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HomeMy WebLinkAbout0097 WHITE OAK TRAIL - Health 97 White Oak Trail 'Centerville A= 191-056 /// I S M E A D O] No.53LOR UPC 12543 smead.com • Made in USA 4µECYC{� �J fAQ) r Commonwealth of Massachusetts /q/- 06 -P ,F Title 5 Official Inspection Form C Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • Y 97 White Oak Trail Property Address r Sherman Owner Owners Name information is required for every Centerville MA 02632 12/28/20 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. A. Inspector Information 1510 15011 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 41*1rM 12/28/20 Inspector i na ur 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,✓ 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. CityfTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �n iw� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •u 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 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 must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman ' Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. City(rown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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: ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom permit and plan on file at BOH Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit. ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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 of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2008 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. City town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 6" 11 Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman Owner Owners Name information is required for every Centerville MA 02632 12/28/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 d-box is 2' below grade, no adverse conditions observed t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 6 infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrators were video inspected, they are end loaded, damp at this time, no indication of past hydraulic failure 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �m (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments u J 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts (.p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �a v 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 12/30/2020 Assessing As-Built Cards TOWN OFBARNSTABLE LOCATION 97 V)46:f^p�0 l! fi i L SEWAGE# 20t981— VILLAGE C 1tv Lk T1, —ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY LEACHING FACII.1'I'Y:(type) 6 AV Q NO.OF BEDROOMS __ OWNER PERMIT DATE: ,/C/7—(}f' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 leachin facility). v — feet FURNISHED BY �N 8� o N https://www.townofbarnstable.us/Departments/Assessing/Property_yalues/HMdisplay.asp?mappar=191056&seq=1 1/2 r j Commonwealth of Massachusetts �n (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >144" 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: 2008 NGW 144" Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 2008 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 66'msl and nearby surface water at 32'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts �. (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •� 97 White Oak Trail Property Address Sherman Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No.. . 00� -c1 '3 _ - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplicaction for tg at i§pgtem Cow5truction Permit Application for a Permit to Construct( ) epair( ) grade 06 Abandon( ) Complete System ❑Individual Components Location Address or Lot No. q 7 LVGtr Te 0 TrA-t'( Owner's Name,Address,and Tel.No. f,44 C Q C-QJl�e.o✓� �(� Assessor's Map/parcel Installer's Name,Address,and Tel.No. /�ovS Fr e lRl�A✓� Designer's Name,Address and Tel.No. p,o /3ox � 6S S���_rn�a25'fso3`� 2ci57 J-,4-0v"r,c11 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building Srn g /e IL/,���c� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 O gpd Design flow provided 3 3 r o gpd Plan Date l G !o -6 P Number of sheets / Revision Date N anr-C- Title Size of Septic Tank Type of S.A.S. A✓� C���� e4� Cf� ,hd�- Description of Soil SCE p L,4-A,,'- Nature of Repairs or Alterations(Answer when applicable) c,rof;oo,S leW Ce r rwao 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 Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date /d -( 7 -or Application Disapproved by: Date for the following reasons Permit No. a-o-og Date Issued /0-I 7�- OW Fee Y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ppYtCAtion for i��J at *pgut te CoYC�truCtiolterntit Application for a Permit to Construct O epair O grade(1Cj Abandon O Complete System ❑Individual Components wry; e a �f�r' i �/� e Location Address or Lot No. q j Owner's Name,Address,and Tel.No. c Assessor's Map/Parcel Installer's Name,Address,and Tel.No. ��`����`` `� S�nrFA�� Designer's Name,Address and Tel.No. �,o .i3ox i, 6. SA110 c� Se.v -'GS-7 F4,4Dw.ct1 dFf -2o/0 bzr 6 3 