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HomeMy WebLinkAbout0421 STRAWBERRY HILL ROAD - Health 421 Strawberry Hill Road,Centerville , UPC 12543 Now 4f4!col513p HASTINGS, MN �f . DATE• 01 _ PROPERTY ADDRESS;421._Strawberry_jjbll.ZQ3d 02632 ------------------------ On the above data, I Inspected the septic system at the above address, This system consists of the following; 1 . 1 -1000 H-10 Septic tank. 2. 1 —Distribution box. 3 . 1 -1000 H-10 leachin it Based on my Ir�s�'eciton, I certify the following oondltlons. 4 . This is a_ title five septic system. ( 78 Code ) 5. The septic system is in proper working order- - .,at the present. - - 6. Pumped the septic tank at time of inspection. 7. The H-10 tank is in the driveway. .. SIC NATURE: N a m e L.3.�.?tDs.Qm t tr- ,. ' ------ Company, Jo?•.2h_P . Hacomber_6 Son , Inc . Address,_ Box-66-_ Cencervi Ile L Na--_02632-0066 THIS CERTIFICATION ODES NOT CONSTITUTE A CIVARANTY OR WARRANTY a J6SEPH P. MACOMBER & SON, INC, Tinks•C's spool s•Loachflolds Pumpsd 4 Instilled Town SswIr Connsotlons P.O. Box 6y75.3338 s,srylil A 02632-0066 COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 421 Strawberry Hill Road Centerville,Mass. Owner's Name: Donna Close Owner's Address: Donna Close Same Date of Inspection: 2121 f o l Name of Inspector: (please print) Joseph P.Macomber Jr. Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 Centerville,Mass. 02632 Telephone Number: —775-3338 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: � asses ` Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails AAInspector's Signature: . t Date: The system inspector shall mit a copy of this inspection report o 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 1****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 i conditions of use. l Title 5 Inspection Form 6/15/2000 page 1 Paae-� ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 421 Strawberry Hill Road Centervi e,Mass. Owner: Donna Close Date of Inspection: 2/21 01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D System Passes: A)Q 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: The H-10 Septic tank is presently in the driveway. 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: 4/d Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken', settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 T :* Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 421 Strawberry Hill Road Centerville,Mass, Owner: Donna Close Date of Inspection: 2 21 01 C. Further Evaluation is Required by the Board of Health: _+a Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. Ve) The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. A4 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply yell'•. 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: x,)nele 3 Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:421 Strawberry Hill Road en ervi e, ass. Owner: Donna Ciose Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each of the following for all inspections: Yes No _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or Clogged SAS or cesspool Static liquid level in the distri4tion box above outlet invert due to an overloaded or clogged SAS or cesspool l 1ch,;ir� �T' C rJry 7 Liquid depth inres&peei•is less than 6"below invert or available volume is less than ''A day flow Required pumping more.than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped—j—. Any portion of the SAS;cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. (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.) AM (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 o� 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 _ he system is within 400 feet of a surface drinking water supply — _the system is within 200 feet of a tributary to a surface drinking water supply !/ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— 1 WPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304, The system owner should contact the appropriate regional office of the Department. 4 s Page 5 of 1 1 *. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 421 Strawberry Hill Road Cen ervi e,Mass . Owner:Donna Close Date of Inspection: 2 21 /01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _/Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks ? _ Has the system received normal flows in the previous two week period ? _ Have large volumes of water been introduced to the system recently or as part of this inspection ? _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? Z _ Was the site inspected for signs of break out ? z _ Were all system components i-Acluding the SAS, located on site? _ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _ Existing information. For example,a plan at the Board of Health. ZDetermined 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)J 5 Page 6 of 1 I _> OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 421 Strawberry Hill Road Centervi le,Mass. Owner:Donna Close Date of Inspection: 2 21 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): oZ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x P of bedrooms):,">1/� 2`� 4..fW, Number of current residents: Oo Does residence have a garbage grinder(yes or no): 4)0 Is laundry on a separate sewage