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HomeMy WebLinkAbout0603 SKUNKNET ROAD - Health 603 Skunknet Road Centerville P 169 011007 i' 4 �I ///1 Alvaro,- UPC 12543 No.5_ 3_ LOR HASTINGS.MN w No.� (�!a (� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Mizpogal *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade�bandon( ) El Complete System WIndividual Components Location Address or Lot No. ("0—'Z Owner's Name,Address and Tel.No. Assessor's Map/Parcel 9 V` 61k 6kr^'ir i r-V Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. WV110-rt,; (S-0 C Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flower O gallons per day. Calculated daily flow 3'�'kcI gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank STD' l 7 Type of S.A.S. Description of Soil S -P•w-,o Nature of Repairs or Alterations(Answer when applicable) Csc_QtiC_i Ljvv CZNc)s? S U, t S` 6(_e_ CU_ S,t*g rc Ci a t!L f� 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 Signed Date ;;Z Application Approved by - - -- Date 3-^1 �l-®m Application Disapproved for the following reasons y Permit No. Date Issued f '`.. ALL)� LL .srw..: •, as, No. d Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: \ # Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Mitpozal 6potem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) El Complete System NKIndividual Components Location Address or Lot No: (�d +wn�v�a i- aQ Owner's Name,Address and Tel.No. Assessor's Map/Parcel 10 r G l` C,(-,-? ct Y 1 r%' V Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3_3�O gallons per day. Calculated daily flow 3 Ac1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ��-+� 7 �`, - 1U`L'�t� Type of S.A.S. VA Cg.Drc- i'l-­% �*tL_ Description of SoilA (At4__�2 5 d` �� F0, irz � Nature/af Repairs or Alterations(Answer when applicable) t 5 t A.��. �" t< Csc (]�G� + tr ' c =� C.i drnZc �0 t, ,` k S Gx Chu— Sr(� / �' fUft (✓l� °,-(r` �`ZI 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 Neta-issned-by-t�€ ` ;� Signed Date Application Approved by t, - --__-- Date" 2.--1 Ll-Oa. ` Application Disapproved for the following reasons s Permit No. -^ D 9 (_d r'�` 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( 4 Abandoned( )by � 0---G E_ SS at 3 Kvn Aft T n «-v yr has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2an2.0 dated Installer Designer /� A Al The issuance of this permit shalYnot be c nstrued as a guarantee that the systM114A � ction as deigned. f j Date Inspector ,1 Y v Y p k No. k,900 — 0 3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS x1i6po5al *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(t..)'Xbandon( ) System located at 61 C 3 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. 1/649 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SIITCH ANY APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERtiCIT (WITHOUT DESIGNED PLANS) c hereby certiry P that the application for dis osal works construction permit sided by me dated concer=2 the property Iocated at (�0u�.(Lu.�� C �% meets all of the following criteria: v• The failed system is conne^ed Co a residential dwelling only. There are no commercial or business r� uses associated with the dwelling. • The soil is classined as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. j There are no wetlands within l00 feet of the proposed septic syrern •/� T"nere are no private wells within 1150 fert of the proposed sepac system •r There is no increase in flow and/or change in use proposed T'nere are no variances requested or needed. C c bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable} If the S.A.S. will be located with 350 F e,of any ve;etated wetlands, the bcaom of the proposed leaching facility will not be located less chart fourteen(1 Y) feet above the ma urnum adiusted P*oundwater table elevation. Please complete the following: q � A) Too of Ground Surface Elevation(using GIS information) B) G.W. Elevatio `© _the �1��<. `r-risk rrS G.W. Adjuscmenc .(►� _ �Q D FF RE�CE E E 1 WEE A.and E t SI(17ED : DATE: (Sketch proposed plan of system on bac"'J. a:h�Lh rain.-t ' � it v .s� ���- TOWN OF BARNSTABLE LOCATION SEWAGE # na VII,LAGE ASSESSOR'S MAP & LOT. INSTALLER'S NAME&PHONE NO. /!SEPTIC TANK CAPACITY LEACHING FACILITY: (ty ) ti /T✓' S (size) NO.OF BEDROOMS BUILDER OR OWNS PERMITDATE: 1100 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 3W feet of leaching facility) Feet Furnished by 7 V 7f1 V Th I V o 7 . - 1 � TC�`v�'N OF BARI SV'ABLE LOCATION 603 _PK(1AK _La SEWAGE # �OA15 VILLAU ep-., ASSESSOR'S MAP & LOT �® INSTALLER'S NAME&PHONE NO. /!