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HomeMy WebLinkAbout0033 PHEASANT WAY WEST - Health - - - - -. -M 33 PHEASANT WAY, CENTEP#ILLE A= 208 075 llll CPCIC�O = 2� UPC 12543 Now HAST1�109,P.1Pt Commonwealth of Massachusetts s Title 5 Official inspection oFom Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y,y n w� 33 Pheasant Way West Z Property Address Barbara Irlen Owner Owner's Name !y? required fd is Centerville ►� MA 02632 1/18/2A6 required for every page. City/Town State Zip Code Date of040ection A Inspection results must be submitted on this form.Inspection forms may notibe altered in any way.Please see completeness checklist at the end of the form. Important:When A. Genera! Information filling out forms on the computer, use only the tab 1. Inspector key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services gyy Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town ate Zip Code 508-775-2825 S15016 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. t 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 1/19/2016 'Inspectorsre Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP_The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.X13 Title 5 official irSpeefim Forth:Subsurface Sewage Otsposal system•Page 1 of 17 1 ,CD�� Vs i Commonwealth of Massachusetts ` W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owners Name information is required for every Centerville MA 02632 1/18/2016 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: System in working condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", ``no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 a Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is required for every Centerville MA 02632 1/18/2016 page. Cityrrown State Zip Code Date of Inspection 13. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owners Name information is required for every Centerville MA 02632 1/18/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is required for every Centerville MA 02632 1/18/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] y ❑ ® 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owners Name information is required for every Centerville MA 02632 1/18/2016 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)] 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): 110x3= 330gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is required for every Centerville MA 02632 1/18/2016 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2014=195gpd Detail: 2015=186gpd 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is required for every Centerville MA 02632 1/18/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is required for every Centerville MA 02632 1/18/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"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.): Lines checked with sewer camera and were found to be clean, properly pitched with no sign of root intrusion. Septic Tank (locate on site plan): Depth below grade: 10" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: 1500Gal H-10 Sludge depth: 6-8" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Tale 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information isequired or every very Centerville MA 02632 1/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2-3" 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? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal H-10 tank in good condition. PVC tees in place and clean. Tank at normal operating level. Inlet cover 10" below grade. Outlet 4" below grade. Zable filter installed on outlet Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 33 Pheasant Way West Property Address Barbara Irlen Owner Owners Name information is required for every Centerville MA 02632 1/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is required for every Centerville MA 02632 1/18/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 DB-3 with 1 line in and 1 line out in good condition. Box is clean and solid with no solids carryover. No sign of overloading or hydraulic failure. Cover 12" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is Centerville req u ired for every MA 02632 1/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-60'x4'x2' ❑ 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.): 1-60'x4'x2'trench with perforated pipe and stone. Leaching found dry at time of inspection with no sign of overloading or hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is required for every Centerville MA 02632 1/18/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of (Massachusetts -- W Title 5 Official Inspection Form Subsurface S- ewa a Disposal - S stem Form Not for Voluntary olunta Assessments p Y ry °M 33 Pheasant Way West Property Address Barbara Irlen Owner Owners Name information is required for every Centerville MA 02632 1/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is required for every Centerville MA 02632 1/18/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +12' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Hand auger on site to 12'with no water encountered. Bottom of leaching at 5'. Minimumm of 7' separation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pheasant Way West Property Address Barbara Irlen Owner Owner's Name information is required for every Centerville MA 02632 1/18/2016 page. Cityffown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f a g ' .I' ®s-2 ore 1 f r s - ( I 9 TOWN OF BARNSTABLE LOCATION Lr•.w.-_SEWAGE # ;�''`AN VILLAGE ASSESSOR'S MAP & LOT��e,07J`. INSTALLER'S NAME & PHONE NO c0", SEPTIC TANK CAPACITY 'S 6V LEACHING FACILITY:(type) �N (size) 1 d)K NO. OF BEDROOMS '' _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �r��\i •••� �v 1 I Z DATE PERMIT ISSUED: °- �y � DATE COMPLIANCE ISSUED: I VARIANCE GRANTED: Yes No l_ ��'� 3� i � o � �� � ����� Ceo��r�` —j'f�w.c� � 2 J�p ���L -=-< { I,OT NO. : _ADDRESS._ A ,OWNERS NAME: f, � SEWAGE PERMIT NO..: NEW: REPAIR: DATE ISSUED: DATE INSTALLED: INSTALLERS NAME: F'c vo INSTALLATION OF: WATER TABLE: FINAL INSPECTION BY: }. DRAWING 0F INSTALLATION ON REVERSE SIDE: 6 L No. Fee i (� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Xkgaal *pgtem Conaruction Permit Application is hereby made for a Permit to Construct( )or Repair,(VI an On-site Sewage Disposal System at: Location Address or Lot No. er's Name,Address and Tel.No. L<eft;7rC, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms-- Garbage Grinder(Alq Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 'J 5,4/10 gallons per day. Calculated daily flow _3 gallons. Plan Date Number of sheets Revision Date Title Description of Soil P01-C) Nature of Repairs or Alterations(Answer when applicable) =0,541u tS0D Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this and o Health. Signed Date � 'C) Application Approved by Application Disapproved for the followA reasons Permit No. 1!