system (yes or no):,u (if yes separate inspection required) Laundry system inspected ( es or no): S p Seasonal use: (yes or no): D Water meter readings, if available (last 2 years usage(gpd)): Sump pump(yes or no): We) Last date of occupancy: — d> COMMERCIAL/INDUSTRIAL Type of establishment: ,Ur¢ Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): ,J4 Grease trap present(yes or no): f2A Industrial waste holding tank present(yes or no):,&20 Non-sanitary waste discharged to the Title 5 system (yes or no): ZA? Water meter readings, if available: ,y�J Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records 1� /I&/�1 , Source of information: c —�T-41 Was system pumped as part of the inspectio (yes or no): If yes, volume pumped: D gallo -- How was q ntity pumped determined? Reason for pumping: TYP7 OF SYSTEM Septic tank, distribution box, soil absorption system 41 Single cesspool Overflow cesspool Privy ,47U Shared system(yes or no)(if yes,attach previous inspection records, if any) Z Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Nr�Attach a copy of the DEP approval Other(describe): Approximate age of all compo nts,date installed If{cr own)and source of information: Were sewage odors detected when arriving at the site(yes or no):.r�� 6 r � J Page 7 of I I "� OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 421 Strawberry Hill Road Centerville,Mass. Owner:Donna Close Date of Inspection: 2/21 /01 BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: cast iron V 40 PVC,&/l6ther(explain): Distance from private water supply well or suction line: /® `t' Comments(on condition ofjoints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System is vented 1400 q)41 A Y la I*fix i� G�j^/v't?�vAy through the house vent. SEPTIC TANK: (locate on site plan) i/ Depth below grade: it Material of construction: oncrete metal A/c fiberglassrtlaaolyethylene At Pother(explain) A.4 If tank is metal list age: A,�Q Is age confirmed by a Certificate of Compliance (yes or no): -,bv(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to boa m of outlet tee or baffle: How were dimensions determined: _ »1G h,- 1�i. 07° Comments(on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, liquid levels as related to outlet invert,evidence of.leakage, etc.): plimp t-he -gepi-i tank avery 2 3 years 1111pt X outlet tees are in of leakage.This H-10 septic tank is in the dr}veway.No evidence of-leakage. GREASE TRAP (locate on site plan) Depth below grade: Material of construction concrete lj. fiberglass g/gpolyethylene441 other (explain): yA Dimensions: AJ4 Scum thickness: Distance from top of scum to top of outlet tee or baffle: 41A Distance from bottom of scum to bottom of outlet tee or baffle: ,i/64 Date of last pumping: f), Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): C,r'PASP tT�z i c nnfi�roccni 7 Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:421 Strawberry Hill Road CEntervil1g,lylas Owner: Donna C1 oca Date of Inspection: 7.91 101 TIGHT or HOLDING TANK:ArL4,e,(tank must be pumped at time of inspect ion)(locate on.site plan) Depth below grade: _A,�4 Material of construction:A;4 concrete*metal vA, fiberglass 1 polyethylene vx?other(explain): N�? Dimensions: AJ/I Capacity: t4.Fp gallons Design Flow: &1,4 gallons/day Alarm present(yes or no): _,4 Alarm level: wif Alarm in working order(yes or no): N4 Date of last pumping: Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not prPsPnt DISTRIBUTION BOX: _,Z0f present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ,el0 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 has one lateral No evidence of 9aiid® carry over No Pyi denr•e of leakage i nt-n cut-oaf—the box. PUMP CHAMBER:,Vc',VQ(locate on site plan) Pumps in working order(yes or no): _glj Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump chamber is not pre4Pnt _ 8 Page 9 of 1 1 r OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 412 Strawberry Hill Road Cen ervi e,Mass. Owner:Donna C ose Date of Inspection: 2 21 61 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: dGR tar. 7Typ leaching pits, number: y,D leaching chambers,number: 0 Nt leaching galleries,number: c) leaching trenches,number, length: Q _& Q leaching fields,number,dimensions: 0 .ZVQ overflow cesspool, number: 4)0 innovative/alternative system Type/name of technology: ��'��_ 29 4�,k Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loamy sand to medium fine sand.No signs of hydraulic failure or ponding.Soils are dry_ Yeaptation is normal The leaching pit is presently dry. CESSPOOLS;j,&&_(cesspool must be pumped as part of inspect ion)(lodate on site plan) Number and configuration: () Depth—top of liquid to inlet invert: Depth of solids layer: d2d Depth of scum laver: 42 Dimensions of cesspool: AIX Materials of construction: ZIA Indication of groundwater inflow(yes or no): dL Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Cesspools are not present_ PRIVY:4ZQjZL(locate on site plan) Materials of construction: Dimensions: A/,9 Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Privy is not present. 9 Page 10 of 1 16 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:421 Strawberry Hill Road Centervi e,Mass. ' Owner: Donna Close Date of Inspection: 2/21 /01 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. . T NQ 10 s r � - T ?