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HomeMy WebLinkAbout0255 SHOOTFLYING HILL RD - Health 255 Shootflying Hill Rd Centerville P A = 214 014 No,42101/3 ORA 1 I ca,mg 10%@ ® O © O i Commonwealth of Massachusetts 0 Title 5 Official inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Shootflying Hill Rdil y� Property Address Matthew Levesque ? \ y ' 0\t-k � Owner Owner's fume requiredl for on ls cCleateftriIe' • a j�'T- 1"� MA 02632 1-4-M every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Shawn Mcelroy Enterprises Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that 1 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 DER approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fai� ❑ Needs Further Evaluation by the Local Approving Authority co 1-4-08 + v' Inspector's Signature Date j The system inspector shall submit a copy of this inspection report to the Approvin Authojy(Bd'gd of Health or DEP)within 30 days of completing this inspection. If the system is a s ared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner sh ll submit the report to the appropriate regional office of the DEP.The original should to 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, t5insp•08M Tdle 5 Qfrtceaf In pu%on Farm:Subsurfam Smage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 . every page. City/Town state Zip Code Date of Inspection B. Certification (cunt.) 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: Ssystem is in good working order. No recommendations. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the❑forthe 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 exfiftration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•08M6 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 every page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cunt.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 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. t5insp•0=6 TitFe 5Official kmpec ion Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (font.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria.are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes'or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z 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 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. t5insp•08/06 Me 50iricial Inspection form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is Centerville MA 02632 1-4-08 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) D) System Failure Criteria Applicable to All:Systems (cont.): Yes No ❑ ® 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. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.363,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yesn or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered ayes'to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has fair.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. t5insp•08106 Title 5 Official trispedon Form:Subsurface Sevvage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owners Name information is required for Centerville MA 02632 1-4--08 every page. cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate'yes"or"non 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 WA) ® ❑ 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)] ( )] t5insp•08106 Title 5 Official Inspecbm FomG Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110'gpd x#of bedrooms): 330 Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [ri yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 1-4-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp-08/06 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-408 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner—not pumped since new. Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons 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) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): . Approximate age of all components,date installed(if known)and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp 08/06 Tide 5 Official it on Form:Subsurface Sewage Disposal Systern-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J' 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 16" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Good Condition. Septic Tank(locate on site plan): Depth below grade: 10" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate7of Compliance?