P A - 188 103 UPC 10259 Q No.H_3OR NAOTINOO UN T WN OF BARNSTABLE LOCATION �G V t �/ � SEWAGE# VILLAGE R . vv Oi4e, _ASSESSOR'S MAP&PARCEL AME&PHONE NO. lJ�-P SEPTIC TANK CAPACITY 1 Q 6 o LEACHING FACILITY.(type) 16tl ; '' � �� (size) NO.OF BEDROOMS OWNER V�r / PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Ae`L 9!60t4—C®.1S1a1- 7�/ 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) NI Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin cility) N Feet FURNISHED BY `� /ylI LG O/U� 9�z 23 8z 33 24 o Z Cc Fa gC 3 Commonwealth of Massachuseft Title 5 Official Inspection Form Subsurface Sewa Disposal Syst+sm Form-Not for Vduntary Assessments � 6 rcudder Bay Circle Centerville MAC RopertyAddms James T Flannery 6 Scudder Bay Circle 6a r rw lnnffo ationis Q" Centerville MA 02632 7/15/2015 requkedforevery page- Cify5own State Zip co le [We of Inspection n' inspection results must be submitted on this form-Inspection forms may not be altered in any way. Please see completeness chocldist at the end of the form. I"p°'tar& A. General information onrr... froth out vul the cotrputer, lY use only the tab 1. Inspector. key to move yotr uuartIns seethe or-dretum ode i Sepehe* key. Name of Inspector 17 Northside Dr. 4 Oozy Nam Cbnpany Address CRyf own SWft 3�.)• �� L1 �I 1 q-74cbde 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 1&340 of Title 5�(310 CM R 15.000)..The system: l."1 Passes ❑ Certditionaily Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority lnspftfs agr>ab" Date 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 write or different conditions of use. Ms-W3 TweSomcls e6pecom Fem[suourace armageolapow symm-Page tom �o� '�S ` Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewgjr D sal System Form-Not for Voluntary Assessments cer Bay Circle Centerville MA RWWIyAddms James T Flannery 6 Scudder Bay Circle Info pion is °""ems"�""� Centerville MA 02632 7/15/2015 required for every page. CRyfrown State Zip Code Oate of tispection B. Cerfification (cons) Inspection Summary: Check A,B,C,D or E/alwayscomplete all of Section D A) System Passes: have not found any inibrrnation which indicates that any of the failure criteria described in 310 CHAR 15.303 or in 310 CMR 15-304 exist Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the rel*c at-er7 t, as approved by the Board of Health,will pass. Check the box for ayes", "rW or"not determined"(Y D)for the following statements. if"not determined,"please explain. The septic tank is metal and over 20 y old'or the septic tank(whether metal or not)is structurally unsound, exhibits substantial MR on or exfiltration or tank failure is imminent.System will pass inspection Nthe existing tank i d with a complying septic tank as approved by the Board of Health. 'A metal septic tan pass inspection if it is structurally sound, mart leaking and if a Certificate of Compliance indi Ing that the tank is less than 20 years old is available. ❑ Y N ❑ ND(Explain belowr Waa-3M3 Wesorftlal mspea6anFamc Sue®,rae Sump.obposel syslere•Page2of17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Di osal System Form -Not for Voluntary Assessments 6 S�cud�er Bay Circle Centerville MA " Roperty"'ddreim James T Flannery 6 Scudder Bay Circle for ation is °"'"�S"a"� Centerville MA 02632 7/15/2015 required for every page. 0yrrown State Zip Code We of hspection B. Certification (cons) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(coat): ❑ Observation of sewage backup or break out or high static water level i e distribution box due to broken or obstructed pipe(s)or due to a broken, settled or une 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 ❑ N ❑ ND(Explain below): ❑ distribution box is lever or replac ❑ Y ❑ N ❑ ND(Explain below): ❑ The system require mping more than 4 times a year due to broken or obstructed pipe(s). The system will pass i pection if(with approval of the Board of Health): ❑ broke ipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ o ruction 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 mannerwhich 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 One 3n3 Tine 5of6dd InspecGonFamc Submdace Savage Disposal System-Paige 3of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a DI oral System Form-Not for Voluntary Assessments s 6?Cuder Bay Circle Centerville MA RopertyAddress James T Flannery 6 Scudder Bay Circle inforrretion is °"'"�S"a"'Q Centerville MA 02632 7/15/2015 required for every page. Glyfrown State Zip Code Date of Inspection B. Certification (conQ 2. System will fall 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 93P.SAS is within 100 fleet of a surface water supply or tributary to a surface water su ❑ The system has a septic tank and SAS and the SAS is wit ' a Zone Tof a public water supply. ❑ The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and t AS 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 er analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates nt and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, pro ' ed 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 ❑ Is41( Liquid depth in cesspool is less than 6°below invert or available volume is less than'%day flow ��,3M3 Tiee50HIM hispectimFame Subsmtase Sewage Disposal System-Page 4at17 le Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Scudder Bay Circle Centerville MA