HomeMy WebLinkAbout0881 SHOOTFLYING HILL RD - Health 881 Shootflying Hill Rd
Centerville P
A 192 009
No. 4210 1/3 ORA
Pendaflex'
;►:�
100
r TOWN OF BARNSTABLE
LOCATION �� ����or Plv SEWAGE #6*-4 —
VILLAGE �' ASSESSOR'S MAP & LOT '
INSTALLER'S NAME&PHONE NO. /TO �J` `"� -7 tF /
SEPTIC TANK CAPACITY /16 C4L�
LEACHING FACII.ITY: (type) (size)
NO.OF BEDROOMS 1
BUILDER OR OWNER C 0 AX e
PERMIT DATE: 212—e 6-4 COMPLIANCE DATE:
Separation Distance Between the.
Maximum Adjusted Groundw r Table to the Bottom of Leaching Facility Feet
Private Water Supply We and Leaching Facility (If any wells exist
on site or within 2 feet of leaching facility) Feet
Edge of Wetland an aching Facility(If any wetlands exist
within 300 fees of leaching facility) Feet
Furnished by
Act dati,S� �qi,.)C
�1
' O P
0
O � p
a '
�M `
{ TOWN OF BARNSTABLE
LOCATION o F�Z S / I / SEWAGE#
VILLAGE ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. l
SEPTIC TANK CAPACITY
LEACHING FACII.rrY: (type) /t:57! (size) kG �w / �5'-+'y e-
NO.OF BEDROOMS 3
BUILDER OR OWNER �G- I��-✓
PERMrrDATE: 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
��� ce
COMMONWEALTH OF MASSACHUSE77S
c EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION MAP. 9�►
Pro a Address: 8 81 Shoot Flying PARCEL .4 ®®-
p rty yina Hill Rd
Centerville LOT
Owner's Name: John Corbett
Owner's Address:
Date of Inspection:
Name or Inspector:(please print) W i 1 1 i am F._ . Robinson S r.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089 BAN 2
Centerville, MA
Telephone Number: f 508) 775-8776. TU" �Y,�P-,_''
CERTIFICATION STATEMENT
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 apd maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Se on 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:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page l
�L
f
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 881 Shoot Flying Hill Rd
Centerville
Owner. Jqhn Corbett
Date of inspections 41
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S stem 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. stem Conditionally Passes:
ne or more system components as described in the"Conditional Pass"section need to be replaced or
repaire The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer y s,no or not determined(Y,N,ND)in the for the following statements.If Mot determined"please
explain.
Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, ibits substantial infiltration or exfrltration or tank failure is imminent.System will pass inspection if the
existing is replaced with a complying septic tank as approved by the Board of Health.
•A metal s ptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating hat the tank is less than 20 years old is available.
ND expla' :
Ob etvation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval f Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain
The ystem required pumping more than 4 times a year due to broken or obsWumd pipe(s).The system will
pass inspector n if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rtmorod
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_ 881 Shoot Flying Hill Rd
Centerville
Owner: John Corbett
Date of Inspection: Ld
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 failid to protect public health,safety or the environment.
1. S stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the
s tem 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. Syste will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is unctioning in a manner that protects the public health,safety and environment:
_ T e 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.
e system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ T I e 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 froul a
privat water supply well" Method used to determine distance
'This system passes if the well water analysis,performed at a DEP certified laboratory,for colifonn
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the pr�sence 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. O,her:
3
Page 4 of I 1
' r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 881 Shoot Flying Hill Rd
Centerville
Owner: John Corbett
Date of Inspection: d
D. System Failure Criteria applicable to all systems:
Y ust indicate`yes"or"no"to each of the following for all inspections:
Yes o
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%atrr
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.]
(Y /No)The system fails.1 have determined that one or more of the above failure criteria exist as
escribed in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
ealth to determine what will be necessary to correct the failure.
