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Home My WebLink About0319 PHINNEY'S LANE - Health 319 Phinney's Lane Centerville P A = 230 013 UPC 12534 ' Mo.2 15360.R {o HASTINOS,YN I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTI.ON RECEIVE® OCT 10 20OZ TOWN OF BARNSTABLE HEALTH CREPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 7 CERTIFICATION �'� Z Property Address: J�� I✓I N�' /—/I/ Owner's Name: Owner's Address: _mil 1 MAP 23 / � t �1 Date of Inspection: PARCEL O\ - Name of Inspector. (please print) G� ! �� LOT Company Name: e,4 vi -- J" _� Mailing Address: y /e)x T;i i,5- 5 4- Telephone Numbeq 2�/ 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: /S- 7— Lz�k 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. Notes and Comments ""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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �� 61 a c Owner. �lE? Date of Inspection: V2 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D AC System Passes: . I have not found any information which indicates that anv of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist Am,failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system. upon completion of the replacement or repair.as approved by the Board of Health.will pass. 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 structumuv nnso und.exhibits substantial infiltration or extltmtion 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 saucturally 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. Svstem will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a vear 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: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. . Date of inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther 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 CM 15.3030)(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. Svstem 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 supple or tributary to a surface water supply. _ The system has a sepuc 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 '•Tbs system passes if the well water analysis,performed at a DEP certified laboratom.for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammoma nitrogen and nitrate nitrogen is equal to or less than 5 ppm•prodded that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other- Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: � D. System Failure Criteria applicable to all systems: You must indicate'ves"or"no"to each of the following for all inspections: Yes Nol _ _✓ Backup of sewage into facility or system or cesspool clogged SAS or ces component due to overloaded or clogged SAS or cesspool Discharge or s g of effluent to the surface of the ground or surface waters due to an overloaded or spool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ iquid depth in cesspool is less than 6"below invert or available volume is less than%:day flow 12equired 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- Al 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. _ Am•portion of a cesspool or pnvv is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analvsis. (This system passes if the well water analvsis. performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.l (Yes/No)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 Svstems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"ves"or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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-suuface drinking water supple the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water suppl-well If you have answered"ves"to any question in Section E the system is considered a significam 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 15.30d. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. S�l Date of Inspection: /C , Check if the following have been done. You must indicate`ves"or"no"as to each of the following- Yes o Pumping information was provided by the owner_occupant.or Board of Health _ ZWere any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period V 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 thev 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: Yes no Existing information. For example.a plan at the Board of Health. 4Z- 13eterinined in the field(if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) [310 CNIR 15.302(3)(b)J Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Gj Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: / _ Does residence have a garbage grinder(yes or no): AO Is laundry on a separate sewage system yes or no):AP[if yes separate inspection required] Laundry system inspected(v,or no):/ /v Seasonal use: (yes or no): /L O Water meter readings.if av le(last 2 vears usage(gpd)): /L�d Sump pump(yes or no): 14"0 Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): god Basis of design flow(seats/persons/sgftetc.): 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/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: �N�"11 wc� ��0 Was system pumped as parr of the inspection(yes or no):�c If yes,volume pumped: Reason for pumping: _gallons—How was quantity pumped determined? R T'YP F SYSTEM Septic tank distribution box,soil absorption system _Single cesspool Overflow cesspool _—Privy — Shared system(yes or no)(if ves,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenancc contract(to be obtained from system owner) —Tight tank —Attach a copy of the DEP approval —Other(describe): Approximate age of all compo ts. dale install (if own)and source of information: Were sewage odors detected when arriving at the site(yes or no):LG^v Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION(continued) ' Property Address: 3/9 vl' Owner. Gl�� Date of Inspection: BUILDING SEWER(locate on site plan) Depth below Dep grade:. Materials of construction:✓_cast iron —✓40 PVC_other(explain): Distance from private water suppiv well or suction line: Comments(on condition of joints.venting.evidence of leakage, etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: (l Material of construction:—concrete—metal_fiberglass_polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance fives or no):—(attach a cope of certificate) �+ Dimensions: Sludge depth: r Distance from top of sludge to bottom of outlet tee or baffle: ..