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HomeMy WebLinkAbout0115 WHITE OAK TRAIL - Health 115 `White Oak Trail _ A = 192-190 Centerville No. 42101/3 ORA ESSELTE 10% O O O O i f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 White Oak Trail Property Address Kathryn Fessler (Ci lot_ k-10 O ner Owner's Name in rmation is Centerville MA 02632 August 25 2008 r wired for 9 e ery page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. ECo-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 Cityrrown State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addre's and tlt*'the:2-, information reported below is true, accurate and complete as of the time of the ins ection. Tare ins pc ion was performed based on my training and experience in the proper function and ma tenance-,.f oAite sewage disposal systems. I am a DEP approved system inspector pursuant tc Section 0.340vof Title 5(310 CMR 15.000). The system: . Co ® Passes ❑ Conditionally Passes -"❑ Fai ❑ Needs Further Evaluation by the Local Approving Authority -a August 25, 2008 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. t5-3010.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 ,M 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is required for Centerville MA 02632 August 25, 2008 every page. Cityrrown 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: Inspector's Note==> Aseptic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-3010.doc-08/06 Title 5 Official Inspection Farm: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. 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is Centerville MA 02632 August 25, 2008 required for 9' every page. Cityfrown 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: ❑ 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. Y 9 p p � Y 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. t5-3010.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is 9 required for Centerville MA 02632 August 25, 2008 every page. Cityrrown 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: 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 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. t5-3010.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is g required for Centerville MA 02632 August 25, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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. t5-3010.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is 9 required for Centerville MA 02632 August 25, 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? 1 pit also inspected ® ❑ Were all system components, excluding the SAS, located on site? Inlet only ® ❑ 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)] t5-3010.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 t Commonwealth of Massachusetts W Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c� 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is Centerville MA 02632 August 25, 2008 required for 9' every page. City/Town State Zip Code Date of Inspection D. System Information 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 gpd Number of current residents: 1 Does residence have a garbage grinder? Removal of grinder is recommended ® 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 d 149 gpd 9 ( Y g (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current 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: Last date of occupancy/use: Date Other(describe): 15-3010.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is required for Centerville MA 02632 August 25, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner inspection?Was system pumped as part of the in sp ❑ Yes 0 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: Age: 30 years. Design plan dated 10131177(Building Department files) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-3010.doc-08/06 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 ;M 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is Centerville MA 02632 August 25 2008 required for 9' , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site plan): Depth below grade: 1.5 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: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 4 in Distance from top of scum to top of outlet tee or baffle 8 in Distance from bottom of scum to bottom of outlet tee or baffle 12 in How were dimensions determined? Design Plan 15-3010.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 �M 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is required for Centerville MA 02632 August 25, 2008 every page. CityfTown 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.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and inlet tee appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Tank is under deck with trap door over inlet end. Outlet end was not accessible for inspection. 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.): 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): t5-3010.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM , 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is Centerville MA 02632 August 25, 2008 required for g every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-3010.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is g required for Centerville MA 02632 August 25, 2008 every page. City/Town State Zip Code Date of Inspection 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: 2 ❑ leaching chambers number: ❑ 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.): Soils above leaching pits appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. One pit was uncovered and found to contain 1 foot of effluent with stain line at 3 ft. t5-3010.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ti 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is Centerville MA 02632 August 25, 2008 required for 9 every page. City/Town 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 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.): 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.): t5-3010.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is required for Centerville MA 02632 August 25, 2008 every page. Cityrrown 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. LEACH LEACH O PIT O PIT Zoo-eox Q LOCATIONS A B C D 1 16.5 Ft 16 Ft 2 If f t 32.5 Ft. Jnil 3 19 Ft. 29 FL ,—, A 4 35.5 FL 42 Ft ry e c D EXISTING DWELLING O WATER LINE # 115 W NOT TO SCALE t5-3010.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 White Oak Trail Property Address Kathryn Fessler Owner Owner's Name information is Centerville MA 02632 August 25, 2008 required for g 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: 30 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: Not available 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Design plan on file with the Building Dept shows bottom of system to be 4 feet above the bottom of a test pit in which no water was encountered. Town of Barnstable GIS Department records indicate that the property is over 30 feet above groundwater table. t5-3010.