(attach'a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 Gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" ` Scum thickness IV, Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 8" How were dimensions determined? Tape t5insp•08106 Title 5 Ofricmi Inspechm Forth_Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 every page. city/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Recommended pumping for solids. All baffles in place. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp-08f08 Title 5 Official fnspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name reformation is required for Centerville MA 02632 1-4-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cost.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level and in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No t5insp-08/06 Rife 5 Official Irtspeclion Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 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: Type: ❑ leaching pits number: ® leaching chambers number. 5-Infiltrators ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/aftemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leach field in good condition with no sign of back-up or break-out. t5insp-08/06 Title 5 Official fnspedim Form:Subsurface Sewage Dispowl System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 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.): t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form Not for Voluntary Assessments w 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 every page. Citylrown state Zip Code Date of Inspection D. System Information (cost.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. - �l- a1 A&- 3"l 44&k } ' Deck 3 i l= t A yo t - - -- -- - x as- 33 l r A'!- f3 - 39 Q a y; t5insp•08106 Me 5Offida4 frr4xmfi n Fcmn:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 255 Shootflying Hill Rd Property Address Matthew Levesque Owner Owner's Name information is required for Centerville MA 02632 1-4-08 every page. City(rown State Zip Code Date of Inspection D. System Information (coat.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to 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 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show groundwater at 20'. l5insp-oa/06 Title 5 Official trispeclim Form:Subsurface Sewage Disposal System-Page 15 of 15 Town of Barnstable of 1HE rqt, Regulatory Services IAMSTABLE r Thomas F. Geiler,Director '$A 6 9. ��� Public Health Division 1 TED MA'S A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 r This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty,the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within.this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit'. If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. - BORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD, MAIZS'I'ONS MILLS, MA 02648 508-771-9399` 508-428-8926 FAX: 508428-9399 SUBSURFACE SEWACIT, DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:11 . Date Of Inspection Ins ect is N e: _ O� er's Nam d Address: CERTIFICATION STATEMENT.;_ 1 Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection,was perform- ed based on my','raining and Experience in the Proper Function and Maintenance of On-Site'Sewage Dis- posal Systems rl system; �. —Passes,. .(. ...:l ..!%`F,..s.t_x..., . . >'I.',Y r, .. .. ..k•e 1 ..�,`.. dN{ �� ���, y. . ConditionallyP es �° Needs Furttie vain:lion the Local Approving Authority Failure tio��g c� Inspector's Signature Date: OV �o.9s,. DO The System inspector shall submit a copy of this Inspection Report to the Approving Authoriity.,with'Thirty (30) Days of completing this Inspection. I I'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 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: A) SYSTE"ASSES: I/ I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated 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,nor,or not determined (Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- '' tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Appi raved by the Board Of Health. Sewa'ge'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): - 1 - SUBSURFACE SEWAGE*DISPOSAI;`SYSTEM INSPECTION FORM PA11T,A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled 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: Condition&;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 HELAT'H DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING 1N A MANNER WI"IICH 