RopertyAddress James T Flannery 6 Scudder Bay Circle Ow ner ow"ems Hartle information is Centerville MA 02632 7/15/2015 required for every page. Cityfrown State Zip Code Date of hspection B. Certification (cons) 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 filet 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 pprn, 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. ❑ afi 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 design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either yes"or"no"to each o Ilowing, in addition to the questions in Section D. Yes No ❑ ❑ the system is with' 0 feet of a surface drinking water supply ❑ ❑ the syste s within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the stem is located in a nitrogen sensitive area(Interim Wellhead Protection — IWPA)or a mapped Zone II of a public water supply well If you have a ered`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. t9 s•3/13 Tide50f6aA 1mpecfWnFame Subwrface SewQge0lspasst System-Page 5af17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa Di sal System Form -Not for Voluntary Assessments 6 SQcudr Bay Circle Centerville MA Property Address James T Flannery 6 Scudder Bay Circle Cw Ow ner's Name inffor ration is Centerville MA 02632 7/15/2015 required for every page. atyfrown State Trp Code Date of Inspection C. Checklist Check if the following have been done. You must indicate`des°or aroe as to each of the following: 'Yes No G� ❑ Pumping information was provided by the owner, occupant,or Board of Health ❑ L1d Were any of the system components pumped out in the previous two weeks? ❑ C1 Has the system received normal flows in the previous two week period? ❑ Ltf 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) ITV ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑. Was the site inspected for signs of break out? 9 ❑ Were all system components, t t y pon , 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: CjY ❑ 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)P10 CMR 15.302(5)) D. System Information Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms(actual): — DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Sm-3M3 rdeSOffuiatkwpectlmFamSubsurfaceSewagemspa System-Page 6ofv L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Scudder Bay Circle Centerville MA htopertyAddrew James T Flannery 6 Scudder Bay Circle Ow ner Ow ner's Name information is Centerville . MA 02632 7/15/2015 required for every page. Ctty/Town State Zip Code Date of Inspection D. System Information Description: So-/7 C o n k ��S �i►h�hw �.� Number of current residents: Afl Does residence have a garbage grinder? ❑ Yes^ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes flex No information in this report.) Laundry system inspected? /V��' ❑ Yes ❑ No Seasonal use? lK Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: C)a vo v Sump pump? Q.j /Awe //'rfgct •9n ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions` Type of Establishment: Design flow(based on 310 CM R 15.203): Gagons per day(gpd) Basis of design flow(seats/persons/sq.ft. Grease trap present? ❑ Yes ❑ No Industrial was o ding tank present? ❑ Yes ❑ No No anitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: tSns•W3 TideSoffidd bspecdwFarm:Subwface SmWeDisposd System-Page 7ot17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DI�poral System Form-Not for Voluntary Assessments 6 Scudder Bay Circle Centerville MA Flop"Address James T Flannery 6 Scudder Bay Circle CW ner taw pees Name inforrmlion is Centerville MA 02632 7/15/2015 required for every page. Cilyfrown State Zip Code Date of Inspection D. System Information (corn.) Last date of occupancy/use: Date Other(describe below): General Information YO/zo 1 L Pumping Records: 1�Q �/wwTt�• S121 I200 L Source of information: �0 tt god i Was system pumped as part of the inspection? ❑ Yes X No If yes, volume pumped: gam How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-313 Tifie5otfieid hspectimFomc SuWW=e SewageOispasai Sotam•Page 8017 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewa a Di oral System Form-Not for VoluTry Assessments 6 Sscud er Bay Circle Centerville MA n-DpegAddrm James T Flannery 6 Scudder Bay Circle Owner Q"nees name Centerville MA 02632 7/15/2015 information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes . No Building Sewer(locate on site plan) Depth below grade: feet Material of construction: cast iron 0•40 PVC ❑ other(explain): Distance from private water supply well or suction line: � ) feet Comments (on condition of joints,venting, evidence of leakage, etc.): C 61IP awew t s� Le- 0vr .e vi de�►�' Septic Tank(locate on site plan): Depth below grade- /• � �G ,/�� p g feet Material of construction: I 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: �02 X`rl 7 xSt7 1-10V Sludge depth: 19ns•3H 3 M8950ffidd hspectm Fame Subsuface Sexege Disposal Syftm•Page g of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Scudder Bay Circle Centerville MA RopertyAddrem James T Flannery 6 Scudder Bay Circle Qm ner Owner's Name information is Centerville MA 02632 7/15/2015 required for every kv page. City/Town State Zip Code Date of Inspection D. System Information (cons). Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N Scum thickness N i/* Distance from top of scum to top of outlet tee or baffle N &( Distance from bottom of scum to bottom of outlet tee or baffle 6?