�r s!1 r ✓a�/) ��/�Jam. f' SEPTIC TANK CAPACITY LEACHING FACILITY: (ty ) rRJ / rr %r �,S (size) /� k NO.OF BEDROOMS BUILDER OR OWNE PERMITDATE: 4=Q `C�OMPL�LkNCE DATE: 0'® 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 13ACK I q � � l aat2j— c I. i COMMONWEALTH OF MASSACHUSETTS FILE COPY EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y h A� �t V V TITLE 5 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 603 Skunkneek-Road FRECEIVEDCenterville,MA.02632 APOwner's Name: Wilbert BeattyOwner's Address: Same PARCEL. ; 1 b® L 2 7 Z00 0 Date of Inspection: 5/14/2004 TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector: (please print) Brad J White Company Name:Windriver Enviromental Mailing Address: 107 N.Main Street Carver,MA 02330 Telephone Number:(508)-866-2576 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: — Date: 5/14/2004 The system inspector shall submit a copy o 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 System Passes. ****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: 603 Skunkneck Road Centerville,MA.02632 Owner: Beatty Date of Inspection: 5/14/2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: System passes.Recommend regular service. 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: T;rla S T—aMfi^"TZ—411 siInnn 2 Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 603 Skunkneck Road Centerville,MA. 02632 Owner: Beatty Date of Inspection: 5/.14/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing"to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(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 5,0 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: T;rIA G Tncnarfinn Fnrm Ail ci)nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 603 Skunkneck Road Centerville,MA.02632 Owner: Beatty Date of Inspection: 5/14/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to.each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow _X__ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be 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 — _ y g ( 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. Title G T--,f;—T7—(/1 VIM) 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 603 Skunkneck Road Centerville,MA.02632 Owner: Beatty Date of Inspection: 5/14/2004 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _ _X Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X _ Was the facility or dwelling inspected for signs of sewage back up'? _X _ Was the site inspected for signs of break out? _X _ Were all system components,excluding the SAS,located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper _m aintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X _ Existing information.For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] T41. C T-c—"r 17nrm ail;iinnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 603 Skunkneck Road Centerville,MA.02632 Owner: Beatty Date of Inspection: 5/14/2004 ww FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330gpd 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):Yes Seasonal use:(yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): 129gpd Sump pump(yes or no):NO Last date of occupancy: Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 3/4/2004 Was system pumped as part of the inspection(yes or no):No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy No 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: System was installed in 2000 per as built plan. Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Tne.+Antinn Fnrm ail�i�nnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 603 Skunlmeck Road Centerville,MA.02632 Owner: Beatty Date of Inspection: 5/14/2004 BUILDING SEWER(locate on site plan) Depth below grade: 39" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line:N/A Comments(on condition of joints,venting,evidence of leakage,etc.):Building sewer is in good conditon. SEPTIC TANK: X (locate on site plan)(Outlet has riser to grade) Depth below grade:24" Material of construction:X 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:8'x 5'-8" x 5'-2" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:Flocking . Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined:Measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Inlet and Outlet tees are in good condition. Liquid level is normal.No evidence of leakage in or out. GREASE TRAP:_(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.): Ti*lu C Tncr +inn Vn 411 cnnnn 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: 603 Skunlmeck Road Centerville,MA.02632 Owner: Beatty Date of Inspection: 5/14/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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:X (if present must be opened)(locate on site plan)(31"below grade) 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.):Distribution box is level.Good condition no evidence of solids carry over PUMP CHAMBER: (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.): Titlr+G Tncr�orfinn Timm�n�i�nnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 603 Skunkneck Road Centerville,MA.02632 Owner: Beatty Date of Inspection: 5/1.4/2004 SOIL ABSORPTION SYSTEM(SAS): X (locale on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: X leaching galleries,number: 4 @ 4' x 4' 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.): Soil is dry.No evidence of hydraulic failure.Vegetation is normal.No ponding on the surface. 