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Home My WebLink About0044 VINE AVENUE - Health 44 VINE AVE. CENTERVILLE A = 226 039 r _ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21 2010 required for Y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:Whenfilling out A. General Information When forms on the I computer,use 1. Inspector: l� only the tab key to move your David B. Mason cursor-do not Name of Inspector use the return key. David B. Mason Company Name r� 4 Glacier path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-833-2177 S 1287 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in-the proper function and maintenance of on site'" sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority T- ;•,, July 21, 2010 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 . X Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21, 2010 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System passed inspection for conditions noted on July 21, 2010 at 8:15 AM. This inspection does not quarentee operation from the point forward. Increase in occupancy may result in hydraulic failure. 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i 'Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M °r 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 21, 2010 required for -July every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21 2010 required for Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21, 2010 required for Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with - t a design flow of 2000 d Y P 9 Y 9 9P ❑ ❑ 10,000gpd. ❑ ❑ 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul required for Y 21, 2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ID ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21, 2010 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information Description: System passes based on the information observed on July 21, 2010 at 8:15 AM. This does not guarentee the continued operation of the system. Increase in occupancy may result in hydraulic failure. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage yes 9 ( Y 9 (gpd))� Detail: 2008- 21,000 gallons and 2009 18,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current/seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts L v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21 2010 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy PP of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road Southboro MA 01745 21 2010 required for � -July , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Compliance issued June 22, 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Not Applicable feet Comments (on condition of joints, venting, evidence of leakage, etc.): Appears in working order Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21 2010 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32 Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 3 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank appears structurally sound. Effluent level with outlet tee. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 44 Vine Ave, Centerville . Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul required for Y 21, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21, 2010 required for Y every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Level with outlet inverts 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.): No evidence of solids carryover. D box is 21 inches below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21, 2010 required for Y every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 3-500 gallons chambers with 4 feet of stone around. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul required for Y 21, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is required for 35 Oak Hill Road Southboro MA 01745 July 21, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21 2010 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: March 2005 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Engineered plan on file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used engineered plan on file based on test hole data. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 44 Vine Ave, Centerville Property Address John and Bette Troy Owner Owner's Name information is 35 Oak Hill Road, Southboro MA 01745 Jul 21, 2010 required for Y every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -_- �p Page 1 of 1 TOWN OF BARNSTABLE LocA,ION y`/ i/i,�� ,e ✓ s ACE x D v o•3 R ASSESSOR'S MAP&LOT nn%/3 INSTALtMVS NAMS&PHONE NO. ? SEPTIC TANK CAPACITY /S O U t L Acm NO FAcum.(h'Pe) 3— A C (size)/2---3.s 2- NO.OF BEDROOMS BUMDER OR OWNER A"A—1 I' PBRMPPDATE.�C—7—(5-2 n COMPLIANCE DATE: Sepaation Distance Between the: Maximum Adjusted Gmtmdwater Table and Bottom of Facility Feet Ptivaw Water Supply Well and Leaebing Facility (If aay w exist on site of wlthin 200 feet of leaching facility) Feet Edge of Wetland and Leaching Fact1'ty(If any well exist Pea within 300 feet of leaching facility) Furnished by L4>il Sit3L 4'�vu54 °ts h O S� K'l O o i httn•//w,,,rw tnwn hnmctahle.ma_tts/assessinv/2010/HMdisDlay.aso?mavvar-226039&seq=1 7/19/2010 BB // TOWN OF BAR.NSTABLE LOCH ON. � y j �/ = A � SE�i"I # 0 6 o.%3 VILLAGP Lys ASSESSOR'S MAP & LOT j9,3 INSTALLER'S NAME&PHONE NO. ! i '" i SEPTIC TANK CAPACITY ! S t LEACHING FACILITY: (type) 3 �� - � G(size) /jq7!-3.$ NO. OF BEDROOMS v BUILDER OR OWNER F PERMIT DATE: 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leachiy Facility Feet Private Water Supply Well and Leaching Facility (If any w Its exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlan s exist within 300 feet of leaching facility) Feet Furnished by O S� { r ,rh i �'G1 +'J9- ii o No. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Rpplitatton for �Diopooaf 6p!gtem Con.5tructton hermit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 44 Vine Ave . , Centerville Assessor's-Map/Parcel �Inrler's Ire, o D 1 and nS O 1.N e pt i c Service Designer's Name,Address and Tel.No. WWP 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 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 3 H2O 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 Piis,B oard of Health. Sign i t Date � Application Approved by Date Application Disapprove for the following reas s Permit No. Date Issued G o3q . No. —4�e` Fee V I THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer: / 1 Yes rPUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS J� Tfppritation for �Diopozal *pztem Construction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. .44 V'ine Ave. , Centerville Z 6. Assessor's Map/Parcel InWIl,Ie.'s i We,t dE jnd on @ pt is Service Designer's Name,Address and Tel.No. P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Y Other Fixtures .,TA Design Flow— gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title �.Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature ' fRepairsorAlteratio s(Answe licable) Title-5 septic system consisting of a tank, D- end kop leach chambers with stone all around.. l 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 his card of Health. Sig*the Date Application Approved b Date Application Disapproveowing reaso s Permit No. ... Date Issued �., THE COMMONWEALTH OF MASSACHUSETTS Frazier BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 44 Vine Ave. , Centerville Wated nstructed in accordance with the p] vision of�tle 5 end the forl)isposal System Construction Permit No .. Installer WrA. o?�1riS On Y'. - Designer n The issuance of this e t all n t be construed as a guarantee that th ,y ill fu, ct as /.r ed. Date Inspector -- — -------------- ' O No. 4d"Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Frazier lwigpozar *pztem ConZtrurtion Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 44 Vine Ave. , Centerville and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructi n in t be completed within three years of the date of p Date: Approved by z r~ d 3 91 116/" 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) ), William E. R ob ins on,Srnereby certify that the application for disposal works construction permit signed by me dated ^L�-`tJ , concerning the property located at 44 Vine Ave . , Centerville meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with dwelling. • The soil is classifi> as CLASS i and the percolation rate is less than or squat to minutes per inch. There are no wetlands within 100 feet of the proposed septic system — There are no private wells within 150 feet of the proposed septic system I There is no/increase in flow and/or change in use proposed • There ar no variances requested or needed. • The m of the proposed leaching facility will qQt be located less than five feet above the maxi tun adjusted groundwater table elevation.f Adjust the groundwater table using the Frimptor me od when applicablef • If the S.A.S.will be looted with 250 feet of any vegetated wetlands,the bottom of the proposed teaching 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) �-/ ,S B) G.W.Elevation +the MAX High G.W. ,kdjustment DIFFERENCE.BETWEEN A and B t� SIGNED : A DATE : [Sketch proposed plan of system on back. y:health folder:cen old O i COMMON-WEALTH OF MP►SSACHL;SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTO\ KA,0210c 161'i 292•560o TRL DY COTE Secreta_r ARGEO PAUL CELLUCCI DAVID B STP.-FH Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:* 26 Pitchers Way, , Name of Owner S Berman .11 Hvann i s Address of Owner: Date of Inspection: _5 X;t—&<_j, Name of Inspector:(Please Prirrt)WM. E. Robinson Sr . I am a DEP approved systeM inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Wm. E . Robinson beptic Service Marling Address: PO Box 10 9, Centerville , MA Telephone Number: 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•sittesewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails /3 Inspector's Signature: 4/�u d L CY/ :...�/�i Date: —C-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 , 1?0 00 J J revised 9/2/98 page Iorll n i• -led o^Recvcird Panr• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) "ropertyAddress: 26 Pitchers Way, Hyannis .)weer: S Berman Date of Inspection: G- INSPECTION SUMMARY: Check . IB, C, or D: A. SYSTEM PASSES: (�v// ✓ I have not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure I 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 es, 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 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address: 26 Pitchers Way, Hyannis Owner: S Berman Date of Inspection: $.,2.