� v: Su This is a copy of the as built. This was on file at the Town Of Barnstable Health Department. Page I I of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propem• Address: 421 Strawberry Hill Road Centerville,Mass. Ownerponna Close Date of inspection:2121 /01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: t d fro �mdi lans on record - If checked,date of design plan reviewed:bserved site(abuoperty bservation hole within 150 fee of S S) �Necked with local Board of Health explain: C7 �f31lUc'r� �S /�u/lt hecked with local excavators, installers (attach documentation) — Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used Water contours map. Gahrety & Miller Model 12/16/94 II 11 • - o A ' Y- T.1T -11'RTTT-1PIf��f'/ P!RIlTRiTT.RSIlI•.T'r �I`" esr�r.*'nern...ntv•s-�an R+n .�-n-.ram-.r-,-.—. -. ._ 1 TOWN OF Barnstable WARD OF HEALTH + T T .--"r-SUI)SURFACF 9EKA(;E DISPOSAL SYSTEM INPEC�TION FORM - PART D^�CEIZTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 421 Strawberry Hill Road Centerville,Mass. ASSESSORS MAP , BLOCK AND PARCEL t _ Zh OWNER' s NAME Donna Close PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J•P•Macomber & Son Ina,!" COMPANY ADDRESS Box 66 Centerville Mass. 02632 Street Town or Clty Stet• iIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 CERTIFICATION STATEMENT 0r I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of The inspection was performed and any ecommendatioils regarding upgrade , maintenance , and repair are consistent with my training and experience in the Proper function and maintenance of on- site sewage disposal systems . Check one ; —�h System PASSED , The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe. environment as defined in 310 CMR 15 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have cony tcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 - 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date ne copy of this cert.ifieation must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF HBAL'111, * If the inspection FAILED , the owner or"'oporator shall upgrade he ayte Within one year of the date of the inspection , unless allowed ortrequiredm otherwise as provided in 310 CMR 15 . 305 . partd . doc Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Coxe Governor �NeY Argeo Paul C•lluodl David B.Struha LL tioarnor � SUBSURFACE SEWAGE DISPOSAL SYSTEM[INSPECTION FORM PART A CERTIFICATION 421 Strawberry Hill Rd AddreasofOwner. Ed Kuhn Property Address: Centerville MA Date of Inspeotion: C/— a —c, �f (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number: ( 5 0 8 )7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA 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: �/Paseea _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails ,� Inspector's Signature: j l C "�^^'— Date: 41`o1 A—Of '7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A) SYS PASSES: 7I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, 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,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 Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Wlntw Street • Boston,Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292-b6p0 I&I Printed on Recycled Paper l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropwgAddreec 421 Strawberry Hill Rd, Centerville Owner. Ed Kuhn Date of Inspection: t/_a',Z—C1 Bj SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution boz is due to broken or abstracted 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 pipes)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C) THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require!hither evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM I8 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 9 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or lea than 5 ppm. 9) OTHER S :1 (revised 11/03/95) 2 Y i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 421 Strawberry Hill Rd, Centerville Owner. Ed Kuhn Date of Inspection: D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 C]WR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to am. the 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 V below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 tunes 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. El OE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant this"to public and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone U of a public water supply well) The o or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program require nts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for thither information.. (revised 11/03/95) 3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECIQdST pnVertyAddrew 421 Strawberry Hill Rd, Centerville Owner. Ed Kuhn Date of Inspection: X-q'7 Check if the following have been done: j-mping information was requested of the owner,occupant,and Board of Health. —,,Is/One of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 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. �he system does not receive non-sanitary or industrial waste flow he site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on the site. _.L//Me 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. 