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ` ) Other Type of Building If 5 /� ✓�� �y No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 c) gpd Design flow provided -3 63 'y gpd Plan Date /0 - eo ^o Number of sheets / Revision Date A✓ow-e Title Size of-Septic Tank 5 � Type of S.A.S. �'f 5� P<C G' 4 CU qh,h�- Description of Soil p 44 N Nature of Repairs or Alterations(Answer when applicable) ' f,e-� 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 Certificate of ' Compliance has been issued by this Board of Health. R. Signed- Gam`'--`-- Date Application Approved by Date /d - I Application Disapproved by: Date for the following reasons a=' Permit No. o?Qog /3 Date Issued -------------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS ram. BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed (� .) Repaired ( ) Upgraded ( X) Abandoned( )by '70Li rr-e I-( fA ��l .S-Prv<<` J,vc at 7 Win,7e O RGI,:� r v << e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a tsa Y G/13 dated /b- /7- 09 Installer 130 Us ic"e- �� Sa-� �j J e C e Designer 0 P C ' L/N V i- ' #bedrooms 5 Approved design flow 3 163-0 gpd The issuance of this permit sh 11 not a constr �d as a- grantee that the system�Jtll_f ncti n as de igned. (/ , 0 G 1 Date � � Inspector !��---------I------Y--------------------\= --�—) — �--- No. 0 0(1�f —f r I3 Fee 'v v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS ,"Ii,5po!5at iip5ter Cou!6tructiou 'Permit Permission is hereby granted to Construct ( ) Rir (/) Upgrade (X) Abandon epa ( ) System located at 9 7 wh/-7Z 0,4(C I < G 60e7 7e.­(,-r I/X-- 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. t, Provided: Construction must be completed within three years of the date of this permit. Date 'I) ( O Approved by ,Town Of Barnstable h� Regulatory Services Thomas F.Geiler,Director • sARN FABLE. ' 9 Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-8624644 Fax: 508-790-6304 Installer &Designer Certification Form Date: � 2 �� 3 2oog Designer: Address: .. W1CIA Address: On / G✓ ( was issued a permit to install a (date) (installer) septic system at Cl� based on a design drawn by (address) dated (designer) 1-certify that the septic system referenced above was installed substautilly accbrdinQ 'to --K� 4.- ..t+ :he design, which may include nunor approved changes such as latera. relocation of the 6tribution box and/or septic tank. I certify►--hat the septic system referenced above was installed with'-.major.chan h �CpW� greater tl]ial�n'10' lateral relocation of the SAS or any vertical'reloeafitin of arty component of the septic system)but in accordance with State&Local'Regtilations. Plan revision or certified as-bolt by designer to'follow. ,t „ri3��MQF Mgs�,y =OAVID. . (Installer's Signature) B• sN I�iASON y _ gNJTAAIP (D er s Signature) (Affix ; ma's Stamp Here) PLEASE RETURN TO BA S7['AB1 E PUBLIC-HEALTH.DIMS;OIL[, C RTI , TE OF. COMPLtA.NCE WILL"'NO E - SSUED BOTH`:T FOIIM . RUIL CAIW APWRECEn :8ARNSI3L PusLtC T, s nSIorr TL3ANK YOU. a Q:HeaA/Septic/Desigper Certification'Form TOWN OF BARNSTABLE LOCATION"I G fN�is 'p,0 k ]i�a-6 t SEWAGE#. 1 VILLAGE �(y G�p�_ASSESSOR'S MAP&PARCEL /q INSTALLER'S NAME&PHONE NO. 014� � ��, -R, C�y� y�2�• �[�° l� SEPTIC TANK CAPACITY 1,�B LEACHING FACILITY:(type) 6 Are .412' (size) t{7'tX 2 NO. OF BEDROOMS OWNER PERMIT DATE: Jl -/7— > COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 / / i Y. aa . . o , Town of Barnstable P# O Department of Regulatory Services : .JtwerABM Public Health Division Date t� i6sp �� 200 Main Street,Hyannis MA 02601 , Date Scheduled ��t f �� ` Time Fee Pd. / T Soil Suitability Ass e sment for Sew e "Dis osal Performed By: b Y Witnessed By: 17 LOCATION& GENERAL INFORMAT Location Address �1 1_L--r— bW) ��A J LOwner's Name G ` I 1'� ` �(!> Address r-� Assessor's Map/Parcel: / Engineer's Name QY�� U4� NEW CONSTRUCTION `- REPAIR, Telephone#� U�3 2I` Land Use tyw_ 1 J !+(__1 Slopes(%) Surface Stones Distances from: Open Water Body ft Pe y Possible Wet Area ft Drinking Water Well :Z:ft Drainage Way ft Property line i /0 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Y }j}jp coo N 3 X 00 Yy to Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER'TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: In. Groundwater Adjustment f[. Index Well# Reading Date: Index Well level�, a Adj,faetor— Adj.Groutttlwater Level PERCOLATION TEST Dated Time. Observation Hole# Time at 9" e _ Depth of Perc Time at G' Start Pre-soak Time @ z 'C�y,'I 1"F j Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,%Grvel O �tv (.