/4- r- How were dimensions detemtined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): A,tQ //4 2 o T- P✓L PV /.v g IV" 34 /ow S'T t fAl 4!2 P • Torn It t4 ?ok Grease Trap(locate on site plan): Depth below grade: fee Material of construction: ❑ concrete [I metal ❑ fiberg ❑ polyethylene ❑ other(explain): Dimensions: Scum thickn Dis ce 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: Data O s•3M3 Mffe50f dal6specdmFmrt Subsurface SewMeMposel System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a DI oral System Form -Not for Voluntary Assessments 6 Scud er Bay Circle Centerville MA RopertyAddraw lames T Flannery 6 Scudder Bay Circle nnaUon is Q" s" Centerville MA 02632 7/15/2015 required for every page. atyf row n State Zip Code Date of hspwdm D. System Information (cons) Comments (on pumping recommendations,inlet and outlet tee or baffle c ition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc..): Tight or Holding Tank(tank must be p ped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ must/be ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Capacity: gallons Design Flow goons per day Alarm pr ent: ❑ Yes ❑ No Alarm I vel: Alarm in worldng order. ❑ Yes ❑ No Date f last pumping: Date ments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No kips•3H3 TiGe50f dW ImpecOonFomc SU6suface Sevxegeoisposd syftm•Page 1f of f7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sevtra a Di osat System Form -Not for Voluntary Assessments 6 SacudTer Bay Circle Centerville MA Rx"rtyAddress lames T Flannery 6 Scudder Bay Circle owner °i"'" Naminfomtation is s"" Centerville MA 02632 7/15/2015 required for every page. Cityrrown State Zip Code Date of bspe eon D. System Information (cons) Distributlon Box (if present must be opened)Qocate on site plan): Depth of liquid level above outlet invert a r— 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.): I P t/k- f At Z ,oi,ar f Ov f-- �� 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 appu nces, etc.): *If pumps oral s are not in working order, system is a conditional pass. Soil Ab rption System (SAS)(locate on site plan,excavation not required): If SAS not located, explain why: tsrs•3H3 TWe50ffrd 11wpw§an Fans Sobsafece&%WeDisposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form MW Subsurface Sewage Di oral System Form -Not for Voluntary Assessments 6$c Ter Bay Circle Centerville MA Ropertyaddrms James T Flannery 6 Scudder Bay Circle Cw ner ow ner's Name information is Centerville MA 02632 7/15/2015 required for every page. CKyNown Sfate Zip Code Date of inspection D. System Information (cons.) Type: leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): T a r'1jx'% - �. '75- 12 L �.. a 2 awn dtAfA S •rdQ s C1*.A .p �7 tes �� V �1 Wt7✓�. �o r N . � ��-e-f 6r�* G 7-6 ,�ct Tvu.% =9.0 - Cesspools(cesspool muse 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 o spool Mated of construction Indication of groundwater inflow ❑ Yes ❑ No Ons.3113 Tige50flidd 68pectooFomc Sulstrface SewegeDisposel System-Page 13 of 17 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Scudder Bay Circle Centerville MA PropertyAddrm James T Flannery 6 Scudder Bay Circle Ow ner mooration is "'° ners t�Farne inform Centerville MA 02632 7/15/2015 required for every page. Cdyrrown State Zip Code Dote of trtspectlon D. System Information (coat.) 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 draulic failure, level of ponding,condition of vegetation, etc.): t5m-W13 7'i6e5of6daf kspectimFomc Submeace SexegeDispasd System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1W EN Subsurface Sewage Di oral System Form -Not for Voluntary Assessments 6 SCudTer Bay Circle Centerville MA Ilop"Addros lames T Flannery 6 Scudder Bay Circle Cw ner Ow ner's Name information is Centerville MA 02632 7/15/2015 required for every page. Cityrrown State ZIP Code Date of inspection D. System Information (conL) 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 [7 drawing attached separately t 1 G 3 ILA' -D 6j=33� A3 = Y3 83=ZG On-3113 TiBe5of6cial impeclionParm Suburface SevogeDisposel System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Scudder Bay Circle Centerville MA RopegAddrmm James T Flannery 6 Scudder Bay Circle owner °""oar's"a`"e information is Centerville MA 02632 7/15/2015 required for every page. City/Town State 23p ODde Date of Inspection D. System Information (coat.) Site Exam: M Check Slope a?'Surface water. L1'Check cellar Shallow wells Estimated depth to high ground water. 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 160 feet of SAS) Checked with local Board of Health-explain: - ,h.Q ILQ,�o�T3. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain:' You must describe how you established the high groundwater elevation: . I.73 f Ae l vz✓ da 1.<< ci c u- ,Dared &R?"