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HomeMy WebLinkAbout0258 PHINNEY'S LANE - Health 258 PHINNEY'S LANE, CENTERVILLE A= 230108 i SIII__/_�,f® J�QftYC[Ea�o2i a No 7 LOR HASTINGS, MN r �I e S Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 258 PHINNEYS L N Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 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. I am a DEP approved system inspector pursuanj to Section 15.340 of - Title 5(310 CMR 15.000).The system: � . ® Passes ❑ Conditionally Passes ❑ Fails µ1 -� C ❑ Needs Further Evaluation by the Local Approving Authority +"r C73 2-22-14 C Inspector' ignature Dates r• L.rr r-a� 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. L15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 "1 t Commonwealth of Massachusetts Title 5 Official Inspection Forrh Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: THE AS-BUILT CARD AND SEPTIC PERMIT GIVE NO MEASUREMENTS TO ANY COMPONENTS WE WERE ABLE TO LOCATE THE SEPTIC TANK AND THEN VIEW THE D-BOX WITH A CAMERA. AT THE TIME OF THE INSPECTION THERE WERE NO CLEAR SIGNS OF FAILURE. THE FUTERE PERFORMANCE UNDER THE SAME OR INCREASED CAN NOT BE DETERMINED 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 T t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 1 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. City/Town State Zip Code Date of Inspection B. Certification (coot.) 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 '/2 day flow t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with 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 11 of�a public water supply well If you have answered"yes"to-any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 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)] 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO THE AS-BUILT THE SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND A 60X4X2 LEACHFIELD 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 Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2012----------305 2013----------289 GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: FEB OF 2014 Date 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection ForM o Subsurface Sewage Disposal System Form Not for Voluntary Assessments s 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: FEB 2014 Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy �] Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy 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 wM , 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owners Name information is required for CENTERVILLE MA 02632 2-22-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: ACCORDING TO SEPTIC PERMIT SYSTEM WAS INSTALLED IN NOV OF 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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: 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: 1500 PER PERMIT Sludge depth: VARYING MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 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? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK SHOULD BE PUMPED EVERY 2-3 YEARS. NO RECORDS WERE AVAILABLE AT TIME OF 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 t5ins•3/13 40 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other.(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every 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.): D-BOX WAS VIEWED BY CAMERA DUE TO THE FACT THAT THE INSTALLER DIDNT PUT ANY MEASURMENTS TO ANYTHING ON THE AS-BUILT CARD 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: NOT LOCATED ON AS-BUILT CARD WITH MEASUREMENTS, NO OBSERVATION PORTS FOUND t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 258 PHINNEYSLN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: i ® leaching fields number, dimensions: 60X4X2 f ❑ 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.): ACCORDING TO THE PERMIT THE S.A.S IS A LEACHFIELD. I WOULD CALL IT A TRENCH. THERE WERE NO MEASUREMENTS SHOWING WHERE IT IS. THERE WERE NO OBSERVATION PORTS FOUND OR VENT PIPES TO BE ABLE TO ACTUALLY DETERMINE THE LEVEL OF PONDING IN THE S.A.S 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 �M 50 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. Cityfrown 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 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forma Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. Cityrrown 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: OFF ACCEPTED AS-BUILT CARD FROM INSPECTION FORM DATED 11-24-1995. THE LOCATION OF AND ELEVATION OF THE S.A.S COULD NOT BE DETERMINED DUE TO THE LACK OF INFO AND MEASUREMENTS ON AS-BUILT CARD Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Forth: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 258 PHINNEYS LN Property Address DOUGLAS NICKERSON Owner Owner's Name information is required for CENTERVILLE MA 02632 2-22-14 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 - s �V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,Property Address: Owner: :) 0 Al Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' - I i ' V i -lam 66 7 DEPTH TO GROUNDWATER Depth to groundwater: 1Tfeet r _„'- method of determination or approximation: 1 .5 1 �� d 31 9 (revised 8/15/95) ASSESSORS MAP NO: — v Fee 30.00 �� 3� �e �° PARCELNO: - THE COMMONWEALT SACH $^ PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE.MASSACHUSETTS application for Migpo5al I&FAc n (Congtruttion permit Application is hereby made for a Permit to Construct( )or Repair( X)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. John Kelly l 258 Phinnys Lane y Centerville 571 Franklyn St Cambridge MA 02139 iInstaller's Name,Address,and Tel.No.W.E. Robinson Sr Designer's Name.Address and Tel.No. P.O. Box 1089 Centerville I 775-8776 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder Ito) Other Type of Building No.of Persons -_Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title — Description of Soil gravel Nature of Repairs or Alterations(Answer when applicable) 1 ,5 0 0 gal tank, d-box and 60x4x2 leachfield 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 n t to place the system in operation until a Certifi- cate of Compliance has been issued b_y this Board-of H th. Date Signed � I Application Approved by Application Disapproved for the following reasons Permit No.� / -�� Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Certificate of (Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( X)on by W.E. Robinson Septic Sery for John belly as 258 Phti nv'� T. na nt-cr•c;1 1 o has bee�n onstructed in acco c with the provisions of Title 5 and the for Disposal System Construction Permit No dated ` Use of this system is conditioned on compliance with the provisions setftarth below: E zt_ No. l -✓� Fee 30.00 THE COMMONWEALTH OF MASSACHUSETTs PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 3Digpogal Dp5tem Conotruction Permit _Permission is hereby granted to W.E. Robinson Septic Service t- to construct( )repair(x, )an On-site Sewage System located at 258 PhinnV s Lane Centerville and as described in the above Application for Disposal•System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: Approved by l / r 'a YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO according to M.G.L. - it does not give you permission to operate). You,must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. DATE ( II Fill in please: L Z- APPLICANT'S YOUR NAME/CORPORATE NAME ��a S t 0�l r�0 w� BUSINESS TYPE: BUSINESS YOUR HOME ADDRESS: 2—.y-8 /i TELEPHONE # Home Telephone Number 7 —y L /- - 7 Q c( NAME OF NEW BUSINESS Se cc Cc7 O ynS EIN: t,/ . _,? e r� Have you been given approval from the building division? YES NO ADDRESS OF BUSINESS JA-� Rid r MAP/PARCEL NUMBER P,2 D O M When starting a new business there are several things you must do in or�er to b/� De in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has beei rn f the permit requirements that pertain to this type of business. VI Authorized Signature"' COMMENTS: r 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has bft infft f e licensing requirements that pertain to this type of business. Auth rized ignature * COMMENTS: Commonwealth of Massachusetts �a Executive Office of Environmental Affairs No V 2 9 199 Department of lux� N Environmental Protection Willlam F.Weld Governor Trudy Coxe 8saetary,EOEA David 0.Struhs commiwioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �ttn PART J; t,4 -z s 5' P n ys '� �r? CERTIFICATION / r�A n A �y�► S i` e 17 It - //-ems Property Address: 1 1 -��/— 9 5� Address of Owner: e n' o9 mot4 A Date of Inspection: (If different) Name of Inspector: W.E. Robinson Sr. Company Name, Address and Telephone Number: W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT 77 77'77 I certify that I have personally inspected the sewage dispos l 5 erh t 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: =� Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: � �--- Date: .. �+�9 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTE PASSES: 1 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 DITIONALLY PASSES: One or re system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes ins coon. �t Indicate yes, no, or n t determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ Thl septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is . I inent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)SWI049 • Telephone(617)292-ON Printed on Recycled Paper I � a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: c2 S Owner: 7 u Date of Inspection: B] SYSTEM C DITIONALLY PASSES (continued) wage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pi s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Boar of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system equired pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection i (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATIO QUIRED BY THE BOARD OF HEALTH: Conditions exist which requir further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the en ironment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE P BLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is wit in 50 feet of a surface water Cesspool or privy is wit in 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS TH 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 cv5tem has a septic tan nd 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 an soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank an soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic ta4anil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a welllysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from t and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. Th Board of Health should be contacted to determine what will be necessary to correct the failure. _ Backup of sewage into facility or s stem component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent o the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ` V' \ (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: oZ rt n /~ A o (- Owner: J o ti rr Date of Inspection: D]SYSTEM S(continued): , Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Li uid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Requ red pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Num r of times pumped Any po ion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any port on of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any port on of a cesspool or privy is within a Zone I of.a public well. Any po ion of a cesspool or privy is within 50 feet of a private water supply well. Any of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acce table wa 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 appl to large systems in addition to the criteria above: The design flow of syste i 0,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment bec use a or more of the following conditions exist: the system is within 4� feet of a surface drinking water supply the system is within 20 feet of a tributary to a surface drinking water supply the system is located i a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a public water supply w II) The owner or operator of any such systems ll bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Ple se consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B .CHECKLIST IVAIrlrk, _5 AAhC Property Address: J_e he) K<.///Owner. Date of Inspection: I l y_q� Check if the following have been done: =Pumping information was requested of the owner, occupant, and Board of Health. "One of the system components have been pumped for at least two weeks and the system has been receiving normal flow rases during that period. Large volumes of water have not been introduced into the system recently or ag part of this inspection. '/As built plans have been obtained and examined. Note if they are not available with N/A. "The facility or dwelling was inspected for signs of sewage back-up. _✓The system does not receive non-sanitary or industrial waste flow `4he site was inspected for signs of breakout. "AII system components, excluding the Soil Absorption System, have been located on the site. fhe 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. L.;r a size and location of the Soil Absorption System on the site has been determined based on existing information or /approximated by non-intrusive methods. _The facility ov ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: °? �' '11 kA-y s 19'n e- Owner: .To h rn X - l l/ Date of Inspection: y _ 9 S FLOW CONDITIONS RESIDENTIAL: Design flow: 333U gallons Number of bedrooms:_ Number of current residents:2- Garbage grinder(yes or no):-A:- Laundry connected to system (yes or no): Seasonal use (yes or no):_A✓ Water meter readings, if available: 9 L- Last date of 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 discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sot a of information: Atr Aa -4 6 System pumped as part of i pection: (yes or no)_ If yes, volume pumped. gallons Reason for pumping: TYPE OF `STEM (/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) and source of information: IVo y 11 Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a. S �''" °� 1 'L n Owner: or-4 Date of Inspection: SEPTIC TANK:_✓ (locate on site plan) t Depth below grade: g Material of construction: _concrete metal FRP other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: A Scum thickness: d Distance from top of scum to top of outlet tee or baffle: gl_�9 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.) A., a tit/ 2 ) -5 GREA P:_ (locate on sit Ian) Depth below grade. Material of constructs n: _concrete _metal FRP _other(explain) Dimensions: Scum thickness: Distance from top of scum o top of outlet tee or baffle: Distance from bottom ot sn m t, bottom of outset tee or baffie: Comments: (recommendation for pumpin , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc., (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: oz S Owner: J"o h r i 1 f— /l X Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on ite plan) Depth below rade: Material of co struction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow:____L_gallons/day Alarm level: Comments: (condition of inlet )e, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids ca.r,o•:c:, evidence of leakage into or out of box, etc.) PUMP CHA (locate on site plan Pumps in working order: es or no) Comments: (note condition of pump ch ber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: c?