1 xP a size and location of the Soil Absorption System on the site has been determined based on existing information or ap roaimated by non-intrusive methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION property Addres&. 421 Strawberry Hill Rd, Centerville Owner. Ed Kuhn Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 3 llon� Number of bedrooms: % 3 Number of current residents: Garbage grinder(yes or no): 6: v _ Laundry connected to system(yes or noV_t-S Seasonal use(yes or no). � c 1 9 9 5 - 6 7 0 0 0gals Water meter readings,if available: 1996 — 84, 000 gals Last date of occupancy:'' �� -�7 1 COMMERCIAL/INDUSTRIAI.: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: i. A System pufnped as part of inspection: (yes or no)� If yes,volume pumped: gallons Reason for pumping: TYPE OF/SYSTEM Septic tanWdistribution 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)and source of information: Sewage odors detected when arriving at the site: (yes or no) /L d (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 421 Strawberry Hill Rd, Centerville Owner. Ed Kuhn Date of Inspeotion: —5- SEPTIC TAN&✓ (locate on site plan)) Depth below iRads:tb' / Material of oonstruc ion ✓concrete_metal_FRP_,other(ezplain) Dimensions: A Shulge depth 3'` , Distance fivm top of sludge to bottom of outlet tee or baffle: /O Scam thiclmess: /—Z• Distance fkom top of scum to top of outlet tee or baffle: $ 1 Distance from bottom of scum to bottom of outlet tee or baffle: / /, Comments: (recommendation.for pumping,condition of inlet and outlet or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) a n ra [_es ;x— �®/cJ JRAP:te plan) grade:construction:_concrete_metal_FRP_other(e:plain) essm top of scum to top of cutlet tee or baffle:m bottom of scum to bottom of outlet tee or baffle: tion for pumping,condition of inlet and outlet tees or ba8les,depth of liquid level in relation to outlet invert,structural intV*, leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) propertyAddrw: 421 Strawberry Hill Rd, Centerville Owner. Ed Kuhn Date of Inspection: L j—,t;_-G `7 726EPT OR HOLDING TANK_ (locale site plan) Depth grade: of eonstavation:_concrete_metal_FRP other(eaplain) ' Ca ty: gallons Bow: eallons/day Alarm Comme to: ( n of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note'if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of boa,etc.)�Q/� PUM CHAMBER:_ (locate site plan) pumps' working order-.(yes or no) ts: (note co of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 T V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 421 Strawberry Hill Rd, Centerville Ow1O1. Ed Kuhn Date of Inspection: _q _ / SOIL ABSORPTION SYSTEM(SAS)-V (locate on site plan,if possible;excavation not requited,but may be approximated PP by non-intrusive methods) If not determined to be present,explain: leach'"pits,number bsching chambers,number. leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number• Comments: (note corption of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) b 0-6 .4 4 i S 1 t, n 51:4.! , c POOLS:_ (loon on site plan) N and configuration: Depth- of liquid to inlet invert: Depth o lids layer: Depth of layer. Dimensio of cesspool: of construction: of groundwater: inflow(cesspool must be pumped as part of inspection) Commen (note condition of soil,signs of hydraulic failure, level of ponduW,condition of vegetation,etc.) PRIVY: (locate site plan) M riaL o construction: Dimensions: Depth of Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) properiyAddeers: 421 Strawberry Hill Rd, Centerville Owner Ed Kuhn Date of Inspeotion: 7 SXXVCH OF SEWAGE DISPOSAL SYSTEM: inch#de ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � Aar j o i C U /6 0 U -f4 n rid x /�a o /ap d vs j DEPTH TO GROUNDWATER 3 ,a 1 _ C; Depth to groundwater: ` teat method of determination or approximation: 1 z 5 1 F (revised 11/03/95) 9 TOWN OF BARNSTABLE LOCATION L1'L( S�'' r,/ -rf.�i' NIA SEWAGE # VILLAGE CbA�?V-- ASSESSOR'S MAP & LOTS f v' INSTALLER'S NAME&PHONE NO. W WV� JSQW I VK"7-3(® SEPTIC TANK CAPACITY 1I— LEACHING FACILITY: (type) —T 9� (size) NO.OF BEDROOMS BUILDER OR OWNER � A� PERMITDATE:3/ /_COMPLIANCE DATE: 31—Afbo 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 c f�tae�SE ;� �— t � �� � � o � r �' � �.f � �� _ . �: H3` __ ���� ASSESSORS NIAPNo, �� - _ Fas...................._....._ No .............._....... PARCEL NO. -. THE COMMONWEALTH OF MASSAC S BOARD OF HEALTH TOWN OF y� Appliration for Eltsposal Murky Towitrur#tun rams# Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: 1 ....... 31:r: asp..........ASk........ ......... ------------------------------------------------------•--- ••- Location-Address - or Lot No. ....._. j�i1.��.N�..................................•----•--... ......Sly-!J s.. ...............................------........----... Owner Address 1 ._.aw;S 8 �2......r :_.._ a .................IT.t" ------------------------------------- Installer Address UType of Building Size Lot.................... .....Sq. feet Dwelling No. of Bedrooms...... ....................................Ex ansion Attic g— p ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria W Other fixtures .------•---••......•............ .. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---------••••-••••-••---••-•-•-------•--------••-•-•-•-•--••............. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ._..._....--•••••---......--••--•--•----•--•---•--•--••-•---••-••---••-•.........................•--......................................................... O Description of Soil......................................................................................................................................................................... x U ••-•---•...............................•----•........_...._......---••- ...........-••--•••-•-----------•--.........---....----...........•.......................................................... U Nature of Repairs or Alterations—Answer when applicable.�L1 ... ._l...... ......t_............. s '`�-:._....'. ?-N •--•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITA LF, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en is Signed -••.....-•..•-.• ................................. ..... �.. ' -.- 9 - Application Approved By......! ... ���........... -.-- ------------------------ --- ----•-�- Date Application Disapproved for the following reasons:...................................... easons:...................................... ..............................................................._ . c ��j Permit No.. "��_ Issued--- ..........................................aa .�—� Date ..yy ^Wl Vyr-'•r. .-Fi. . .i r.:. d-'s`�l+,. yi�.:*fi:•.w+r,Tr*+.-s".. ..f y; :��...1(Z+'�.•�., .,,y.,. . ��' �..V .i'-.::'-.;...+1.s.:3V.ro r...�Y•. /�.K.-...:..t r-y.:..gr`.'*....,r.�7�'M'fh�' No1.. _...... Fu$. . ©....._ THE COMMONWEALTH OF 14ASSAEHUSETTS BOARD OF HEALTH y� TOWN OF Y70QVN=tb A/ -XVpliration for Pi posal Works Tonstrurtion V rrntit `5 Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ......`.� �.__.....`3 :!'L! - ares,.........V�.u.------.(ZS ... ------.Qj RgJAI&........................................................... Location-Address or Lot No. �_.......... k! ............................................ ...... ---.....-•--••-- •------••---.....--•---••---...--------•---...----•• Owner W . Address l' l �� .!CrvS6` �a _ . .---------------Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms__....� ................................Expansion Attic ( ) Garbage Grinder ( ) aAq Other—Type of Building No. of persons............................ Showers YP g --•--•--•-•................. (----)..— Cafeteria ( ) dOther fixtures ---------------•--•- ..................................................... WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length.................Vidth---:---,:_.__-. Diameter................ Depth................ xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 0.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2_"..:..........minutes per inch Depth of Test Pit.................... Depth to ground water........................ fYi - ------------------ .............. ------------------- --•----- .-------------------=............................... 0 Description of Soil....................---------------------•------------------.............-•-•--•-•--•--------•t- W a U Nature of Repairs or Alterations—Answer when applicableA/W..7--io.-----Y _h_1:�.._..t_ -- ...._ !Sr�'`� n. .(? Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with s t eheh provisions of'I'L� 5 of the State Sanitary Code— The under gned further agrees not to place the system in operation until a Certificate of Compliance has een is / � ' �� _ Signed.. - --- - - - Application Approved B ... .,? ....... ---------- --- ..._ �_ Date Application Disapproved for the following reasons:--------------------••-••• _...................... ............... ..................................r.____......_...._.___._.__._._.........__._______..__.._.__..._......._......._.__......_........ ._.........._____........................_. .. � � ................................. ` ,,,,ate No.. ... ........... Issued.• ......Date ---------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YARMOUTH (Intifiratr of Tontplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (10) by.... e :........ ...........••-•-----•-••----.....---....---•-•-----................. staller at.. ..............................................��' K .� -�. ! �-- �1 Y�.4 Ls................. ............. has been installed in accordance with the provisions of TI ofThe State Sanitary Code as described in the application for Disposal Works Construction Permit No... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUE® AS A GUARANTEE THAT THE SYSTEM 1 II FUNCTION SATISFACTORY. DATE.... s to . / ..........•-------•-•---•-_..... ——————————————————————————————————— ———�--------------- --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOpW_N of YARMOUTH Disposal orko Tons�nrtiott ramit Permission is hereby granted....:N --••••......----• - - - to Construct ( ) or Repair (,%&v) an Individual Sewage Disposal System at No.:..`,Zl S3 t�t�S.....__1 !.-(t cR e ". .....,.....-- . --- �,,,0o��1 Stre """ as shown on the application for Disposal Works Construction ..m;,y .__"f?_ Dat �i.. .-�.� .. ' ------------------------ Board of Health / DATE......---------.......----------------------•----------------•=--