-- vases #M41 z Before filing this Inspection Report, please see Report Completeness Checklist on next page. Sns-3M3 Ti6e60r6cid hupec6on Fame SubaLirface SemegeDisposO SyMm-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Scudder Bay Circle Centerville MA Property Address James T Flannery 6 Scudder Bay Circle Ow ner Ow nees Name Formation is Centerville MA 02632 7/15/2015 required for every page. Cityl row n State Zip Code Date of hspwtbn 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 InIbrmation—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3M3 Ti9e5Of6cial Inspection Famt Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS A EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d d DEPARTMENT OF ENVIRONMENTAL PROTECTION A MAP PARCEL ; O Loy' TITLE 5 CIFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 Scudder Bay Circle Centerville MA 02632 Owner's Name: Craig&Colleen Riley RECEIVED Owner's Address: Same Date oi'1 nspection: February 14,2004 F E B 2 5 2004 Name of Inspector: PATRICK M.O'CONNELL TOWN OF BARNSTABLE Company Name: SEPTIC INSPECTION SERVICES CO. HEALTH DEPT. Mailing address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Teleph)ne Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below i;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 I �ti1111ftN/lj�� approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: OF�11I,t+•�i _X_ Passes •* Conditionally Passes RICK w Needs Further Evaluation by the Local Approving Authority • Fails 0'C Inspector's Signature: <) Date: _2/114/04_ I lit it The systein inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)w•itltin 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or gmater,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 authorit y. Notes and Comments: Tank in good condition,not in need of pumping.Observed one foot effective leaching in one leaching pit. ****Tliis report only describes conditions at the time of inspection and under the conditions of use at that time.This:inspection does not address how the system will perform in the future under the same or different conditions,of use. Title 5 inspection Form 6/15/2000 page 1 Page 2 :Ff I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Scudder Bay Circle,Centerville Owner: Craig&Colleen Riley Date of Inspection: February 14,2004 Inspeclf)n Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX (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. Comm-nits: B. Sy;tzm 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. Answei )es,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain 'he septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing.tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating;that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstruc:ed 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 exg lain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass ins pection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND exr lai a: I Page 3 J 1 l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: b Scudder Bay Circle,Centerville Owner; Craig&Colleen Riley Date of Inspection: February 14,2004 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. I. 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 systero 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 l of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*'".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and thy: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: Page 4 :if I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Scudder Bay Circle,Centerville Owner: Craig&Colleen Riley Date of Inspection: February 14,2004 D. System Failure Criteria applicable to all systems: You mu:it indicate"yes"or"no"to each of the following for all inspections: Yes No _X:_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X:_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 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 '/2 day flow — _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution 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.] _No_ {Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be con sidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no i:he 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 hav(!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. Page 5 if 11 C'IFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propervi Address: 6 Scudder Bay Circle,Centerville Owner: Craig&Colleen Riley Date of l:nspection: February 14,2004 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 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 {_ 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) _ { Was the facility or dwelling inspected for signs of sewage back up? _X_ __ Was the site inspected for signs of break out _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 mainter(atice 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 Cis at issue approximation of distance i� unacceptable)[310 CMR 15.302(3)(b)] Page 6 A l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Scudder Bay Circle,Centerville Owner: Craig&Colleen Riley Date of Inspection: February 14,2004 FLOW CONDITIONS RESIDENTIAL Numbe.-of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIG-S flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Numbe-of current residents: 4 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): Seasonal use:(yes or no):No Water ranter readings, if available(last 2 years usage(gpd)): 2002—284,000 gal.2003—269,000 gal.=757 gpd Sump pump(yes or no): No **Residence has irrigation system which contributes to avg.gpd. ** Last da-:e of occupancy: Currently Occupied COMAIERCIAL/INDUSTRIAL Type of a stablishment: Design flow(based on 310 CMR 15.203): gpd Basis or design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water raeter readings,if available: Last da.e of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumpbrg Records: Last pumped two years prior to inspection. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Singic cesspool _Ov.-rf low cesspool _Pri vy —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 obtaineI fi-om system owner) Tight :ank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 1/30/95. Were sewage odors detected when arriving at the site(yes or no): No Page 7 )f I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTAR�c'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: 6 Scudder Bay Circle,Centerville Owner: Craig&Colleen Riley Date of Inspection: February 14,2004 BUILD)NG SEWER: X (locate on site plan) Depth below grade: 1' Materia I s of construction:_X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: 25' Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: X (locate on site plan) Depth he low grade: 16" Material of construction:—X—concrete—metal fiberglass__polyethylene_othcr,;explain) — If tank s metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificati:) Dimens ions: 10.5' long x 5.8'wide—1500 gal. Sludge dc;pth: 5" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance Lrom bottom of scum to bottom of outlet tee or baffle: 12" How,Aeia dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Wank not in need of oumain¢ tees intact and clear GREA31 TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass_polyethylene_other (explain):_ — Dimens ions: Scum tlric;cness: Distance f•om top of scum to top of outlet tee or baffle: Distance f-om bottom of scum to bottom of outlet tee or baffle: Date of las t pumping: Comments (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as relatod I outlet invert,evidence of leakage, etc.): I i Page 8 J 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Scudder Bay Circle,Centerville Owner; Craig&Colleen Riley Date of 1(nspection: February 14,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene__other(explain): Nme—m-ions: Capacity -allons Design.F low: gallons/day Alarm pr-sent(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Commen s(condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Observed_ no solids or high stains in box Box is slightly out of level LPN I receiving slightly more flow than L-3#2. PUMP CHAMBER: No locate on site plan) ( P ) Pumps in working order(yes or no): Alarms in working order(yes or no): Comment;;(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 :)f 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Scudder Bay Circle,Centerville Owner: Craig&Colleen Riley Date of Inspection: February 14,2004 SOIL/k,BSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS n of located explain why: Type leaching pits,number: Two 1000 gal.pits. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool,number: in system Type/name of technology: Comm(rri:s(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Observed one foot effective leaching in L01 which is receiving more flow than Lu#2.Ln#2 believed to be in t etter condition than L #1. - D CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Numbe and configuration: Depth- top of liquid to inlet invert: Depth of solids layer: Depth of E cum layer: Dmmensio»s of cesspool: Materials 3f construction: Indication of groundwater inflow(yes or no): Comment:,(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: IVo (locate on site plan) Materials(If construction: Dimew ions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t Page H,of 11 fJFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Scudder Bay Circle,Centerville Owner; Craig&Colleen Riley Date of)Inspection: February 14,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide U sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchn-arks.Locate all wells within 100 feet.Locate where public water supply enters the building. �u0 �Cy 43 0 '51 �, 15 -W) 1 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propero!Address: 6 Scudder Bay Circle,Centerville Owner: Craig&Colleen Riley Date of Inspection: February 14,2004 SITE EXAM Slope None Surface viater None Check ce(lar Dry Shallow wells None Estimated depth to ground water: More than 15 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _X Clb.,vrved site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain: Checked file C iel,ked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows groundwater well below el. 10 and above el.5.USGS topo map shows property at or above el.20.Previous inspection on file stated groundwater 18.5' below grade. Bottom of SAS is 9' below grade,leaving a minimum of 5'separation. r r' c COMMONWEALTH OF MASSACHUSETTS ~~ EXECUTIVE OFFICE OF ENVIRONMENTAL.,y DEPARTMENT OF ENVIRONMENTAL TIOl`�B O ONE WINTER STREET,BOSTON MA 02108 (617) 292-5 ��00 �o TRVPY COXE Y re Secretary ARGEO PAUL CELLUCCI e DAVID B.S'IRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address SCo�Qr (�e.7�W t u- 'v Name of Owner WA- Address of Owner: 3 SU A 6e_ :Piz-_ee_ Date of inspection: I-19-A0oo � N V. Name of Inspector:(Please Print) I am a DEP approved system inspector pursuant to Section 15.340 of T-rde 5(310 CMR 15.000) Company Name: f do S42 tC AN 46M !