E. Large S stems:
To be consi Bred a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You must' icate either"yes"or"no"to each of the following:
(nic follo g 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
e system is within 200 feet of a tributary to a surface drinking water supply
t system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Z ne 11 of a public water supply well
If you have swered"yes"to any question in Sectinn E the system is comsidered a significant threat,or answered
"yes"in Sec ion D above the large system has failed.The owner or operator Ora"large system considered a
significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The tem 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: 881 . Shoot Flying
en E ervi e
Owner: ozbett
Date of Inspection:
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
V 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)
j
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 baffle 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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 881 Shoot Flying Hill Rd
en ervi e
Owner: Jonn Corbett
Date of Inspection: w(
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: ,7
Does residence have a garbage grinder(yes or no): A-
b
Is laundry on a separate sewage system( es or no):/`_U[if yes separate inspection required]
Laundry system inspected(yes or no): lo�
Seasonal use:(yes or no):/V C>
Water meter readings,if avaible(last 2 years usage(gpd)): 2.002 43, 000 gals
Sump pump(yes or no):IV 2003 45, 000 gals
Last date of occupancy: b
COM ERCUTANDUSTRIAL
Type of stablishment:
Design f ow(based on 310 CMR 15.203): gpd
Basis of Jesign flow(seats/persons/sqft,etc.):
Grease p present(yes or no):_
lndustri waste holding tank present(yes or no):_
Non-san tary waste discharged to the Title 5 system(yes or no):_
Water ter readings,if available:
Last dat of occupancy/use:
OTHE (describe):
GENERAL INFORMATION
Pumping Records
Source of information: / C'r
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason fo pumping:
TYP F SYSTEM
eptic 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 comp nM d stalled(if known)and source of information:
�7
Were sewage odors detected when arriving at the site(yes or no):�'
6
Page 7 of I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 881 Shoot Flying Hill Rd
Centerville
Owner: JohnCorbeff-
Date of inspection: /+—IV—
BUILDIN SEWER(locate on site plan)
Depth bolo grade:
Materials o construction:_cast iron _40 PVC_other(explain):
Distance fir inprivate water supply well or suction line:
Comment (on condition of jout ,venting,evidence of leakage,etc.):
SEPTIC TANK:,_/ocateon site plan)
at
Depth below grade: /
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: l Li
Sludge depth:_ t/
Distance from top of'sludge to bottom of outlet tee or baffle:
Scum thickness: 3 I'
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baM : /6
How were dimensions determined:_ Q f071
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence,of leaks e,etc. ly
GREA TRAP:_(locate on site plan)
Depth be ow grade:—
Material f construction:_concrete metal_fiberglass_polyethylene other
(explain)
Dimensi s:
Scum thi kness:
Distance iom top of scum.lo top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of I st pumping:
Comme is(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relat to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11 L j
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 881 Shoot Flying Hill Rd
en ervi e
Owner: John Corbett
Date of Inspection: ;-—71—OTT
TIGHT or HC LDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below ade:
Material of co truction: concrete metal fiberglass_polyethylene other(explain).
Dimensions:
Capacity: I allons
Design Flow:rofalarm
allons/day
Alarm presen
Alarm level: rking order(yes or no):
Date of last p
Comments(c float switches,etc.):
DISTRIBUTION BOX: (if present must be opcned)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUAIP CI MBER: (locate on site plan)
Pumps in w rking order(yes or no):
Alarms in orking order(yes or no):
Comments I note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
I
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 881 Shoot Flying Hill Rd
Owner•
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): !/(locate on site plan,excavation not required)
If SAS not located explain why:
Type
J'aching pits,number:_
✓leaching chambers,number: a�-
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
G 0 6ric" t
CESSP LS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top liquid to inlet invert:
Depth of soli layer:
Depth 'f scu layer.
Dimensions o cesspool:
Materials of co struction:
Indication of undwater inflow(yes or no):
Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of nstruction:
Dimensions:
Depth of solo s:
Comments( ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address• 881 Shoot Flying Hill Rd
CPni-arvi 1 1 P
Owner• Tnhn Corbett
Date of Inspection: /•��� ��
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.
10
�-1
✓ i 11
7
� L
i
l r
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 881 Shoot Flying Hill Rd
Centerville
Owner: John Corbett
Date of Inspection: ' —01 tom;
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water eet
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)
Che ked with local Board of Health-explain:
ecked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
t
11
No.
' Fed 5
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
ies
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
- 2pplication for Miqual *p5tem Construction Permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
se $} p%t 'lying Hill Rd. John Corbett
81 sor s ap azce �0
Centerville
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
M. E. Robinson Septic Service
P
Type of Building:
Dwelling No.of Bedrooms_ 2 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable)
of a D-box and 2 concrete
chambers with stone all around -
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this)9optof sal C�
Signed i o Date
Application Approved by m Date
Application Disapproved f r the following reaso 6L V
Permit No. Date Issued
's
TOWN OF BARNSTABLE '
LOCATION �� �5'�s l �/� i;� /y� SEWAGE #6C-4 �I G
VILLAGE C ASSESSOR'S MAP & LOT
INSTALLER'S NAME 8c PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �'' f y' �' ,�� C C (size) — smoF�o
NO. OF BEDROOMS U _
i BUILDER OR OWNER CC ItX z-
PERMITDATE: 9 COMPLIANCE DATE: /C
I Separation Distance Between the-
i
j Maximum Adjusted Groundw r Table to the Bottom of Leaching'Facility Feet .