�/ Scum thickness: //I— Distance from top of scum to top of outlet tee or bale: Distance from bottom of scum to bottom of outlet t or tie How were dimensions determined: o/" Comments(on pumping recommendations, inlet and utlet tee or baffle condition, structural integrity. liquid levels lated to outlet invert, dence of l ag , etc.): / f.� 40 � G��c-!� ef�_f 5 -1(- ,,.tom — // (oa7 GREASE TRAP.-A2 locate on site plan) Depth below grade:— Material of construcnon:—concrete—metal fiberglass_polvethylene 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: - Comments(on pumping recommendations. inlet and outlet tee or baffle condition. structural intcgrity. liquid levels as related to outlet invert. evidence of leakage. etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: nYie Owner. Date of Inspection: TIGHT or HOLDING.TANK: tank must be pumped at time of inspecdon)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: eallons Design Flow: r ailons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Continents(condition of alarm and float switches. etc.): DISTRIBUTION BOX: �(jfnt must be opened)(locate on site plan) Depth of liquid level above outlet invert: C-�, Comments(note if box is level and distribution to outlets equal.any evidence of solids carryover.any evidence of ge into or out of x,etc): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber.condition of pumps and appurtenances.etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /.f" AlOr"s <` Owner. _> Date of Inspection: / SOIL ABSORPTION SYSTEM(SAS): (locate on site plm excavation not required) If SAS not located explain why: Type /� J leaching pits.number:_ �1?T/ �G►�`Q✓S �i1/ / leaching chambers.member: L 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 hvdraulic failure,level of ponding,damp soil,condition of vegetation. etc.): /' / Cv �� .5t c S 1 _ ��G7 0 U it L %P CESSPOOLS: spool mist be pumped as part of inspecuonXIocate on site plan) Number and configuration: Depth—top of liquid to uilet invert: Depth of solids laver: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil. signs of hydraulic failure. level of ponding.condition of vegetation.etc.): PRIVY' /v (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �/ //1 r an F Z—' Owner. Date of Inspection: p1 SKETCH OF SEWAGE DISPOSAL SYSTEM . Provide a sketch of the sewage disposal svu=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. �5c1c 07< a O C ArA�ie 1 f Page 11 of- g 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 7 SYSTEM INFORMATION(r ontinued) Property. Address: > r 1 h 0 P Owner. Date of Inspection: v SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water 1.heet Please indicate(check)all methods used to determine the high ground water,elevation: Obtained from system design plans on record-If checked dace of design plan reviewed: pbserved site(abutting propem rva /obsetion hole within 150 feet of SAS) Checked with local Board of Health-explain To,H Wj-1 a s Checked with local excavators installers-(attach doc=en=on) Accessed USGS database-explain: You must d scribe how you established the hi ground water elevation: /k1dLf ------------------- -� �Ct TOWN OF BARNSTABLE LOCATION ► ••✓may°' Ys L .✓� SEWAGE# 1 ' 2�� VILLAGE 4 A-11"EA �> /'� ASSESSOR'S MAP&LOT A 3 L: '- INSTALLER'S NAME&PHONE NO. 41241--4 ��'/� s r SEPTIC TANK CAPACITY LEACHING FACILITY: (type) iAl AY"'48 (size) NO.OFBEDROOMS— BUILDER OR OWNER PERMTTDATE: '? —. ;� d,— ,�? COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by E � u . v hYl.iu1V is i✓ ,f ^ y No. v Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS fication for Mig oral p Stem Construction permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: Location Address or Lot No. 9494 ner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: ^� Dwelling No.of Bedrooms J Garbage Grinder(IV) 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 Nature of Repairs or Alterations(Answer when applicable) �G 2 A.:pE T le 4 41 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 issue b this oard o lth. o Signe Date 2 Application Approved by o Application Disapproved for the following reason Permit No. / Date Issued d _ r No. Fee r ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS f 0[ppYication for Migogal *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System°at: Location Address or Lot No. ne e,Address and Tel.No. J j `�1 Cl /j .r/.v E�/s !/•a.✓E (j.9 2!3/9/I Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. T fI Type of Building: Dwelling No. of Bedrooms Garbage Grinder(IV) Other'"` Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures . ? Design Flow gallons per day. Calculated daily flow gallons. ' f Plan Date Number of sheets Revision Date Title ti 'k Description of Soil i. Y � Nature of Repairs or Alterations(Answer when'applicable) G/l A T[f 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 b this Board o dalth. Signed Date Z o2 ' Application Approved by Application Disapproved for the following reason ' Permit No. Date Issued i -. .- C THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/�r p aced( )on by fob f3,4ot &4, q J 7.o F ar .3/ S f'� ti�� ' L,v G � t 2 v> Ile has been constructed in accordance 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 set forth below: e-,—`G � No loop" Fee. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS f Migogal *pgtem Congtruction Permit Permission is hereby granted to an AP,--Z� �`� '� to construct( )repair( On-site Sewage System located at 3 cl i7>;j y •�` -✓ C�' •{vTE 2 v i�� 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 constructio /must b/co pleted within two years of the date below. ® o Date: Approved by � '!/ E ,