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable CF THE 1p� Regulatory Services BARNSTABLE, : Thomas F. Geiler,Director 9 MASS. �A 1639. Public Health Division rF0 MA'S A 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. QASEPTIC\Disclaimer Private Septic Inspections.DOC TOWN OF BARNSTABLE LOCATION l l S LJ�i+t 0�, t m t I SEWAGE # VILLAGE Ce4�21r V I SIP ASSESSOR'S MAP& LOT %-1-1 lq® INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 S 0 D LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 L BUILDER OR OWNER �°1 ry, 11 FeSS� r PERMITDATE: 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 facilitypp Feet Furnished by CCo LEACH LEACH ! O PIT 20 0-BOX O PIT LOCATIONS A 8 C 0 1 16.5 ft 16 FL 2 17 ft 32.5 ft J 3 19 ft 29 ft 4 35.5 ft 42 ft H A /�/yy B LL C � EXISTING DWELLING 0 WATER LINE # U 5 ` W , i ~ _ NOT TO SCALE 3 r - 7 TOWN OF BARNSTABLE w � LOCATION f` ��c i C% [ SEWAGE # VILLAGE Vc V F--- ASSESSOR'S MAP & LOT/907_/c'?0 INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 -SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER rcaS_1 ��'�P flf .S'�� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No VLC`-A T I N S EV A G E PERMIT NO. 1 L A G E INS-TA LLER'S NAME & ADDRESS t , BUILDER OR OWNE DATE PERMIT ISSUED 192 DATE C0-MPLIANCE ISSiUfD -/ 6' �..s' ._.-- � �� J °� �� � ✓�� i /�i �� va / r � ,� ���--> / `._._-- D� t —.. • C t"• � t, . �r. ��" � ��,� �. ,_ .. Commonweafth of Massachusetts Executive Office of Environmental Affairs Department ®f Va oCF Ie 8lgeC1f9 9 WilliamF. Weld Environmental PrAt�Ctl® � Gwmor T .. Trudy Coxe A sep t 4,EOEA 350 MAIN ST,W. H 4* David B. Struhs tiCommissioner SUBSURFACE SEWAUL UIJt'Uo^,- STEM INSPECTION FORM PART A CERTIFICATION MAP# 192 PAR#190 PROPERTY ADDRESS: 115 White Oak Trail, Centerville ADDRESS OF OWNER: DATE OF INSPECTION: July 2, 1997 Russel Terkelsen NAME OF INSPECTOR James D. Sears COMPANY NAME, ADDRESS AND TELEPHONE NUMBER: A&B CANCO, 350 MAIN STREET, WEST YARMOUTH, MA 02673 (508)775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS Inspector's Signature: Date: July 2, 1997 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, or C A) SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below., B] SYSTEM CONDITIONALLY PASSES: N/A One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. 1 (REVISED 11-03-95) One Winter Street Boston, Massachusetts 02108 Fax(617)�56-1049 Phone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 115 White Oak Trail, Centerville Owner: Terkelsen, Russell Date of Inspection: July 2, 1997 B] SYSTEM CONDITIONALLY PASSES (continued) 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 leveled 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 bf Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _N/A_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacterial 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. 3) OTHER 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 115 White Oak Trail, Centerville Owner: Terkelsen, Russel Date of Inspection: July 2, 1997 D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined N/A in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: N/A 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 exits: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 115 White Oak Trail, Centerville Owner: Terkelsen, Russel Date of Inspection: July 2, 1997 Check if the following have been done: X Pumping information was requested of the owner, occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection X As built plans have been obtained and examined. Note if they are not available with N/A X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow X The site was inspected for signs of breakout. p 9 X All system components, including the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 115 White Oak Trail, Centerville Owner: Terkelsen, Russel Date of Inspection: July 2, 1997 FLOW CONDITIONS RESIDENTIAL: Design Flow: 330 gallons Number of bedrooms: 3 Number of current residents: 1 Garbage grinder(yes or no): YES Laundry connected to system (yes or no): YES Seasonal use (yes or no): NO Water meter readings, if available 95 96,000/96 6,400 Last date occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharge to the Title 5 system:(yes or no) Water meter readings, if available: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: TWO YEARS AGO System pumped as part of inspection:(yes or no) NO If yes, volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes, attach previous inspection recods, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: PERMIT#748 Sewage odors detected when arriving at the site:(yes or no) NO 5 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115White Oak Trail, Centerville Owner: Terkelsen, Russell Date of Inspection: July 2, 1997 SEPTIC TANK:_X_ (locate on site plan) Depth below grade: 21" Material of construction: X concrete metal FRP other(explain) Dimensions: 1,500 GALLON PRE CAST Inlet Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: N/A Inlet Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A Comments: (recommendation for pumping, condition of inlet and outlet tees ;or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) TANK AT WORKING LEVEL, INLET TEE IN PLACE, TANK UNDER DECK, INLET COVER HAS TRAP DOOR IN DECK, UNABLE TO GET TO OUTLET COVER. GREASE TRAP:_N/A_ (locate on site plan) Depth below grade: Material of construciton: concrete metal FRP 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 115 White Oak Trail, Centerville Owner: Terkelsen, Russell Date of Inspection: July 2, 1997 TIGHT OR HOLDING TANK:— N/A-(locate on site plan) Depth below grade: Material of construciton: concrete metal FRP other(explain Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) D-BOX IS 16" X 16113411 BELOW GRADE, BOX IS CLEAN, LEVEL, NO SOLID CARRY OVER, ONE INE IN TWO LINES OUT. PUMP CHAMBER:—N/A— (locate on site plan) Pumps in working order:(yes or no) (note condition of pump chamber condition of pumps and appurtenances, etc.) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 White Oak Trail, Centerville Owner: Terkelsen, Russell Date of Inspection: July 2, 1997 SOIL ABSORPTION SYSTEM (SAS):_X_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 2 leaching chambers, number: leaching galleys, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) TWO PRE CAST PITS, BOTH HAVE 6"WATER IN BOTTOM. PIT#1 IS 39" BELOW GRADE, COVER IS 4" BELOW GRADE. PIT#2 IS 40" BELOW GRADE COVER IS 26" BELOW GRADE. CESSPOOLS:_N/A_ (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 cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc) PRIVY: N/A (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.) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 White Oak Trail, Centerville Owner: Terkelsen, Russell Date of Inspection: July 2, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR BENCHMARKS LOCATE ALL WELLS WITHIN 100' -D£QK IL J I�.s 19 0 DEPTH TO GROUNDWATER Depth to no groundwater: 12 feet method of determination or approximation: TEST HOLE NOTED ON PLOT PLAN, NO WATER AT 12' BOTTOM OF PITS 9' BELOW GRADE. 9 PERMIT NUMBER DATE COMPLETED BY HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 115 White Oak Trail, Centerville Lot No. Owner: Russell Terkelsen Address: Contractor: Address: Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. Date month/day/year STEP 2 Using Water•Level Range Zone and Index Well Map locate site and determine: OAPprooriate index well.................................................... © Water level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well month/year STEP 4 Using Table of Water•levei Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3). and water•level zone (STEP 213) determine water level adjustment ...................................... STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water level at site (STEP 1) Figure 13--Reproducible comutation form.