Private Water Supply We and Leaching Facility (If any wells exist
on site or within 2 eet of leaching facility) Feet
a Edge of Wetland an aching Facility(If any wetlands exist
i Within 300 fee of leaching facility) Feet
Furnished by
i
C
s� I
F
`r^•r � l
Feed 5 /
` No. "�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLES MASSACHUSETTS
ZIpprication for Mioogar 6potem Construction Permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
t -
Location Address or Lot No. Owner's Name,Address and Tel.No.
881 Shoot Flying Hill Rd. /, John Corbett
Assessor'sMap/Parcel Centerville 'V
[Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
. E. Robinson Septic Service
O Box 1089 Centerville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
_ Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Yank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Tit 1 A—S 1 P a nh S y S t orn r_nn s i c;t-!n
of a -D-box and 2 concrete chambers with stone all around.
Date last inspected:
-• Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate ofCompliance has been issu d by thi o .ofHea
° Date7—�
Signe / Q
Application Approved by a, Y Date
Application Disapproved for the following reaso X
a
Permit No. Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Corbett Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( X )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service
at881 Shoot Flying Hill Rd. Centerville h n constructed in accordance-
with the provisions of Title 5 and the for Disposal System Construction Permit No dated
Wm. E. Robinson Sr.
Installer Designer
The issuance of this permit shall lIn.t be o s e - ss 4 guarantee that the syste'rn wi 1 funccytion�as/designed. 4
Date 11 Inspector if 1 i 1 tC %I O t',P ( '` - ��
— -----------------------------
No' D�v (40 1 o
THE COMMONWEALTH OF MASSACHUSETTS
-' PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Corbett Migpooal *p5tem Construction Permit
Permission is hereby ted to Construcs( )Repair( X)Up rade( )Abandon( )
System located at Shoot Flying Hill R . , Centerville
' 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:Con c 'on mus be completed within three years of the date of
Date: DO `� Approved by
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
-1, William E. Robinson,s�eby certify that the application for disposal works
construction permit signed by me datedL-�� , concerning the
property located at 881 Shoot Flying Hill Rd. , Centerviltaets all of the
following criteria:
• The failed systemfasCLASS
to a residential dwelling only. There are no commercial or business
uses associated willing.
The soil is classif I and the percolation rate is less Wan or equal to5 minutes per inch.
There arc:no welln 100 feet of the proposed septic system —
• There are no pri L wells within 150 tees of the proposed septic system
There is no i j m flow and/or change in use proposed
• There are no requested or needed.
• The bottom f il�proposed leaching lility will ngt be lotted less than.five feet above the
maximum justed groundwater table elevation:[Adjust the groundwater table using the Frimptor
method w applicable)
• If the S. S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
lea chin facility will not be located less than fourteen(14)feet above the maximum adjusted
group vater table elevation,
Please complete the following
A) Top of Ground Surface Elevation(using G1S information)
B) G.W.Elevation +the MAX. High G.W. Adjustment.
DIFFERENCE BETWEEN A and B —
SIGNED : l 2��r'�r/"� DATE:
[Sketch proposed plan of system on back].
+bwhh folds rat
.,
.,.. � -�
;, ' .
�` t ! s r F �r�. . 4 t .. ,
` 1=------! f7
>�; ..
t _a.r
_ � r. ri. t � +Si.. t
s ' t
I
s
TROY WILLIAMS
SEPTIC INSPECTIONS ��'
Certified by MA Department of Environmental Protection t � (508) 760-187
40 Old Bass River Road
LLO TH EPI1E
South Dennis,MA 02660
00 CorTunorrnreatth of Massachusetts
Executive Office of ErrAomentai Affairs (COPY
Department of
Environmental Protection
WlZam F.Wald
G&AM r
maXe
y.