&q Date Issued &- �— -- ---- -------------------- J /' 2 F I � ..•� �� r�• yF e4 I No. La t � Fee THE COMMONWEALTH OF MASSACHUSETTS + PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS -01ppYicatiou for Migpogar *pgtem Cottgtruction Permit Application is hereby made for a Permit to Construct( )or Repair(,v)an On-site Sewage Disposal System at: l P { Location Address or Cot No. Owner's Name,Address and Tel.No. Installer's Name,A-dddresss and Tel.No. Designer's Name,Address and Tel.No. �.y;i >~,�� _. Type of Building: Dwelling No.of Bedrooms Garbage Grinder(A10 t, Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow t r _gallons per day. Calculated daily flow J gallons. Plan Date Number of sheets Revision Date Title Description of Soil = `t- V ri" 0 Nature of Repairs or Alterations(Answer when applicable) a. wz i ����. \��? Date last inspected: Agreement: k l The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate.of Compliance has been issued by this 3oard of Health. r .> Signed 'f -Date - Application Approved by Application Disapproved for the following reasons -. - -- 5 4 Permit No. Date Issued - � ; t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARN STABLE, MASSACHUSETTS Certificate of Compliance - - THIS IS TO CAR r Y,that thepn-sit Sewage Disposal System installed(<kol re paired/replaced(+' )on J L t �=h by r,��Y�- �a��� ._:� for � as has been constructed in accordance with the provisions of Title 5 and the for.Disposal System Construction Permit No. ZT 9 q I dated Use of this system is conditioned on compliance with the provisions set fo ] below: No. �J - 0 d- Fee, ) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH'DIVISION - BARNSTABLE, MASSACHUSETTS ligpogat *pgtem Construction Permit Permission is hereby granted�o �© to construct( )repair(�)an On-site Sewage System located at qt 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. All construction must be completed within two years of the date below. Date: / — 9 5 Approved by_ f f" ` . . 0 O [JF i , I CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) L , hereby certify that the application for disposal works construction permit signed by me dated � , concerning the property located at <53-13 � meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase inflow and/or change in use proposed • There are no variances requested or needed. SIGNED : _ DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. ? A v-2.S 7 SUBSURFACE SZWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property -3 3 Ce_ilree a, Owner's name Ve,114k Date of Inspection PART A CHECKLIST Chec if the following have been done: Pumping information was requested of the owner, occupant, and Board of / Health. v 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. V As built plans have been obtained and examined. Note if they are not available with N/A. t - The facility or dwelling was inspected for signs of sewage back-up. i� he site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. --Z— 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. Zhe size and location of the SAS on the site has been determined based n existing information or approximated by non-intrusive methods. The facility .owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. REMO S EP 1 5 1995 Wool e 5 � 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 1-)- number of bedrooms number of current residents n/ garbage grinder, yes or no 4— laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: -t� Last date of occupancy GENERAL INFORMATION Pumping records and source of information: /A Al System pumped as part of inspection, yes or no if yes, volume pumped 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: material of construc ion: concrete metal FRP other(explain) dimen/ditance depth from top of sludge to bottom of outlet tee or baffle hickness ce 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 r pumping, condition of inlet and outlet tees or baffles, depth of liquid Ivel in relation to outlet invert, structural integrity, evidence of le age, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site pl'n) dep h of liquid level above outlet invert Comments: (note if lev and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan pumps in rking order, yes or no Comments: (note conditio of pump chamber, condition of pumps and appurtenances, recommendatio s for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not r uired, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs ofihydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration `% — depth-top of liquid to inlet invert o^^ depth of solids layer depth of scum layer dimensions of cesspool G 77 6, 8 ' 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, recommendations for maintenance or repairs,etc_. ) X e )z 12 ' PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, signs of hyd aulic failure, level of ponding, condition of vegetation, recommenda ons for maintenance or repairs,etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' .r� a, o yIt (3 DEPTH TO GROUNDWATER ;-d 4 depth to groundwater method of determination or a prox matio 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? !/ Discharge or ponding of effluent to the surface of the ground or surface waters? -42Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: Abelow the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? 4-Z within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? AZless 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. tl TOWN OF � ��- BOARD OF HEALTH P . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED j STREET ADDRESS ASSESSORS MAP, BLOCK AND. PARCEL # O 73' OWNER' s NAME 1d&116 h PART D - CERTIFICATION NAME OF INSPECTOR W.E. Robinson Sr COMPANY NAME W.E. Robisnon Septic Service COMPANY ADDRESS P.O. Box 1089 Centerville MA 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 1 775-8776 FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on— site sewage disposal systems. Check one: System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER (where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc 13 ;.