�1 U t ton►M t=�i A�f N G Mating Address: `1>>cT� 10 h 0t CC4V7-cr,7Uj LL r; A 4 U 2&3 r— Telephone Number: y 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: V/e Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspectors Signature d- Date: 1-de aaad The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 office of the Department ot'Environmental Protection. The original should be sent tools, system owner•and copies sent to the buyer,if applicable, and the approving authority. . . NOTES AND bOMMENTS �- t � �Q-F.m aft-•-( I S� � revised 9/2/98 Page Iof11 iJ Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION IconCkwed) Property Address: fn I G"nC(2. Owner: S•S A-m Date of 4upecti4n: INSPECTION SUMMARY: Check A, B, C, o/ D: A. SYSTEM PASSES: r/ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYS CONDITIONALLY PASSES: t I One more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon comple of the replacement or repair,as approved by the Board of Health,will pass. 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,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is 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 complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced _ - The system required pumpirrg•rnore than fourtimes a year-due to broken or obstructed pipe(s1. The system willgass- inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:. (0 Owner: -2,. s A-*x n1 S Date of . 1— ► 5—d-6(s c) C. ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the pu Iic health,safety and 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 W A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH,AND SAFETY AND THE ENVIRONMENT— Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) S WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FU ONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. he system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. e system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid).- 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) F Property Address: Owner: 5 A-M+K L 3 Date of 4upectkm: 1—t ci-9-000 D. SYSTEM FAILS: You must indicate either "Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No 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 r/ 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. . o� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). - Number of times pumped_. J� Any portion of the Soil Absorption System,cesspool or privy is.below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is.within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic-compounds, ammonia nitrogen and nitrate nitrogen.. - E. LARGE SYS AILS: You must indicate ' her"Yes" or "No" to each of the following: The folio g criteria apply to large systems in addition to the criteria above: The system se es a facility with a design flow of 10,000 gpd or greater(Large System)and the s stem is a significant threat to public health and safet and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B • CHECKLIST Property Address: b S Pei rc��,Co� Owner: s•S A-M M 5 Date of Inspection: 1—I h_o O Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health. None of the system components hawsJ),een puRiped4=atJeast two weeks and•tde'rystem hasAmewmceivipgaresi -flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. . _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System,have been located on the site. _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on•the site has been determined based on:- _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / (15.302(3)(b)] The facility owner(and occupants,if different from..owner).,were,pravided.with informationffln.th&4=o er.raaintanac of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM=FORMATION Property Address: Co 5CA-Qr io5l G✓,de, C"-t"", Owner: S•S A-m m,5 Date of Inspection: I— I cl -O U FLOW CONDITIONS RESIDENTIAL- Design flow: g.p.d./bedroom. Number of bedrooms( esign): 4 Number of bedrooms(actual): Total DESIGN flow Number of current r 1dents: ?A-,zT-Tm� v�Ag7� Garbage grinder(yes or no):, Laundry(separate system) (yes or no If yes,sepacate.inspection.required _ Laundry system inspected (yes or no) Seasonal use(yes or no). Water meter readings,if av [table (last two year's usage(gpd):��� Sump Pump(yes or no):_r_i Last date of occupancy:• LZ—W —C( COMMERCIAL/INDUSTRIAL: Type establishment: Design fl pdpd ( Based on 15.203) Basis of des n flow Grease trap pr ent: (yes or no)_ Industrial Waste [ding Tank present: (yes or no)_ Non-sanitary waste 'scharged to the Title 5 system: (yes or no)_ Water meter readings, available: - Last date of occupancy: OTHER:(Describe) Last date of occupancy: •66VERAL INFORMATION . PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)� 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other / C� APPROXIMATE AGE of all.components, date installed-4if known)-and source of,inrm foation: 1-L-1• `t Sewage odors detected when arriving at the site: (yes or no) revised 9/2/.98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (� s6AJac CtcdE Cl,f'F24Au•-,6-' Owner: S TA VW'S Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron VC_other(explain) Distance from private water ply well or suction line Diameter Comments: (condi ' of joints, venting, evidence of leakage,-etc.) -- SEPTIC TANK:— (locate on site plan) t� Depth below grade: Material of construction: ✓concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is