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'CHE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF'APPROPRIAI'E)DETEIIMINESA'f�,HAT'=THE SYSTEM=IS FUNCTION- ING IN A MANNER THAT PROTECTS THE.PUBLIG,HEAL'1'H AND SAFETY AND THE ENVIRONMENT The system has a Septic Tank and Soil AbsorptioirS,ysteni 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 with-a Zone .1 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 froni a Private Water Supply Well,unless a Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the"facility and the presence of auuuonia nitrogen and nitrate nitrogen is equal to or less tip. .,. _ .. _ _ _.. . .. "than 5 m. np 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 correct the failure. Backup of.sewage into facility or system component due to an overload or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground o`r surface waters due to an overloaded or clogged SAS or cesspool Static liquid'level in the distribution box°a6ove outlet invert flue to aii overloaded or clog- " ged SAS or cesspool. Liquiil'ilepth in cesspool is than 6"below mvert or available volume is less than 1/2 day flow. ; Required puinpiug more than 4 times iu the lasf_ycar due to'cliigged or obstructed pipe(s). Number of tines pumped - 2 - til)13SllIZFA( 1 SEV1'A('.N; DISPOSAL-SYST,li'm-INSI-ECI'ION FORM PART A i CER•17F.ICA'1'ION (continued) 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 ] 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 SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd 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:►if,a surface drinking'water'supply r1'he system is,withini 200.Feet of a trfb.utiii•y,to`-a suri'ace;drit►king.water supply The system is located in a nitrogen sensitive area lnterim`Wellbead'P..rotection Area ,�Y r; •,' ' ;':' `(IWPA)or a.mapped,Zone'll of,a public;water:s.upply.well.!? The owner or operator of any such systen 'shall bring the system and facility-into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 13 CHECKLIST Check if the following have been done: 1/1--pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast 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/As-built plans have been obtained and examined. Note if they are not available with N/A. T I'he facility or dwelling was inspected for signs of sewage back-up. _V The system does not receive non-sanitary.or industrial waste.flow. V The site was inspected for signs of breakout. f✓All system cotnponents,.exclnding the Sail,Absorptiofn.System,have been located oil site. 'File septic tank manholes were uncovered,opened-,,and the,interior,of the septic tank was in- ....` sp,eded.for condition of,bat tles or,.tees,material.of consti uct�on,dimensions,depth of liquid, depth of sludge,depth of scum. I'lie size and location of the Soil Absorption System►in the site has been determined based on existing information or approximated by non-intrusive methods. - 3 - l SUBSURFACE, SH;WAGE°DISI'OSAI,;SYSrI'LM :INSPECTION .FORM PART B CHECKLIST(continued) tl The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of Subsurface Disposal System. r� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM- INFORMA'1'1(.)N -. FLOW CONDITIONS RESIDEN'I'I L: Design Flow: allons Number of B :edrooms Number of Current Residents: Garbage Grinder: �� Laundry Connected T'o S,ystem:weQ Seasonal Use:�llJ— Water Meter Readings,if vailable: Last.Date of Occupancy: __.. COMMFRCIALANDUSTRIAL:/a Type of Establishment:' ... Design Flow: gallons/clay Grease`I'rap Present:`(yes'or'nii)"°' Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of'.Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source of information: aAl System Pumped as part of inspection:7/, --- If yes,-volume-pumped: gallons Reason for Pumping: r Ef�F SYSTEM: ✓Septic'1'ank/Distributiou Box/Soil Absorption System Single Cesspool Overflow Cesspool ' Privy ; Shared System(If yes,attach previous inspection records,if any)—- - Other(explain): -PPRO I TE GE of Ilc n onents,date installed(if-known)and soiiice'of inf6Hhition:' Sewage odors detected when arriving at the site: -- - -- _ -4- `'"J-` %'SClI3S1JItFAC`,E'"SFWAGWDISPOSA "SYSTEM' :INSI'EC'I'ION FORM TART C GF,NFIW, INFORMATION (continued) SEPTIC TANK: / pat&/ 9- u Depth below grade: Material of Construction: Ll--Concrete metal FRP Other (explain) Dimensions: ` Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Continents: (recommendation for pumping,conditioin