�L_0--w C. RTHER 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 ublic health, safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMIR 15.303(1)(b)THAT THE SYSTEM 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 1 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 revises 9/2/98 P2Qc3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icorttinued) Property Address: 26 Pitchers Way, Hyannis Owner: S Barman Date of Inspection:,S5 D. SYSTEM FAILS: You mu)indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes o Backup of sewage into facility-or system component due to an overloaded orclogged 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. RGE SYSTEM FAILS: You ust 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 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) :he ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 26. Pitchers Way, Hyannis Owner: S Barman Date of Inspection: Check if the followinghave been done: You must indicate either "Yes" or "No" as to h f each o 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 leest 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. j _ 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) / 115.302(3)(b)) The facility owner(and occupants,if different from owner) were provided with information on the propermaintenancs-0f SubSurface Disposal Systems. Xe_Lsed 9/2/98 page 5or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address:26 Pitchers Way, Hyannis Owner: S Barman Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: ys n g.p.d./bedroom. (design): Number of bedrooms(actual):3 Number of bedrooms 1 9 — Total DESIGN flow c rJ_ Number of current residents: .3 Garbage grinder!yes or not: Laundry(separate system) lyes or no):A-0; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no):/1- O Water meter readings, if available (last two year's usage(gpd): 1999 107 , 250 gal. Sump Pump (yes or no).-A-0 1998 108 , 750 gal. Lest date of occupancy: COMMERCIAL/INDUSTRIAL: Type o establishment: Design ow: qpd I Based on 15.203) Basis of esign flow Grease t p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non•sani ary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last d •e of occupancy: OTHER (Describe) Last d to of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)/L6 If yes, volume pumped: gallons Reason for pumping: TYPE OF/!YSTEM 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(if known)and source of information: {EtS�A1✓�t;� 3 `o�� '�''� Sewage odors detected when arriving at the site: (yes or no)ZL !� d revised 9/2/9E Page 6(if 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) 'ropertyAddress:26 Pitchers Wav, Hyannis Owner: S Berman Date of Inspection: BU ING SEWER: (Local on site plan) Depth elow grade:_ Materi I of construction:_cast iron_40 PVC_other(explain) Distan a from private water supply well or suction line Diam er Co ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: —01 _ (locate on site plan) ) l Depth below grade: / / Material of construction: `_/concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Wage confirmed by Certificate of Compliance_(Yes/No) ` ) Dimensions: (sl _` &6 Sludge depth: /e, Distance from top of sludge to bottom of outlet tee or baffle: �� Scum thickness: O 1 t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outlet teeepr baffle: I`f How dimensions were determined: 6�[��"�=K r '" f L ;omments: (recommendation for pumping, condition of inlet and outlet tees J,orr b ffles, depth of liquid level'n relation to outlet invert, structural integrity, eviden a of leakage, etc.) �U� .r3 l ��p�� l�l S' C1 �c � � lsG Gar- 17� s T."•-, ,C !3d P72 -S 2E m 72c GR TRAP: (locate o site plan) Depth be l w grade:_ Material construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensio s: Scum th' kness: Distanc from top of scum to top of outlet tee or baffle: Distan from bottom of scum to bottom of outlet tee or baffle: Date o last pumping: Cc ents: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evide ce of leakage,etc.) revised G/2/9 G Page 7or11 •- ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION!continued) -,opera,Add,ess: 26 Pitchers Way, Hyannis Owner: S Berman Date of Inspection: TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b low grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimensi ns: Capacit gallons Design ow: gallons/day Alarm resent Alar level: Alarm in working order: Yes_ No_ Date f previous pumping: Comm nts: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:V (locate on site plan) Depth of liquid level above outlet invert: 6 Comments: (note if level and distribution is equal, evide, eV oIids carryover, evidence of leakage into or out of box, etc.) - PUMP HAMBER:_ (locate on site plan) Pum in working order: (Yes or No) Alar s in working order(Yes or No) Com ents: (note ondition of pump chamber, condition of pumps and appurtenances,etc.) revised 5/2/5a Page 8ofll • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) t Address26 Pitchers Way, Hyannis operty ,. Owner: S Berman Date of Inspection: S--7, SOIL ABSORPTION SYSTEM(SAS): Ll (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:-2— 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�ydulic failure, level of pondin , damp soil, condition of vegetation, etc.) CESSPOOLS:_ (locate on site plan) / Number and configuration: irk Depth-top of liquid to inlet invert: U 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) Comm nts: !note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Tofsolids: te plan) construction: ids: Dimensions: ! ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revi5�^. Pagc9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) "Irop"Address: 26 Pitchers Way, Hyannis .owner: S Berman .)ate of Inspection: 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) a2 c aI'L �7 J a b � revised 9;2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rOP"Address: 26 Pitchers Way, Hyannis Owner: S Berman Date of Inspection: 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 � 1 Estimated Depth to Groundwater Z-3 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 V Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how Youestablished the High Groundwater Elevation. (Must be completed) /90 lam► IQ ^z C-7 V 1 revised 9/2/9S Page I1 of 11 � � I