Inetal,list age_ ls.age-confirmed by Certificate of Compliance_(Yes/No) Dimensions: SOO «� Sludge depth: "Z' -f- Distance from top of sludge to bottom of outlet tee orbaffie: - 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: How dimensions were determined: cy( Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert,structur"tegrity, evidence of leakage,etc.) NO J u t P i 3 7 00 I N L�-r- -j GREASE TRAP: (locate on site plan) Depth below grade: Material of coristructi _concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from to of scum to top of outlet tee or baffle: Distance from b om of scum to bottom of outlet tee or baffle: Date of last pu ping: Comments: (recommend 'on for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of I ekage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: & � CIJCIe Ce' t(c Owner: 547VXr'1k5 Date of Inspection: I--i�{ TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below rade: Material of c struction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions• y Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alar in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of a m and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) rl �,f Depth of liquid level above outlet invert: Z `� � 1 �S�JTI� --T72" Comments: lll, (note.if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAIM _ (locate on site plan) Pumps in wo ing order:(Yes or No) Alarms in wo king order(Yes or No) Comments: (note conditi n of pump chamber,condition of pumps and appurtenances,etc.) revised 9;2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Czar , Owner: SA-rn f' t S Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries,number:- leaching trenches,number,length:Y leaching fields, number,dimen ions: overflow cesspool,number:T Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition.of vegetation, etc.) CESSPOOLS:_ (locate on site plan) Number avid configuration: Depth-top of liquid to inlet in ert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of constructio . Indication of groundwa r: inflow (cess of 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 ite plan) Materials of c struction: Dimensions: Depth of solids: Comments: (note condition of s 'I, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) revised 9/2/98 Page 9of11 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (� r-64� et re Owner: !G 4-Mw--r Date of Inspection: --i q—00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) C -{-- l 0— L6 Dg� E/ 6 33 I � 131 1 31 IG a 6 6G H3r `ISf revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SY WASPECT11ON FORM PART C SYSTEM INFORMATION(cotttirmed Property Address: S`CAar °l Q4Z(G Owner: 5 97ry,M�s Date of Inspection: NRCS Report name `-Bat a3TA(Q Ca 73:S m 9-0 Soil Type_ S Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet -6e(eW Sys��^'l Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property,observation hole, basement sump etc.) _-Determined from local conditions V/ Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) lots MIl�' t tea- wr 0 3 LocA�- CC&,,,!4-),z-asx� s ����c� 3—if oe7-a 4`Trau S revised 9/2/98 Page 11of11 TOWN OF BARNSTABLE LOCATION 6 �SL_,kqU-e,,- lj�C/ c jr SEWAGE #2 "f��� VILLAGE .jp,-I LiA C ASSESSOR'S MAP & LOT/�g INSTALLER'S NAME & PHONE NO.-TP- Ij�AC�Crnhe I^ fah /p.,C SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 1006 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER B OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �/ 13 / e Jr V No....9..y g� ) FIW-- ( D 3 $ 30 . 00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iration for Diopwial Wor1w Ttimitrttrthin Prrnti# Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 6 Scudder Ba ,Circle Centerville Location-Address or Lot No. Sa_mmis W J.P.Macomber Jr. Owner Address IustatIer Address Type of Building Size Lot............................Sq. feet Dwelling�No. of Bedrooms----------------------------------------- Expansion AtticGrinder Showers) ( )914 Other—Type of Building ............................ No. of persons (C�ajba e Cafeteria p-' Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow----------------------......................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter._--.-. -------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.............--..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------------------------------------•--•---------------- Date........................................ 0 Test Pit No. I................minutes per inch Depth of Test Pit-------------..---_ Depth to ground water.......... (i Test Pit No. 2................minutes per inch Depth of Test Pit--.................. Depth-to ground water_.--------..---.-.---- a -•••------•---------•--•------•---------------•--------•-••----------••-•..........---•---•........•......................................................... 0 Description of Soil.........................................Sand...&....Gzaitel.......................................................................' "4 U --•-••---------•----•---•-••--••••••-••-•-----------•-------------------•--•-------••-•---•---•--------•-••-•-----------.....---------------•---•---................................................... W -••------•------------------••-----•----------•--------------.....--•-••••••••-••-•-------------------••--------------......