DavM IL tC4ffdnWekwwtdtais
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 6 8 S F/y �, H:// Rot ' Address of Owner. qN N g a k'r
Date of Inspection; // r 3(��' Of different)
Name of Inspector: �-&y t );l ('. ,�.,g Sc- e
Company Name, Address arfd Telephone Number:
SQL C�6n Je -
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 o"ite sewage disposal systems. The system:
V Passes
_ Conditionally Passes
_ Needs Further Evaluation By the local Approving Authority
Fails
Inspector's Signature: Dater
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional 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:
Check A, B,C, or D:
A) SYSTEM PASSES:
�I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components reed to be replaced or repaired. The system, upon completion of the replacemem or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all Instances. If'not determined', explain why noo
The septic tank is metal, craciced, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
ir—l.ed 1/15/951 t
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: g l S 41 ; l/
Owner:
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES (continued)
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 pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The svctem has a septic tank ano soli absorption system and is within 100 feet to a surface water supply or tributary, tc a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
)I 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 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.
:evised 8/15/95) 2
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: / ,S F H
Owner: �?A G✓
Date of Inspection:
11 I/3/9 ,
Dl SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
— Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of.a public well.
Any portion of a 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.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone It of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/9S) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: k
Date of Inspection:
Check'if the following have been done:
V/ Pumping information was requested of the owner, occupant, and Board of Health.
, one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
N�'%As built plans have been obtained and examined. Note if they are not available with WA.
/The facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow
V The site was inspected for signs of breakout.
�AII system components, excluding the Soil Absorption System, have been located on the site.
ZThe 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 or
approximated by non-intrusive methods.
V The facility ownP, (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised B/15/95) 4
1.
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
_ SYSTEM INFORMATION
Property Address: 'WOE/' _S ° ��`1 '`' S h5
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:330 gallons
Number of bedrooms:_
Number of current residents:
Garbage grinder (yes or no):�°
Laundry connected to system (yes or no):�FS
Seasonal use (yes or no): No
Water meter readings, if available: p y — /O"o 5 ti/-
y
Last date of occupancy: Q (- c,
COMMERCIAUINDUSTRIAL: 111/,j
type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title S system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
/� s T ,�,�✓J<- /vl w✓L L y � / / ,,o t.i ; h�L f'T�o Y,.. �'77�v�.c a�..,�.,tom, .
System pumped as part of inspection: (yes or no) /mac
If yes, volume pumped eallons
Reason for pumping:
TYPE (�F SYSTEM
Septic tank/d4Hib"49a-aeu/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 0
1 f � �.� 'i". a S—y.—f c.'5�,v.
Sewage odors detected when arriving at the site: (yes or no) /*-/0 -
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: / S ,o}
Owner: ��k�f
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grade: 01/
Material of construction: ✓concrete _metal _FRP —other(explain)
Dimensions: $' K y K 6 /o C.0
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: NOW/5
Distance from top of scum to top of outlet tee or bafflers `-Q
Distance from bottom of scum to bottom of outlet tee or baffle: IV
Comments:
)recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) �, v . /e--1- �'-d 0,-.)+(,-* "A
U,f-, 'c, k%-c, t' t_ U cJlc►w1 s !�
poi A0 (� v f . �.J w s r.r r h . a 1 j 1, f-�y c'Lo67 /) Jo J �- S y S )01 c
/ In wo✓Y i vt cJ 6�-�cr �
GREASE TRAP:
;locate on site plan)
Depth below grade: .
material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
,cum thickness:
Distance from top of scum to top of outlet tee or baffle:
`-Iistance from bottom 01 «ts- I- honor- of outlet tee or bathe
Comments:
recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
ntegrity, evidence of leakage, etc.)
irevised 8/15/951 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: / 54 Lot F61 i Lt S �/
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_,��-1
(locate on site plan)
Depth below grade:
Material of construction: _oonaete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Nlarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
locate on site plan)
Depth of liquid level above outlet invert:
Comments:
.note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER: )V49
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 54-4
Owner:
Date of Inspection: /9 s
SOIL ABSORPTION SYSTEM (SAS):_Z
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
if not determined to be present, explain:
Type: ``
leaching pits, number: c� �XC 11.ca �.�— b.r �S►�ti
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
,Comments: (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
bt o -I . ,G 4 co a b—k-� (, c._ �'. 1 v c c✓ t
CESSPOOLS:
;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:
,ndication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
I
(revised 8/15/95) $
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
P roperty Address: i S 4 �- r y;�;5 /�-��lea .
Owner.
Date of Inspection:
/C-?
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
as '
_ , C X6 ��..c 4� 1, �o•J-
DEPTH TO GROUNDWATER
Depth to groundwater: — feet — adjusted high groundwater level
method of determination or approximation: „J
revised 8/15/95) 9