of inlet and outlet tees or baffles,depth of liquid level in relation to out t invert,structural integrity,evidence of le kage,etc V ff H GREASE TRAP,; Depth Below Grade: Material of Constructiom: concrete metal FRP Other (explain): Dimensions: Scum'Thickness: Distance from top of scum to top of outlet tee or baffle: Continent°s: (recommueudation`f®r pumping,condition of inlet an outlet lees or baffles,depth of liquid level in relatiou`to outlet invert,structural integrity,ev�deiice of I'eakage;etc)v TIGHT OR HOLDING TANK Depth Below Grade: Material of Construction: concrete metal - FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:�� Depth of liquid level above outlet invert: Comments: (note 'level and distribution is equal,evidence of solids ca over,evidence of leakage into or etc.) PUMP-CHAMBER: ` <, Pump is . i;working.order ,. Conuiieuts: (note condition of punip chamber,condition of pumps and �ppiirtenauces,etc.) _ 5 _ f SUIISURFACE'SEWAGE DISPOSAL SYSI''KM"INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): 1/ (Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, mmnber: Leaching chambers,number: (j2 Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow_cesspool,number: Connueuts: (note conidti of soil,signs of h draulic failure level ol'pondHIP condition of vegetation,etc.)_ '1. CESSPOOLS 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 o,f--gr►indwater. r 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: ��Tr Materia s of construction: Dimensions: Depth of Solids: Connnents: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) I ' _ -t_..± __ ..__ ro ._ 'i.+a.E,1t:,4:' r 5[, .ti•t L `'t` x 1:''i, l.rs�ll — 6 — 51113S11RFA(:'E;`SI%WA(':1;`I)ISI't)SAf;'SYS'I'I+;IN'•INSI'E("1'IUN FORM 1''A R'I' C SVS'I'1?,NI INFOlIMATION (conlivaed) SKETCH OF SEWAGE DISPOSAL SYSTEM: luclude ties to atleast two permanent references,landmar(s or benchmarks. Locate all wells within 109 Feet. l ,A DEPTH 'rO GROUNDWATER: Depth to gromidwater: 2Y Feet �y r Method of Ueterm tion or Approximation: /7 I'r //yJf� ev bl��� in G1/G? 1 - 7 - TOWN_ OF BA_RNSTABLE LOCATION ,� _ N c/ SEWAGE # PILLAGE C Pf�/` �l ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY - LEACHING FACILITY: (t7'Pe) �`^ IS (size) - NO.,OF BEDROOMS 3 ` BUILDER OR OWNER - PERMTTDATE: - COMPLIANCE DATE: --- Separation Distance.Between the:,: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet ' Private Water Supply Well and Leaching Facility_(If any wells exist Feet on site or within 200 feet of leaching facility) . i _ Edge of Wetland and Leaching Facility(If any wetlands exist Feet ,within 300 fC5 pf leaching facility) / Furnished byl.aw✓r gcI,e L p L v p y7' l -F- 3 5' - A a-G-7a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE 4 F RM C PART A EIVED CERTIFICATION MAY 14 2002 Property Address: 255 Shoot Flying Hill Road ' Centerville, MA 02632 TOWN OF BARNSTABLE Owner's Name: Adam Penni HEALTH DEPT. Owner's Address: Same Date of Inspection: May 3, 2002C Name of Inspector: (Please Print) James M. Ford J Company Name: James M. Ford Mailing Address: P.O. Box 49 Map:214 Osterville,MA 02655-0049 Parcel: 014 Telephone Number: _ (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: May 8, 2002 The system inspector shall submi opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 255 Shoot Flying Hill Road Centerville, AM Owner: Adam Penni Date of Inspection: May 3, 2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 255 Shoot Flying Hill Road Centerville, MA Owner: Adam Penni Date of Inspection: May 3, 2002 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 255 Shoot Flying Hill Road Centerville, MA Owner: Adam Penni Date of Inspection: May 3, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/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 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 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 255 Shoot Flying Hill Road Centerville, MA Owner: Adam Penni Date of Inspection: May 3, 2002 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 255 Shoot Flying Hill Road Centerville, MA Owner: Adam Penni Date of Inspection: May 3, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2001 -78,000 gals.; 2000-43,000,gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAI✓INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: none on file 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 ✓ Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Aug. 6197-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 i Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 255 Shoot Flying Hill Road Centerville, MA Owner: Adam Penni Date of Inspection: May 3, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Approx. 22" Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage Recommend pumping every three years. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete. _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 255 Shoot Flying Hill Road Centerville, MA Owner: Adam Penni Date of Inspection: May 3, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): The D-box was level. There were no signs ofsolids or leakage. The D-box was clean There were no signs of backup or failure from the leach field. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 255 Shoot Flying Hill Road Centerville, MA Owner: Adam Penni Date of Inspection: May 3, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers, number: leaching galleries,number: ✓ leaching trenches,number, length: 5-maxi infiltrators with 2'stone-per design plan 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.): The leach field was located, but not dug up. There were no signs of backup in the leach field. The bottom to grade was approximately 5'below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 ' Page 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 255 Shoot Flying Hill Road Centerville, AM Owner: Adam Penni Date of Inspection: May 3, 2002 Map:214 Parcel: 014 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. d � I I — r6 � O I Q cn f-6 00 c co 10 i Page I 1 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 255 Shoot Flying Hill Road Centerville, MA Owner: Adam Penni Date of Inspection: May 3, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30' +/- 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: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:_topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach field to grade was approximately 5. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 30'+/-to ground water at this site This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. I1 No. I Li i LI Fee ®o P �`f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS lie , 01pplication for Migogar *pgtem Construction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. 2 1 A Ow is Name,Address d Tel.No. Assessor's Map/Parcel 6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. gay'to to '� )1 - S j�S' �ow+� ea 3c z - �.tI I i Type of Building: Dwelling No.of Bedrooms - Lot Size boa j sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 6 gallons per day. Calculated daily flow b G gallons. Plan Date z 197 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 4 t r" G -t Description of Soil /9 �- 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 Ti le 5 oft nvironmental Fode and not to place the system in operation until a Certifi- cate of Compliance has been issued t is�o d f Hf� Signed Date �6 7 Application Approved by Date Application Disapproved for the follow' g reasons Permit No.T7- Date Issued fLT No. �•r Fee p j / � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. � Yes ' µ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for�Migogar *pgtem Construction Permit 6 Applk ation for a Permit to Construct( )Repair( )Upgrade( )Abandon(,�) 11&om le�ystem . El Individual Components 3/K j. Location Address or Lot No.?i A 71.! ! 1 Ow er's•Name,Address lT n- No. Pi, Assessor's Map/Parcel., Installer's Name,Address,and Tel.No. c si ne`r' Name,Address and Tel No. "`! ' -- '�';�' F'vY Eo � ' �.;]It'- ti �•`S,� Cade ��-,. ,•. 3C I/rzt l Type of Building:{ f 7 Dwelling Nu.of Bedrooms Lot Size 6D, q r sq. ft. Garbage Grinder Other �Type,c Btuilding No.'ofkPersons >R r i /Showrers( ) Cafeteria( ) Other Fixtures r r Design Flow 3 0 gallons per day: Calculated daily flow t' t'G gallons. Plan Date y 9 Number of sheets Revision Date 4Title ' Size of SepticfMnk j�r� Type of S.A.S. •f, r r U' j Description of Soil.77 1 c c Nature of Repairs or Alterations(Answer when applicable) Date last inspected:, Agreement: ,�' The undgAigned agrees to nsure the construction and maintenance of the af9re described on-sites wage disposal system in accordance with the provisions of Title 5 of th nvironmental ode and not to place the system in operation until a Certifi- cate of Compliance has been issued is`` ar of H f+ p Signed �� ?)"a: 6 Date G h ; Application Approved by .a Date 0~ Application Disapproved for the following reasons a41 Permit No. q 7-. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of :Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired ( ) Upgraded Abandoned( )by rsc,zrct-c r r CIO sr;P,or rho^' at C c r It A bias_been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 1 2 ated i Installer �v' /� C s Designer ') -+� C a /?� C The issuance✓of this perm v-sh//al}no/e�r - strued as a guarantee that the system willl,function as designed Date t�� l A '� Inspector f�� ' .�`( , V� .1 , i r+� ------ No. �'!� 0.!� Fee! .. �� THE COMMONWEALTH OF MASSACHUSETTS q PUBLIC HEALTH"DIVISION - BARNSTABLES MASSACHUSETTS p, c r` Migosml */pgtem Con5truc�tion Permit Permission is hereby granted to Construct( `)Re air( )U grade( ' )Ab don( ) System located at L v r t. / ��oe 1 ( •`/l /t t✓. s I and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. -� Provided:Construction must be completed within three years of the date of this permit: Date: ,,.'�.- Approved by � � cyf_TOWN (�OJFBARNSTABLE LOCATION O°5 J J�'�WT 1-` ^ all SEWAGE # 01-7' 333 1 VILLAGE C1Q/t��ry�l� ASSESSOR'S MAP & L0To114i I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 5ClU yOx-7 X a I� LEACHING FACILITY: (type) 1'f'1RX1 1 n�l9i�l0iJ (size) NO. OF BEDROOMS 3 BUILDER OR OWNER AbA^n P'2,,^t PERMITDATE: COMPLIANCE DATE: F14,197 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leac ng facility) , Feet Furnished by Al- Deck A3- — a3- 33 Ay- y-7 13y- 39 0 a Ia y S ---_-_ q TOWN OF BARNSTABLE dU A SEWAGE# LOCATION S ' VII.LAGE r' " "J r ASSESSOR'S MAP & LOT / � inn C'� �.70•8 INSTALLER'S NAME&PHONE NO.IT SEPTIC TANK CAPACY LEACHING FACILITY: (type) (size) '7 x z/� ' f NO.OF BEDROOMS— — BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: l, Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet:: on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by A B1 = aI� A3 - 97' off' }louse 33 = 39� A a Aq =$3 � .B y z 3 N r r! � TOWN OF BARNSTABLE LOCATION S�oo�-�'/c��na /-li l l 1Po� SEWAGE # ti - ,V1LLAGE C'crt-ic r u,// ASSESSOR'S MAP & LOT / INSTALLER'S NAME&PHONE NO. e>r 40 I a H; Q0^94 SEPTIC TANK CAPACITY 1,500 On./ 1:4 in LEACHING FACILITY: (type) :Z/1-r,/4/'c ,4 o rS (size) 7 / ,x y4 NO.OF BEDROOMS 3 BUILDER OR OWNER ► 'P a c PERMIT DATE: 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Ai = 3 I ' .- A2 = �® 99 t' Nousc 33 = 39 A 13 Ay 3 N 7 4 7. pl 1, w p AT`,�- `Se"> ROFILE ' ,'', SEPTIC : TEST:` HOLE; -LOGS DF, FIN."GRADE �NOTTO SCAW Z. ACCESS�;COVER TO WITHIN e AC( TI .17) TO 'm -E�S 'COVEk *TER Gf INE R: N6 WITHIN Ir OF FIN. GRADE 2%:SLOPE REQUIRED OVER SYSTEM ITN 47 MINIMUM .75',,OF COVER .0VER 'PRECAST �XCW ESS: Y� DATE: 3' MAY, PERCI� RATE dokubk �Somc RUN PIPE, LEVEL DOUBLE WASHED PEASTONE —FOR FIRST 2- Ab I aw R 4mb I �p tLASS; SotL�; TAW (H A- --A 40 0 0 0 RUS 0 0 0 0 0 0 0 0 ELEV. .'C HED &ONE OR MECH�ICAL ELEV. [2D OMPACTION. (15.221 DEPTH OF FLOW SLOPE) S LOPE). EE 'SIZES: INU7 A 'LOCA`nON ':MAPl.­ 3/4� TO 1 1 I:r DOUBLE WASHED -STONE OUTLET DEPTO 0 LEACHING 6 OUNDATION SEPTIC TANK s D', BOX AS ESS RS.,',&%P FACILITY, TRCZONIN ............. .44 .�YARD ',SETBA KS-'j 5 R F. R F. FLOOD ZONE: ::5- ev N OTE5;. S PTIC 1 DATU M IS A- DESION, (GARBAGE DISPOSER Is DESIGN WG p r) BEDROOMS GPD) 2. MUN CIPAL WATER. FLOW MUMr G P D DESIGN USE A 3. MINI PIPE PITCH BE :1 ER r FOOT. r 8 PT C�.TANK: 3��,GP 0 AAS UNITS -TO 4. DESIGN LOADING ALL :PR CAST BE Hb H E I FOR' 5. PIPE`jOINTS TO BE MADE ',WATEkTIGHT.:�� GALLON rS USE A, LIP EPTIC TANK LS Tor BEIN:�ACCORDANCE WITH MASt'. LEAC HING: CODE TITLE V. ENVIRONMENTAL 7. THIS PLAN r IS* FOR PROPOSED,�WORK' -ONLY, AND -NOT !O'--,-8E SIDES: USED FOR LOT LINE STAKING. -74 '7,V.3 To r 130TTOM: 8. PIPE FOR tEPT' IC 'SYSTEM SCH. 40 PVC. _S.F. .9. COMPONENTS NOT ,TO' BE BACKFILLED OR �CONCEALED VT TOTAL. -PD BY BOARD 'OF HEALTH 'AND'.PERMISSION OBTAINED: INSPECT10N FROM -BOARD OF HEALTH.- THE 0. CONTRACTOR �SHALL BE� RESPONSIBLE� FOR VERIFYING LOCATION OF. ALL UNDERGROUND OVERHEAD UTILITIES PRIOR > OF WORK. LEGEN D L f LA N 7E AND SEWA GE ION OF 100xO EXISTING SPOT ELEVATION IN 'THE TOWN :OF: F 00 PROPOSED CONTOUR 0 EXISTING CONTOUR 100— PREPARED FOR: 0 BOARD BYALTH SCALE. DATE., APPROVED DATE- 6n off 506—W2-4541 fm WS W2 Lo 4fl F AFINE FIN down cape , engineering, in c. H. "LA L No,26348 CIVILrr ENGINEERS L,&ND SURVEYORS 939 r St. yarmou h ma, 02675 , E DAT H. ��OJALA, ''P.E. ME, F7