��' �h n n Yf A'9 rn C e,vtTZ/ Owner: J"p h n K e-/f Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: �✓ �/ �` �. / �� �� �`J Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: `f .r 7, leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ (locate on site plan) i c� J Number and configuration: �f /" w 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 (cesspool must be pumped as part of inspection) Comments: (note conditon oil, 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, sign of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 02 `� ��'. n n J h e— Cc h 7P- Ile Owner: C a ti n e,l! Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' . I m 4 j� /ry �6 DEPTH TO GROUNDWATER Depth to groundwater:_,2-- feet method of determination or approximation: (revised 8/15/95) 9 TOWN'OF BARNSTABLE LOCATION SEWAGE # C VILLAGE IL' j- 1 ASSESSOR'S MAP 6i LOTZ3 INSTALLER'S NAME 6z PHONE NO. 60+ 1� 'o "•S 4 <•- ? '7 t'17� SEPTIC TANK CAPACITY Z LEACHING FACILITY:(type) �/ ,T Q (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER G" DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r A/ V-7 r fa ASSESSORS MAP NO: Fee 30 . 00 No. PARCEL N(: '4 e THE COMMONWEALT11 OF MASSACHRETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS appitration for �Bizpozal *paem C ow5truCtton Vermtt Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at: Location Address or Lot No. 2 5 8 Ph i nny s Lane Owner's Name,Address and Tel.No. John Kelly Centerville 571 Franklyn St Cambridge MA 02139 Installer's Name,Address,and Tel.No.W.E. Robinson Sr Designer's Name,Address and Tel.No. P.O. Box 1089 Centerville 775-8776 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(no) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil gravel Nature of Repairs or Alterations(Answer when applicable) 1 , 500 gal tank, d-box and 60x4x2 leachfield 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 n t to place the system in operation until a Certifi- cate of Compliance has been issued by this Board f He th. / Signed Date 6 V Application Approved by `9 Application Disapproved for the following reasons Permit No. � "' i Date Issued /J_ "V. � �� r. Ni19 V` 30.00 . / /x F J Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE- MASSACHUSETTS ZIppfication for Migo$, *p5t�em Con!trUCtibn Permit Application is hereby made for a Permit to Construct i 4 pp y � ( )or Repair( X)an On-site Sewage Disposal System at: Location Address or Lot No. 258 Ph inn f s "Lane Owner's Name,Address and Tel.No. John Kelly Centerville 571 Franklyn St { Cambrid a MA 021 9 Installer's Name,Address,and Tel.No.W.E. Robinson Sr Designer's Name,Address and Tel.No. P.O. Box 1089 Centerville 775-8776 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder 00) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. PI'an Date Number of sheets Revision Date Title •�:;",,.. Description of Soil gravel L Nature of Repairs or Alterations(Answer when applicable) 1 ,500 gal tank, d—box and 60x4x2 leachfield " Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system ' a¢ in accordance with the provisions of Title 5 of the Environmental Code and n t to place the system in operation until a Certifi-cate of Compliance has been issued by this Board f H th. Signed Date�A Application Approved by ' Application Disapproved for the following reasons ,f Permit No. ! "' Date Issued ��'' /��i ''0 / +✓ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS C.ertif irate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( X)on by W.E. Robinson Septic '8ery for John Kelly as 258 , as been onstructed in acco d ce with the provisions of Title 5 and the for Disposal System Construction Permit No. 'r dated Use of this system is conditioned on compliance with the provisions setlov,below: lei No. Fee 30.00 —THE COMMONWEALTH OF MASSACHUS�ETTS NNW,- PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS lioo.5al *proem Construction Permit ermission is hereby granted to W.E. Robinson .Septic Service to construct( )repair(X )an On-site Sewage System located at 1 258 Phinny.' s Lane Centerville and as described in the above Application for Disposal-System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All constr©uctioonn'm-ust be completed within two years of the date below. Date: 7..� -` /�7 �✓ Approved b �L%�/2�% l f A CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated �l"02 `/ g , concerning the property located at 7�V / 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 d • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: L� v DATE: �� C LICENSED SEPTIC SYSTEM INSTALLER IN 7ME TOVJN OF BAORNSTABLE?'UMME [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. c► r� J co V f G I