�5 !a ► 4 DEEP OBSERVATION HOLE LOG , Hole# = 2- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) �'T f 7 DEEP,OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. o si ten i Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No /Yes T Within 100 year flood boundary Nov Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perviousiniterial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious matertal7 Certification �O C! I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performed by me consistent with . the required training,ex 'sea a pe•ie ce described m 310 CMR 15Wo ? Date L9D�j lure Stgna , Q:\SEPTIC\PERCFORM.DOC i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 97 White Oak Trail ' e Property Address Peggy Crump _ Owner Owner's Name information is _. required for Centerville. MA 02632 July 10, 2008 _ 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 CityrTown State Zip Code<` _ 508-428-1779 SI 12855 Telephone Number License Number 4 , a B. Certification I certify that I have personally inspected the sewage disposal system at this addres and that-the r-- information reported below is true, accurate and complete as of the time of the insp ction. -We insFgction 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 July 10, 2008 Vlne�ctoe—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. 08-180 Crump.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 White Oak Trail Property Address Peggy Crump Owner Owner's Name information is Centerville MA 02632 Jul 10, 2008 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: B) .System Conditionally Passes: µ ❑ 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 ornot) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 08-180 Crump.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M5 97 White Oak Trail Property Address Pe Crump p Owner Owner's Name information is Centerville MA 02632 Jul 10, 2008 required for y every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: 7 ❑ 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. ❑ 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. 08-180 Crump.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 White Oak Trail Property Address Peggy Crump Owner Owner's Name information is Centerville MA 02632 Jul 10, 2008 required for Y every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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: I D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® El clogged 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_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 08-180 Crump.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 White Oak Trail Property Address Peggy Crump Owner Owners Name information is Centerville MA 02632 Jul 10, 2008 required for y every page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 a design flow of 2000gpd- 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. , 08-180 Crump.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 i Commonwealth of Massachusetts w Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments kM 97 White Oak Trail Property Address Peggy Crump Owner Owners Name information is required for Centerville MA 02632 July 10, 2008 every page. Cityrrown 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: ❑ ® 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)] 08-180 Crump.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 97 White Oak Trail Property Address Peggy Crump Owner Owner's Name information is Centerville MA 02632 Jul 10, 2008 required for y every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown Number of current residents: 0 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 20,000 gal=27 g ( Y 9 (gpd)): gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Vacant 4 Months. 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: Last date of occupancy/use: Date Other(describe): 08-180 Crump.doc•08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 7 o1 15 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '°M •''� 97 White Oak Trail Property Address Peggy Crump Owner Owner's Name information is Centerville MA 02632 Jul 10, 2008 • required for Y every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1972 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-160 Crump.doc•08106 '_ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 White Oak Trail Property Address Peggy Crump Owner Owner's Name information is Centerville MA 02632 Jul 10, 2008 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): • ' Depth below grade: 1 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 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: 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 bottom of outlet tee or baffle How were dimensions determined? . 08-180 Crump.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 White Oak Trail Property Address Peggy Crump Owner Owner's Name information is Centerville required for MA 02632 July 10, 2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cost.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction.- 0 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 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): 08-180 Crump.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 White Oak Trail Property Address Peggy Crump Owner Owner's Name infonnation is Centerville MA 02632 Jul 10, 2008 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm resent: P El 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-180 Crump.