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 or 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.): Tiflo C Tncnonfi nn Fnrm�n Ci�nnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 603 Skunkneck Road Centerville,MA.02632 Owner: Beatty Date of Inspection: 5/14/2004 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. C 3 �4 p 0 t 2 fwo0'je-D 61 Z° 3-2 i 3 C3 - 33 ' a3 � 3►' T41. G Tncnnr}inn 17nrm 4/1 ci')nnn 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: 603 Skunkneck Road Centerville,MA.02632 Owner: Beatty Date of Inspection: 5/14/2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6'+ feet Please indicate(check)all methods used to determine the high ground water elevation: i X Obtained from system design plans on record-If checked,date of design plan reviewed: 2000 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:No indication of groundwater at 6'.As built plan indicated no groundwater at 6'dated 2000. Title C T1ICMPLtIAT P_o;11 ci,)nnn 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n1a. . X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 6'X6'LEACH PIT leaching chambers,number: jaLa leaching galleries,number: jaLa leaching trenches,number,length: nLa leaching fields,number,dimensions: nLa overflow cesspool,number: nLa Alternative system: n& Name of Technology: ja& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING,THE LIQUID LEVEL WAS AT THE BOTTOM OF THE PIPE AT TIME OF INSPECTION.EFFEr+' e CESSPOOLS: (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: n& Depth of solids layer: nLa Depth of scum layer. n[a Dimensions of cesspool: nLa Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:Wa Depth of solids: Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta revised 9/2/98 Page 9 of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE 'Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .. c CERTIFICATION Property Address: 603 SKUNKNET RD. CENTERVILLE MAP 169 P 011-LOT007 Name of Owner MARINO 1° Address of Owner: SAME Pfl' VEn Date of Inspection: 1/26/00 FEB JC 1a: Name of Inspector:(Please Print)JOHN GRACI ;� 2000 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) j3. 7VWN0F Company Name: n/a v. HFAC1NDEpr Mailing Address: n/a �,' Telephone Number: n/a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: _ Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does X Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:1/26/00 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving.authority. NOTES AND COMMENTS THE SYSTEM FAILS TITLE SEPTIC INSPECTION.THE LEACH PIT HAD NO LEACHING LEFT AT,THE LIQUID LEVEL WAS AT THE BOTTOM OF THE PIPE AT THE TIME OF THE INSPECTION.THE PIPE THAT COMES INTO THE 1000 LEACH PIT IS 2'LOWER THAN NORMAL,THIS MAKE THE SIZE OF THE PIT 6'X4'. revised 9/2/98 Page 1 of 11 i :......... ..........: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 603 SKUNKNET RD. CENTERVILLE MAP 169 P 011.-LOT007 1 Name of Owner MARINO Address of Owner: SAME Date of Inspection: 1/26/00 ��i�•Crf C c� Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) IA/V p Company Name: n/a Mailing Address: n/a gAR OINNOF Telephone Number: n/a H1HOFPT CERTIFICATION STATEMENT I certify that I have personalty inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: _ Passes The inpection Is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Eyalqation By the Local Approving Authority performing at the time of the inspection.My inspection does X Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:1/26/00 The System Inspector shal submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design now 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. ' NOTES AND COMMENTS THE SYSTEM FAILS TITLE SEPTIC INSPECTION.THE LEACH PIT HAD NO LEACHING LEFT AT THE TIME OF THE INSPECTION.THE PIPE COMES INTO THE LEACH PIT 2'LOWER THAN NORMAL ELEVATION. revised 9/2/98 Page 11 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: n/a B. SYSTEM CONDITIONALLY PASSES: nLa One or more system components as described in the"Conditional Pass"section need to W replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n& 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 n& 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 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 IN ACCORDANCE WITH 310 CMR 16.303(1)(b)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 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. - The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. - The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n/a.(approximation not valid). 3) OTHER n1a revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1126/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n&. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy Is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS Is over the invert pipe,Is In Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further Information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing Information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 FLOW CONDITIONS RESIDENTIAI: Design flow:-M g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):$ Total DESIGN flow: IV Number of current residents:A Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):_NO Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): n!A Sump Pump(yes or no): NO Last date of occupancy: n& C O M M E RC IAL/IN DUSTRIAL Type of establishment: n& Design flow: WA gpd(Based on 15.203) Basis of design flow: Wit Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ, Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) n& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS PUMPED IN OCT.BY ROBINSON INFORMATION FROM HOMEOWNER System pumped as part of inspection:(yes or no):NO If yes,volume pumped n1a- gallons Reason for pumping: n& TYPE OF SYSTEM ' X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: Wit APPROXIMATE AGE of all components,date installed(if known)and source of information: A Sewage odors detected when arriving at the site:(yes or no): MQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 BUILDING SEWER: (Locate on site plan) Depth below grade: 1'6" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n(a Comments: (condition of joints,venting,evidence of leakage,etc.) n(a SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ Wa Dimensions: L 9'6"H 6'7"W 4'10" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 3" 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: In How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: n/a Scum thickness: n(a Distance from top of scum to top of outlet tee or baffle:im(a Distance from bottom of scum to bottom of outlet tee or baffle nla Date of last pumping: n/a 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.) n/a revised 9/2/98 Page 7 of t t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 i TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n/a Dimensions: Wa Capacity: Wa gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:jila- Alarm in working order:Yes—No—: MO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet Invert:n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DID NOT EXPOSE PUMP CHAMBER: DLO (locate on site plan) Pumps in working order:(Yes or No): MO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 111 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON PIT leaching chambers,number: -n(a leaching galleries,number: j3& leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: ILA Alternative system: n& Name of Technology: -n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING THERE IS NO LEACHING LEFT IN THE PIT THE PIPE IS AT THE WRONG ELEVATION, CESSPOOLS: (locate on site plan) Number and configuration: ILA Depth-top of liquid to inlet invert: n& Depth of solids layer: nla Depth of scum layer. ILA Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:nla Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a g4e t: p C � a53 revised 912198 Page 10 of 11 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 603 SKUNKNET RD.CENTERVILLE MAP 169 P 011-LOT007 Owner: MARINO Date of Inspection:1/26/00 NRCS Report name: n/a Soil Type: n& Typical depth to groundwater: nla USGS Date website visited: nLa Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-10+FEET revised 9/2/98 Page 11 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 603 Skunknet Rd Centerville Owner's name 2 �p2 Frank Vallarelli Date of Inspection S_ PART A MAY 2 6 1995 CHECKLIST HEALTH DEPT. TOWN OF BARNSTABLE Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. V _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. I_ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the / site. ✓ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. If/ The size and location of the SAS on the site has been determined based / .on existing information or approximated by non-intrusive methods. ✓ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS.' r 1 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms _ number of current residents 0_ garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: S"13'�S Last date of occupancy GENERAL INFORMATION Pumping records and source of information: J�U rY1nP d AA L U +Old System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Ty4e of system JJ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: ;7 arc nld ola�� 00 Sewage odors detected when arriving at the site, yes or no r 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: IV material of construction: `� concrete metal FRP other(explain) - dimensions: �� k q ' X sludge depth -)r distance from top of sludge to bottom of outlet tee or baffle PV scum thickness ,W distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) Ail 11ee S DISTRIBUTION BOX: (locate on site plan) y- V' 4&)6uj 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, recommendation for repairs, etc. ) PUMP CHAMBER: I� (locate on site plan) Apumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, - recommendations for maintenance or repairs,etc. ) NO pow? - - r 10 .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B i SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: (OOC Flo fo c ed Type. leaching pits and number leaching chambers and number ®Oo leaching galleries and 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, recommendations f NOA/e or maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration V/R 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of pondin condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance. or repairs,etc. ) 091�, r 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE r=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' c � o I pax c l DEPTH TO GROUNDWATER depth to groundwater method of determination or ap roximation: •��'ev i o us ���- �o�e. I • 12 SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) _ Backup of sewage into facility? Discharge or ponding of effluent to the surface of the round or surface waters? g V Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? N Required pumping 4 times or more in the last ea number of times pumped year? Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? I within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? less than 10o feet but greater than 50 feet from a private supply well with no acceptable water quality analysis? If the wellhas been analyzed to be acceptable, attach copy of well water analysi! . for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. ' .I r , o 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION ame of Inspector W.E. Robinson Jr ompany Name W.E. Robinson Septic Service ompany Address P.O. Box 1089 Centerville MA 02632 ertification Statement certify that I have personally inspected the sewage disposal system at his address and that the information reported is true, accurate and omplete as of the time of inspection. The inspection was performed and ny recommendations regarding upgrade, maintenance and repair are Dnsistent with my training and experience in the proper function and anitenance of on-site sewage disposal systems. -ieck one I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15 . 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. ispector ' s Signature w�2�?�'�Yr���6 %, `9A ate -iginal to system owner i Dpies to: 3uyer (if applicable) 3,pproving authority l I r sl O-C ION SEWAGE PERMIT NO. IAA L AG I N S T A LLER'S NAME i ADDRESS � / BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ;2 /S-- � f TOWN OF BARNSTABLE LOCATIOI � _S t V - 1 4, SEWAGE VILL.&GE LV1 &ASSESSOR'S MAP & LOT v INSTALLER'S NAME & PHONE NO. O�i� e '" SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /LS Cry ` (size) G + 6 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER / DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: es IJo ,. Ks A ry J 7 ♦ r No. 3'_1�3. -- FE$....YO ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ ... ...................OF........................................-................................................. Appliratiun for Diipuiittl Workii Tonti rnrtiun Famit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: .......�1-••.-.�.......�.� �. .....��..Ce --------------------------------------------------------------------------••--•-•-•-••••••••-••-•- Location-Address 7 or Lot No. Aku.e-r_:_i :.A:.'1_.�4�'�l.t................................ ,C��C� ®�.-�C"--.�1...LS.1.4_:d��►`��............_. 1 _ owner]�_ Address 4 !��... ................. ••-•.....................•-•........-•-••• Installer Address d Type of Building Size Lot___ t__ QQ....S . U Dwelling—No. of Bedrooms...... __________________Expansion At (,iscy) Garbage Grind r (+gyp) j A4 Other—Type of Building f__5`n wy___4. No.r of persons______ __________________ Showers (Z-) — Cafeteri Q' Other fixtures ......._d-4_S.q_--••--1,�. v+.s_7 t v'................................................................................................. W Design Flow....................S__6..............gallons per person per day. Total daily flow................:�'_Z_®_.............gallons. WSeptic Tank—Liquid capacity.1000_gallons Length__CS?`___/.._. Width._5'-=.9__._ Diameter________________ Depth................ x Disposal Trench—No_..........__________ Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No.._...l..__.- _..,-____.__ Diameter._._(-0._�. _.._. Depth below inlet__ ........... Total leaching area:S_1Q___._sq. ft. Z Other Distribution box (✓) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •--•------------------•-•-----•---._...-•-----------•---......._....._......._._...-------•------•------•---•----------------••-•--•---•-•-------•-•- 0 Description of Soil........................................................................................................................................................................ x V W ----••••--------------------•-----•••---•--•----••-----------..._..•••--•--• ---•---•-•-•----•---••------••--•-•--------••-••---••••••-••-••--•••---••-••••---•••••••------•••-.._..•-•-•.._.._......._. UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ----•------•--•..............•-•-•-•-_.._---•-•----•-•-•---•--..._...._.._..._..._...._....•-_•---••----••-•--•-•-•-----•-------••••--•••-•--••......-••-•-----........................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL III LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n iss board,of`'liealth. ApplicationApproved By___C_ .... ............................................................................... Date Application Disapproved t following reasons:............................................................................................................... -----•------•-•.................................•---•------._.....___.