----...--------------------------------------------••-•-------•-•---•-...... U Nature of Repairs or Alterations—Answer when applicable.............................----.-..-................--.....-----.---.......................... box-------I=--•1.0-©a...qa-1.1on---1-e-ach...pi-t••••••••.......••--•..............1-1500 gallon tank 1- distribution -1 .. .. ...a ...n - n -- ...........:.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issue by the oa of health. --------------------- - - -- -------------- --------- 25./...9.a..... Dace Application Approved B ----����y ------------- .- ---- --- -- ---- ----- ------- �--------...................................................... Dace ----... Application Disapproved for the following reasons- ----------------------------- -------------------------------------------------------------------------------------------------- ........................... ................ Dare Permit No. T.......f.. Issued 1 i .. Dace �j 00 No...__...1. �' Fas.... 30........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Dhi-puual Works Tomitrnr#iun Vamit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 6 Scudder Bay Circle Centerville (�`` ......................................--• . -----------------...----••-• -•--•----------------------------- Q__ �6 --- ... - Location_ Address or Lot No. Sammis W J.P.Macomber Jr. owner Address Installer Address d Type of Building Size Lot---_----_------------------Sq. feet Dwelling Y- No. of Bedrooms._.......'...............................Expansion Attic ( ) 'Garbage Grinder ( ) a`4 Other—T e of Building ............................ No. of ersons------_____________-__--.-_- Showers Other—Type g p ("- ) — Cafeteria ( ) � Other fixtures ------------------------------------------------------------------------------------- ...............................................................Design Flow............................................gallons per person per day. Total daily flow....._......................................gallons. WSeptic Tank—Liquid capacity------------gallons Length-------------_ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------_-------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Prq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 04 ..................................•-------•------.......---•....---•--•-------------••---•----------......................................................... DDescription of Soil-------................................. and---&--Gxsa-ve!-1-------•------------------•--------•-••--•-•-------•----•-•-•---------.................... W c, ----••----•--•--•--•-----•----------------••----•---------•--------------•-------•------------------•----------------------•------•------•-•---------•----------•--•----------------•-•----------------- W x -----------•----------------••-----•----•-•--------••----•---•-----•------•- -•--•------------------------•--•------------------------••••----•---•-•---•------------•-------------------••--•••-•---- U Nature of Repairs or Alterations—Answer when applicable.---_.__ --... 1-1500 gallon tank 1- distribution bc1x------1_1-0-0_0...na.1.1fa!a...Leaf--h "ai-t-----------------------••------------------------------------------------------------------------------------.-----.---..---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the.boa of health. S ne ... /...l�l/�. Dace Application Approved B ��- ...� ..... /-- ----- Date Application Disapproved for the following reasons: ................ ............................... ....... ........................................ . . ................... ............ ......................... . ....... -. Permit No. _.....(. �- Issued .....__.)_/_.._ / �� Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tex#ifira e of Tomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by .... .9.1---Roat.e----6.A---Wes.t----Ra.]rn.s.t.abLe-------------------------------------------- ----------------------------------------------------------------------------------------- Installer J.P.Macomber & Son Inc. at ------------------------------------------------------------------ -------------------------------------------------- -------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...` y---7-��..�f_�..0......... dated .-./f. ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY_-,.,_. ��� (;��� DATE....... ................................. - ... �.----------------- Inspector ----- �%.. ......._----------------------------- y- - ---------------------- ---------------> THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �j TOWN OF BARNSTABLE- No.lq.. . 8� FEE..$...30.00 Diupilout urk �unu rnr#iun rruti# J.P.Macomber Jr. Permissionis hereby granted....................-...........-------•--•-.------....-----........-------•------------------......--••----...----.._......-----••--.•..... to Construct � ) or Repair (XX) an Individual Sewage Disposal System at No...591 oute 6A West Barnstable ------------------------- ------- ----- Street as shown on the application for Disposal Works Construction Permit No`j`l.,kRn Dated-----41-11 _. ............................................. 1 i/1------------------------•----------------- I C/ ......_---'-_--.--._-- Boaid of Health DATE............ /1 L j......-- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS