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HomeMy WebLinkAbout0075 STONEY CLIFF ROAD - Health 75 Stoney Cliff Road, Centerville A= � o UPC 12534 ' N , -153L R MABTINOs NO i �® JOV - r No. 1000— 2-7-S Fee $50� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYtcatton for Mtzpaoal 6pttem Conttructton Vermtt Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. ls��Yl Owner's Name,Address and Tel.No. 75 Stoney Cliff, Centerville Wm Dutton Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 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 Tank Type of S.A.S. Description of Soil S and. Nature of Repairs or Alterations(Answer when applicable)Title—5 septic system consisting of a tank, D-box, and. 2 concrete leach 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 oard f Health. Signed I I Date Application Approved by Date Application Disapproved for theYollovgg reasons Permit No. aOPv •- `.') 3 Date Issued 0 ao No. �'(�Q7{�_ a�7 _. "'Fee $5 n 0� THE COMMONWEALTH OF MASSACHUSETTS _ Entered in corngutec: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Zizpozar *pttem Construction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 75 Stoney Cliff, `�1enterville Wm Dutton Assessor's Map/Parcel ry Installer's Name,Address,and Tel.No. Designer's Name Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville ,N 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 Tank Type of S.A.S. ,t Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system consisting of a tank, D-box, and. 2 concrete leach chambers with stone . Oil 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 thi_sj3oard.Qf Health. r Signed �t+ 1 Date Application Approved by Date Application Disapproved for theYollowqg reasons r a Permit No. goyr> Date Issued THE COMMONWEALTH OF MASSACHUSETTS Dutton BARNSTABLE, MASSACHUSETTS itertificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Dis.posal System Constructed( )Repaired (X )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 75 Stoney Cliff Rd. , Centerville has been constructed in accordance with the provisions of Title 5 and the for Did osal System Construction Permit No. -4 dated Installer Wm. E. Robinson ar. Designer The issuance of this pe7lnit shal not be construed as a guarantee that the sysf�m will function as,/&.(sigf Date Inspector E' 1. 1 — ------------------------------ No. eZO�in - THE COMMONWEALTH OF MASSACHUSETTS Dutton PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Zisspogal *pttem (fo ��ruction Permit Permission is hereby granted to Construct(, Re air(X))Up ade( ))Abandon( ) Systemlocatedat Stoney Clif Rd.. , Centerville � v 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: .� ^.5`" UCH Approved by ` t�V/77 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) j, William E. Robinson,S1Iiereby certify that the application for disposal works construction permit signed by me dated sl 0-4-1 , concerning the property located at 75 Stoney Cliff Rd,, Centerville meets all ofthe following criteria: • The failed syste/dee ted to a dential dwelling only. There are no commercial or business uses associated lling. The soil is classSS -and the percolation rate is less than or equal to S minutes per inch. There are no wlW feet of the proposed septic a�stem _ There are no pithin 150 feet of the proposed septic system There is no inc and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the ma2dmum adjusted groundwater table elevation: (Adjust the groundwater table using the Frimptor method when applicable) • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the MAX High G.W. Adjustment DIFFERENCE.BETWEEN A and B SIGNED : ��—w✓- DATE: (Sketch proposed plan of system on backi. y:health folder:cen rT I p� V ti> COMMONWEALTH OF MASSACHUSETTS v ExECUTIVE OFFICE OF EI,�i]R0- '�IE\TAL AFFAIRS DEPARTMENT OF EN-VIRONNIE\TAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02106 1617-292-5400 WILLIAM F.WELD TRUDY CO>: ARGEO PALL CELLL•CCI - D.4VID B STRL'h Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission PART A CERTIFICATION r Property Address; 7S S�o@JQ� C11 t 1C(1t�C'Vj1I `Address of Owner: �hw �>z�F�t►.� Date of Inspection: 1 Ll+ `j °3-.'(If different) Name of Inspector: et o i� �►t_E��CC:) 1 am a DEP ap, roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: //_�r erg 'e �n y'l'r-,I we a A- � Mailing Address: p �o�c 3��{ H fAS H 19-© 0--C Telephone Number: r �*42— /4&: o CERTIFICATION STATEMENT I ce.^.tfi that I have personall- inspected the sewage d!sposal system at this address and that the information reported beio% is true, accurate and complete a. of the time of tnspec*oo-�. The inspection was performed baser on m% training and experience to the proper function and maintenance of on-s-te sewage disposa; systems. The sv.terr,: Passes _ Concit,onaiiv Passes _ Neec. Furthe• Evaluation 5% the Local Approving Authonn _ Fa.•s _ _ Inspector's Signature Date: \1 Svs:e7 Inspeeo• sha!' subma a copy of this inspection report to the Approving Authorin- within th,m• (30) days of completing this inspection. It the sN-stem is a shared system o• has a des,gn floµ. of 10,000 gpd or greater, the inspector and the system owner shall submit the repo- to the appropriate regional orrice of the Depa.merit of Envtronmenta� Protection.. The orig.-nal should be sent to the system ovine And copes :-nt to the buyer. if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: have not found any information which indicates that the systern violates any of the.failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicate✓ below. n COMMENTS: (�q,�P�ijy1 S� ���n♦CA t �-ytl sC�►e►v i y`)� -b! ( L Ia=& QA e `ETA B) SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass- section need to be replaced or repaired.. The system, upc completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NDt. Describe basis of determination in all instances. If'not determined". explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; c the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tan; 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. (rev.sed 04/25!97) Page 1 of 10 SUBSL.IRFACE SEWAGE DISPOSAL SYSTEM INSPECTIO.N FORM PART B ,..:...>:.....CHECKLIST Vad Property Address: —IS S A Owner: G-10-A'F'1✓1-wj Date of Inspection: ;-L`s�qj ou must indicate either 'Yes`or Check if the following have been done: Y 'No'as to each of the following: Yes No - . Pumping information was provided by the owner, occupant,.or Board of Health. None of the system components 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 pan of this inspection. 1t As built p!ans have been obtained and examined. Note if they are not available with N/A. The fac!litn or dwelling was inspected for signs o-sewage back-up. _ The wstem does not receive non-sanitary or industrial waste flow. _ The site %%as inspected for signs of breakout. e So+: Absorption Sister-, have been located on the site. A!I ssteT components. excluding th terior of the septic tank was inspected for condition of The sept c tarsi: manholes µere uncovered. opened. and the in baffles or tees. materta; o construction, dimensions, deptn of liquid, depth of sludge, depth of scum. The s;ze and location of the Soil Absorption System on the site has been determined. based on: _ The fac•iln o\•ne• iano occupants. if dmerent trorn owners were provided with information on the proper maintenance o.. Sub-Suriace Disposal Svstem_ Existing information. Ex. Plan at B.O.H. _ Determined in the field of am of the failure criteria relater to Par, C is at issue, approximation of distance is unacceatabie (15.3023),,V (revised 04/25/57) - - page 4 0! 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 9 SYSTEM INFORMATION =: Property!Address: '�S V60E J C 1 1 r"} Owner: C�,4FFI Date of Ihspect)on: FLOW CONDITIONS RESIDENTIAL: Design flo% g.o.d.!bedroom for S.A�S Number of bedrooms.0 Number o-current residents-OL Garbage g g:,der (yes or'no':�. " Laundry co-.'^ected to system (yes or no` �- Seasonal use Ives or no-: t j Water meter readings, if available (last two (2; year usage tgr>d,: LxA.A.-, Sump Pump Ives or no) Lai:da;e o'occupancy V� COMMERC IAL'INDI.'STRIAL: Type of establ)shmen: Design flow-_ ahonslda� _ .. Grease trap present. Ives or no Industrial %baste Holding Tani; present. wes or no :on-sanrtan, Haste discharger to the T,toe 5 system. ives or no %later meter readings. if availabie Las:pa;e or o c::pan.c. OTHER. De;cnbe Last care of occucanc% GENERAL INFORMATION PUMPING. ECORDS a d source of information. T}yr�V � System pumped as par, of inspection: Ives or no If yes, volume pumped(SbOCI allons _ Reason for pumping Mp-IrjTh1UCg_ TYPE OF SYSTEM Septic tank distribution boxrsoil absorption system _ Single cesspool Overflow cesspool Prn) Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technologv etc_ Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 11JSP-r\Itd I 1 Sewage odors detected when arriving at the site. (yes or no) U -.---.__-_____.._..____ (revised 04/25/91) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIA - .PART C .. ._ - SYSTEM INFORMATION (continued) Property Addr-ss: ��5 j�"t ls�I F Owner: N , Date oY Inspection: 12A( l 7l SOIL ABSORPTION SYSTEM (SAS):T (locate on sitepian, if possible; exca� ion not required, but may be approximated by non-intrusive methods: If not determined to be present, explain: Type: ._.. _....._ ._.:. .......__....._._.. _ ._ __.. .. _ _... _.. __........ �. -- - _ _-.... _leaching pits. number,_ .. - �____ ._.._...._ .... _,..z- leaching chambers, number:_ leaching galleries, number: leaching trenches, number,iength: leaching fields, number, dimensions. over,"ion• cesspool, number Alternative system Name of Technology Comments. mote condition of soli, s gr s of hydraulic failure, level of ponding, on or ve etation, etc.) ` / N Jv 1 CESSPOOLS: (locate on site plar. Numbe, and configjra:,or. Depth-top of liquid to inlet tm•er, ��II Depth of solids laye-- 122 Depth of scum layer. (')'' Dimensions of cesspool- Materials of constructiocQji_� E3�oC� Indication of groundwate- IV C) inflow icesspool must be pumped as par, of inspection's IkC,C Comments: (note condition of soil, signs of..bydraulic failure, Wvel of ponding, condition of vegetation, etc.) V r r . i rV l PRIVY: .. (locate on site plan) materials-'of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04;2s/97) rage t of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C [ SYSTEM INFORMATION (continued' Property Address: 15 (Nk� Owner:C-A1T h iN Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) C � .A1,a �i - � � � DISPOSAL SYSTEM INSPECTION FORM SUBSURFACE SEWAGE D , PART C - SYSTEM INFORMATION (continued) ,� C�►� c- Propert� Address-� J b Owner: ,-,I l 1 Date of Inspection: i h) Depth to Groundµ•atert 6 Fee: Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property. observation hole, basement sump etc.) Determine it from local conditions Cneck with loca! Board o- nea!tr Check FE.I.AA hiaps Check pumping record-- Check loca! excavators, installers Use LSCS Data r, Describe it %•ojr.�own v.oros no•,% co:: es:abhshed the `-q£- CrourdAater Elevation. (Must be completed: nn dVol o�,jC T,0�ksTiclAT7ONS 14 (zav:aad Page 10 of 10 COMMO.NN EALTH OF MASSACHL;SETTS _ EhEc TIVE OFFICE OF E:N'VIRONMENTAL AFFAIRS = - F DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON KA 0210c 161;i 292-550t, ` TRL DY COL Secretan ARGEO PALL CELLUCCI DAVID B STP.;.'HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:7 5 Stoney Cliff -Rd.. , .wit 1 anAf6or,er Wm. Dutton Centerville AddessofOwner: Date of Inspection: 6 —/:7--a--<- Name of Inspector:(Please Print)WM. E . Robinson Sr. I am a DEP approved system)inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) Corr,panyName: Wm. E . Robinson Ileptic Service Marling address: PO Box 0 9. Centerville .--MA Telephone Number: 7 7 5- 7 7 0 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-sit e Zsses disposal systems. The system: Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: C�Fa/ I L Date: 41—/O2_0 0 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 r C, r g° 200 k i��a;., .a revised 9/2/9E page Iorll i• -.^!ed on Recvded Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (corrt roved) 'rap"Address: 75 Stoney Cliff Rd. , Centerville Jwner: Wm. Dutton Date of Inspection: �/' INSPECTION SUMMARY: ChecoA'- 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: 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined-, explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required 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 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corrtinued) Property Address: 75 Stoney Cliff Rd . , Centerville Owrw: Wm. Dutton Date of Inspection: G D- SYS FAILS: You must i dicate either "Yes" or "No" to each of the following: I h ve determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this det rmination is identified below. The Board of Health should be contacted to determine what will be necessary to correct.the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or,obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of'a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARG SYSTEM FAILS: You must ndicate 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 ealth and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner r operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of th Department for further information. revised 9/2/ 98 Pagc4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION fcorttinued) Property Address:75 stoney Cliff Rd- , Centerville Owner: Wm. Dutton Date of Inspection: C. )RTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ditions exist which require further evaluation by the Boa►d of Health in order to determine if the system is failing to protect the c health, safety and the environment. 1TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303 f1)(b)THAT THE SYSTEMMOT 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 (approximation not valid). 3) OTHER 0. revised 9/2/98 Page 3of11 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 75 Stoney Cliff Rd.. , Centerville Owner: Wm. Dutton Date of Inspection: Ga,/�_�, Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components 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. _ As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1.5.302(3)(b)1 The facility owner (and occupants,if different from owner) were provided with information on the proper maintanaaca of SubSurface Disposal Systems. re.Lsed 9/2/98 Page So[11 b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION rropertyAddress: 75 Stoney Cliff Rd.. , Centerville Owner: Wm Dutton Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: f/Sd g.p.d./bedroom. Number of bedrooms(desi n):.3 Number of bedrooms (actual):_ Total DESIGN flow �10 Number of current residents: Garbage grinder(yes or no):.Z--¢ Laundry(separate system) lyes or no),rZ O ; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no): /G 0 Water meter readings, if available (last two year's usage(gpd): 1999 137 , 000 gal. Sump Pump (yes or no): /, Last date of occupancy: 1998 126, 000 gal. COMM CIAL/INDUSTRIAL: Type of tablishment: Design flo : gpd I Based on 15.203) Basis of d ign flow Grease tra present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non-sanita -waste discharged to the Title 5 system: (yes or no)_ Water met r readings, if available: Last date f occupancy: OTHER: ascribe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Z:�ZA System pump d as part of inspection: (yes or no)-L1v If yes, volume pumped: gallons Reason for pumping: TYPE OF STEM 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) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known) and source of information: 0 �� 3 Sewage odors detected when arriving at the site: (yes or no)•L-0 revised .9/2/10E Page 6(if 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 75 Stoney Cliff Rd.. , Centerville owner: Wm. Dutton Date of Inspection: BUILD G SEWER: (Locate site plan) Depth belo grade:_ Material of onstruction:_cast iron_40 PVC_other(explain) Distance fr m private water supply well or suction line Diameter Comment ' (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) 1 Depth below grade: / Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth:_ Il Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ ! r Distance from top of scum to top of outlet tee or baffle: ) Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: /1 e-LA�l 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,, structural integrity, evide a of leaks e, etc.l e r/ �cS � ib L T� %� I[ B � ma x- a LL r GREAS RAP: (locate on ite plan) Depth below rade:_ Material of co truction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from p of scum to top of outlet tee or baffle: Distance from ottom of scum to bottom of outlet tee or baffle: Date of last p mping: Comments: (recommenda ion for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of le kage,etc.) Lre'vised G/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION(continued) i-ropertyAddress: 75 Stoney Cliff Rd.. , Centerville Owner: Wm. ut t on Date of Inspection: '-4—-b'>✓� TIGHT R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate o T'site plan) Depth belo grade:_ Material of onstruction:_concrete_metal Fiberglass_Polyethylene_other(explain) Dimensions Capacity: gallons Design flo gallons/day Alarm pr ent Alarm level Alarm in working order: Yes_ No Date of pre ious pumping: Comments: (condition f inlet tee, condition of alarm and float switches, etc.) 14 DISTRIBUTION BOX:111 (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 C)sit ER:_ (locate oit plan) Pumps ining order: (Yes or No) Alarms iking order(Yes or No) Commen(note co of pump chamber, condition of pumps and appurtenances, etc.) revises. 5/2/58 Page 8of11 J ° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 75 Stoney Cliff Rd.. , Centerville Owner: Wm t, Dutton Date of Inspection: e._/2—&-0 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries, number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, le v I of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS:_ (locate on site plan) ' Number and configuration: L� Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comme ts: (note c dition of soil, signs of hydraulic failure, level of ponding, condition of vegetatidn,"etc.) PRIVY: (locate n site plan) Materi Is of construction: Dimensions: Dept of solids: Co ents: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) �reviSe: cJ�L,'7� Pagc9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Nop"Address:75 Stoney Cliff Rd . , Centerville lwner: Wm. Dutton ,)ate of Inspection: G - -a•-a-(j 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) rddx l 1 revised 9;2/9? Page 10of11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cor 6nUed) ropert Address: 75 Stoney Cliff Rd.. , Centerville Owner: Wm. Dutton Date of Inspection: /"I-6-6 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater<Feet 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 Used USGS Data 4, Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/9E Page ttorll TOWN OF BARNSTABLE LOCATION SEWAGE # C-� -- VILLAGE f' ;——, C ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 70 1, : ,�° 7 7 s:og r SEPTIC TANK CAPACITY _f I j LEACHING FACILITY: (type) ! (size) lA I NO. OF BEDROOMS lBUILDER OR OWNER �! PERMITDATE: S S- COMPLIANCE DATE: -9-G--� Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Botto f Leaching Facility Feet Private Water Supply Well and Leaching Facili (If any wells exist I on site or within 200 feet of leaching faci ' ) Edge of Wetland and Leaching Facility(If y wetlands exist Feet I within 300 feet of leaching facility) Furnished by Feet i j a . l� { �nJ -1