___..._.._.._...---.......---.........------------.....----•-•- ................................................ Date PermitNo......................................................... ............ t!.�' f y Fxa..... ........ ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................................... ..OF....................... .................................. ..... ......_........... Appliratiun for Diupuuttl Vorkg Tontitrurtion ramit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: I 77- C2� .. .......��. d:'.( f'1.[f'.. ...........i F........... ........-•-------------....................................------•---............................. __ Location-Address or Lot No. Y..t...� ... .........................•--._... �.....��L.�_... .1% .1....! G.. h�.............. .. Owner Address a ...............�- .L._�.z •---•-.. ._.%:...(......---.._............ ........••. ---•-•-•••........-•-......-••.............._.. Installer Address Type of Building Size Lot....L.�;,..�0U....S . U Dwelling No. of Bedrooms._.._.__..._...__ Expansion Attic�. g— 11-••-•----........ p (p,.x) Garbage Grind r (ti,r�) P4 Other—Type of Building _(__5 7o y...lkr.�J No. of persons___-__�f---•-------------- Showers (�) — Cafeten Otherfixtures ........L).t ................•--..........•..--..._...............---...-----................................. w Design Flow....................�_. _.............gallons per person per day. Total daily flow................ .............gallons. WSeptic Tank—Liquid capacity.j.aQf,2_gallons Length..1^..%.._. Width........ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......!.............. Diameter._.. .....C. ..... Depth below inlet _.......__.__. Total leaching area....... _Y.....sq. ft. Z Other Distribution box Dosing tank ( ) a Percolation Test Results Performed bY.......................................................................... Date................... :. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ LT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ......................................................_................................................................................... •--••-------•------ 0 Description of Soil................................................---•---•-•------...---•--...-----------.._...._..----------------•---------........-----•---•...........---•••-•••••... x c, -------•----••••-••-------••-••-----------------------------••-•-----------•-----•....----------•---•---------...•--•-------------------••--••---•-- w VNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------•-------------------------------------------------------------•---...-------••---••••....----------•----------••-•-••-----------••-• ............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issue&& board of Health. "l.r Application Approved B ........................................................ ...- . ........ Date Application Disapproved f f ollowing reasons:---•-------------•-----------------•---....---•--••-------•------•-•-•-----------------•--...................... ...................................................................----•----•-•------_..............._............••---•------------------••.....•--•--------••-------•--......----•••......--•--...... i Date Permit No.............. Issued. ..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................................I.......OF..................................................................................... Trrtifiratr of Toutplittnrr THJ SS�IS T CERTIFY, That the Individual Sewage Disposal System constructed (; ,�6r Repaired ( ) by...s-'-•`'•..�` ,...... . �.% . .....•-- ' < ................................ he------ te.------ tar---- ...---------•--- •---- ------------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code tle rued in the application for Disposal Works Construction Permit No._l_3_."_ ��;............. dated_. ____,._. ..(_'_. .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE/CONSTED AS A GUARANTEE THAT THE SYSTEM Wl TION SATISFACTORY. DATE.... s :. `_.... Inspector --•-•••----•••--•--•-•••........._....---.......---•--••..--..-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l , � ..............OF.......................�yNo .................. FEE........................ 'Diullofa1 u fonutritrttion rrmit Permission is ereby granted =� ` r - ----•----- ---- ----------------- at Street as shown on the application for Disposal Works Construction Permit No........... -': _,Dated.......................................... / ` ..... ............................................................... DATE. / v - Board of Health -------- ---.�.................................... FORM 1255 A. M. SULKIN, INC., BOSTON ' o"�'LEZf=.26X6 -`7-�-�--�• -__.� _ GE�,.iEt�.b.�... t�i©TE.� (D--Att_L Et E,,'b Nov✓A..1 Ae c M to ao.,1 SEA. LF-Vc1. S� -�. _,•_;� �.,._. -_ N e.as�D ©«,t U�.aC.��S tau�•r u►y1 'P�.�.s.ltE _ 2Q--- Pt-icN A!L LIWES I► Naz'aj is E 3PTCa1F t'Ei�. ,Dq,/:Z> 4• i �� + ® - U. PIPES I-C, -A*J0 IQ TH£ SYST�,� 544lw� � ftC ST 12,0" cif. sC.k e c>L)L.E Ap P.,/C. 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