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ti. 97 White Oak Trail Property Address Peggy Crump Owner Owners Name information is Centerville MA 02632 Jul 10, 2008 required for y every page. Citylrown State Zip Code Date of Inspection F D. System Information (cont.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: One pit. ❑ 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.): Overflow pit in hydraulic failure, had backed up into cesspool. 08-180 Crump.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 White Oak Trail E Property Address Peggy Crump Owner Owners Name inforrnation is Centerville required for MA 02632 July 10, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information` (Cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration One with overflow pit. Depth—top of liquid to inlet invert Depth.of solids layer 0.1 Depth of scum layer Dimensions of cesspool 6x6 Materials of construction Block Indication of groundwater inflow ❑ Yes No rf t Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool was found empty at time of inspection, observed solids on top of outlet pipe and tee indicating overflow pit is in hydraulic failure. 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, N etc.): fi Y 08-180 Crump.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 s Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for-Voluntary Assessments c\` s•°•y 97 White Oak Trail Property Address Owner Peogy Crump _ -------...---- -_----._ _.._..___— --- ---- _ -------------- Owner's Name information is required for Centerville _MA_ _ 02632 _ July 10, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. White Oak Trail Water Service .\F�lYr\/,♦ ! / f\/4/\ \ \'Y \fY?.,`\lYrYrY!\/L/\f\JL/Lr,f Y ! f J f ! t ! ! _ \ Y \ \ \ \ \ \ \ Y ♦ Y \ \r\f\fY'\?4/\/ / J / I / r I r r / / / / • 31 42 Commonwealth of Massachusetts Title 5 Official Inspection Form o k.jW Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 White Oak Trail Property Address Peggy Crump , Owner Owner's Name information is Centerville MA 02632 Jul 10 2008 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 ground water: N/A 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: 08-180 Crump.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable P�pptNE Tn.-� O, Regulatory Services 7 BARNSfABLE. Thomas F. Geiler, Director ' y MASS. 1639. Public Health Division prED��s Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTICADisclaimer Private Septic lnspections.DUC ASSESSORS MAP : / / TEST HOLE LOGS PARCEL : FLOOD ZONE: SOIL EVALUATOR: I I � !�Nk % I SD I Pout U LA p�1 vim►�Jl 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: JTJ G°pV�T /T Pn'��2 DATE: 1 I n 1 200 I b Health Regulations. Al t"�.�?:'4jZ , ,y PERCOLATION RATE: c-- 2- M 1Q. I a.. r 2) The installer shall verify the location of utilities, sewer inverts and septic ,� --- - �5 - - ------ -- r� ' ` , components prior to installation and setting base elevations. ,Z I 7H-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first T _ two feet out of the d-box to the leaching shall be level. b"I b Dat IL 4) This plan is not to be utilized for property line determination nor any other 3 purpose other than the proposed system installation. ►A �o 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H10 septic components. � ��1�'''' 7) The property is bounded by property corners and property lines. LOCATION MAP q 8) The property owner shall review design considerations to approve of total 0 G 4 Flw � � G ti r I design flow and number of bedrooms to be considered for design. Receipt q 91 of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. lieIb , 9) The existing leaching or cesspools shall be pumped and filled with material a�' + Y per Title V abandonment procedures. Those within the proposed SAS shall be removed aloe with contaminated soil and replaced with clean n j`�`� �J g P ea sand per ti tJ, t� Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service SEPTIC SYSTEM DESIGN pp p � � g ' line. The line is to be sleeved as aforementioned and maintained in place. •. : 11) If a garbage grinder exists it is to be removed and is the responsibility of the A - .; .....r..5" FLOW ESTIMATE owner to ensure such. 12)The installer is to take caution in excavation around the gas line. ' BEDROOMS AT ) I D GAL/DAY/BEDROOM -?3CbAL/DAY t31j/ 13)The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. SEPTIC TANK t� '70�OGAL/DAY x 2 DAYS - ( GAL USE 1500 GALLON SEPTIC TANK irk' SOIL ABSORPTION SYSTEM LL AQZ� SO Ow rrS , 41 SIDE AREA: Z ' X I dAYIb �' �. BOTTOM AREA:— L � _.2-4419 4 D, 7 MASON n, ` I C SYSTEM SECT I ON jjjjliii �1• rod, ►� �., �7 � —► '" � „� �� � r 'jrC'� �� `,� ?; � _ � I�-I G► 14 le I 1 11•hF'ECIl{jt►.) �atL"r` rll� drm AT TIK �,1 bi' .3✓8'r 1"� T +1 flC F'i I+TRl2- At21 ' t41C' .n ' r { I t • • p p q 4 ! 4 + 0 • ! 0 GAL ��r�� m �. d 0 00 o 0 ♦ • 0 1 r 0 � 0 !! SEPTIC TANK : ��r��: '� �r . i� ->7p�g.�.�.._.w�/y—.;ram..._. _ J ' � *. S I TE AND SEWAGE PLAN # < rl W ,rvG :ZC7 ` FLOCAT j"� 1� b 1 T a PREPARED F OR M o SCALE o Mh.1• ; . DAV I D B . MASONy DATE: l0 Z04 , a O DBC 'ENVIRONMENTAL DESIGNS Y Z ' , EAST SANDWICH . MA Nl HEALTH AGENT - 2177DATE ( 508 ) $33.mf.,