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HomeMy WebLinkAbout0555 PHINNEY'S LANE - Health 555 Phinney's Lane Centerville P A = 230 116001 �i ffi i alto 1521/3 ORA 100/- P2 r TOWN OF BARNSTABLE _L.00A'TION ihAq 5 L✓l �E#a✓t SP IVIL(PAGE mow'A ASSESSOR'S(MAP&PARCEL INKS NAME&PHONENO. SEPTIC TANK CAPACITY 14500 LEACHING FACILITY:(type) ��l�wl�2c1's (size)Q x', NO.OF BEDROOMS OWNER Lar-ICI n PERMIT DATE: T DATES f Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY . ! r•r r ! ! r f r f f f f ! ♦ 4 ti•, , • 4 t • t • ' / f•f f"f / ��� f f f l f 4•t�t 4 \ • 4 \ \ 4 • \ \ 4 \ , 4r4/\f\f\ft ftf4f• t \ \ f\r4 f,f\/ � i •• 4 t 4 4 k t • 4 \ • \ t • k k J�y. 4 t \ t t \ 4 t \ 4 t , • • t • , t � . 4 • t 4 • • 4 4 4 '�i4 f f r r f r f f >,• ff / f / fff 47 31 • �N � f Commonwealth of Massachusetts 007 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 555 Phinneys In Property Address Sean Larkin rV . Owner Owner's Name r information is ✓ +?? required for every Centerville Ma 02632 4/26/16 a page. City/Town State Zip Code Date of Inspection -j 1+ Inspection results must be submitted on this form. Inspection forms may not be altered in aAr way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain ,Q Company Name 8 Johns path Company Address S Yarmouth Ma 02664 Cityrrown State Zip Code 508-364-9587 S103522 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 pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local A roving Authority 5/2116 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 555 Phinneys In Property Address Sean Larkin OW40 Owner's Name inform red for every information is requi Centerville Ma 02632 4/26/16 page:' City/Town State Zip Code Date of Inspection B. Certification (cont.) a r. 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 contains a 1500 GI septic tank as well as a dbox and 2 500 gl leaching chambers. installed 11/18/05 There are no signs of back up into dbox or chambers. Chambers were dry at time of inspection. Roots were noticed in chambers. 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 Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is Centerville Ma 02632 4/26/16 required for every page. City/Town 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 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is Centerville Ma 02632 4/26/16 required for every page. Cityrrown 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is Centerville Ma 02632 4/26/16 required for every i page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System contains a 1500 GI septic tank as well as a dbox and 2 500 gl leaching chambers. installed 11/18/05 There are no signs of back up into dbox or chambers. Chambers were dry at time of inspection. Roots were noticed in chambers. Number of current residents: Vacant 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 ears usage d 118 Gpd 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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 M 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Unknown Date Other(describe below): General Information Pumping Records: Source of information: Unknown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 117 Commonwealth of Massachusetts a F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 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: Installed 11/18/05 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. Cityrrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 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.): Tees are in place and levels are normal. 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 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 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 Level and at normal level 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.): No signs of carry over 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 500 gl ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of ponding or break out. Roots in Chambers were noticed 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 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.): No ponding no break out 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 5/2/2016 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION 6J S? & o L n swmw#�✓►Sri VILLAGE %UcuI ASSESSOR'S MAP&PARCEL Ip 'S NAME&PHONE NO r �IcJnK.t i l SEPTIC TANK CAPACITY 15 LEACHING FACILITY:(type) Oka iwn (size) $60 NO.OF BEDROOMS OWNER L�_r IU n PERMIT DATE: CDATL � a Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility Of any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY I ♦ ;;; ;i'i i i r;i i r;;;`r 1 . I I r I r I r r r r r r r `r�r`,r;;;;`r irrr rrrrrrrr , Fatio 47 I 31 i http://www.town.barnstable.ma.us/assessing/HMdisplay.asp?mappar=230116001&seq=3 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 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 a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ It 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: 11/18/05 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: plans on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: NGE at 132" 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 555 Phinneys In Property Address Sean Larkin Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 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 TOWN OF BARNSTABLE ` 3CaTION sr�rS' /�'a1%l L.a•. �'AP SEWAGE# ®®��6 1if VIL3.AGE �' ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY ''®� LEACHING FACILITY: (type) ��i� (size) NO.OF BEDROOMS OWNER PERMIT DATE: -00-1 —'00'—1 0,10 COMPLIANCE DATE: Ooo � Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist /a within 300 feet of leaching facility) ./ Feet FURNISHED BY t � � �� ��.��� _ , � . : . ,� . . ,� _ .� , . � � o %'�' � � � �9 � ,_ � 3 � �-� ,� �� �� � > � � � � � �.� � ��` � No. LAC V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNS'TABLE, MASSACHUSETTS Yes 9pplication for Mi5po5a1 *p!5tem Con5trurtton Permit Application for a Permit to Construct( ) Repair Upgrade(ff Abandon( ) ` Complete System ❑Individual Components Location Address or Lot No.�� /^ y� ti Owner's Name,Address,and Tel.No. c L Assessor's Map/parcel o�2 -1 v Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building �G ° No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min,required) gpd Design flow provided gpd Plan Date ��� o Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boardaf Health. , p S� Sign�W - - Date Application Approved by 1, A Date Application Disapproved by: 4C Date for the following reasons Permit No. ` Date Issued No. l// rJ�/d Fee # a �•/' Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALT1+DIVI`SION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pp ication for Migpoga1 *p5tem Congtruction Permit Application for a Permit to Construct Repair Upgrade Abandon S (Com lete System ❑Individual Components Location Address or Lot No. �yT, Owner's Name,Address,and Tel.No. Assessor's Map/parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 1.4 Lot Size sq. ft. Garbage Grinder ( ) f Other Type of Building �Gb°G - No.of Persons Showers( ) Cafeteria( )f Other Fixtures Design Flow(min.required) -� -3 gpd Design flow provided 3 gpd Plan Date �`g Number of sheets �, Revision Date Title s Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) t Date"last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewagedisposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of ' Compliance has been issued by this Boar Health. - / p .Sf Sign 4 4 Date Application Approved by / Date Application Disapproved by: l Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded Abandoned( )by ���1 L at Ss�r.�ii�/���� �' C�yT haasseen,construct inc rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. L/7.0 dated Installer �/�`� GGCC�o� Gf Designer .�3�q l//O �'. ��i�J'07✓i f.�?�'- #bedrooms Approved design.flow "k:4 o gpd The issuance fthi permit shall not be construed as a guarantee that the system ncti n as deessj(gned. Date .r of this ( (D U y Inspector --ram v ———— —————————————————————————————————————— No. Fee 0/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Migogal,�§pgtem Congtruction ermYit Permission is hereby granted to Construct ( ) Repair ( � Upgrade ( 01 Abandon ( ) System located at 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. Provided: Constructio must 1 completed within three years of the date of this a e. it. esDate Approved by r Dec 16 05 04: 15p 508-833-2177 p. 1 Town of Barnstable rho Regulatory Services . Thomas F.Geiler,Director .issg, public Health Division . Ep °i Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Desizner Certification Form Date: (,: lla Z00 , Designer: D MA SCtJ_I j Installer: _ Address: _.'`I �� Gt Q � Address: ] r Qn - L4QPr-�I-�was issued a permit to install_a (date) y (installer)septic system at � '[ �L`-� )qsed on a design drawn by ( s) A'111 D M!kS o — elated �J (designer) V I certify that-the. septic system- referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical.relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. �`Iustaller's ignatme} Ws1 er's Signature} (Affix Designees Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATU OF COMPl dANCE WILL NOT BE ISSUED UNTIL BOT9 THIS FORM AND AS- BUILT,CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DWISIE3N. THANK YOU. • 1 Q:HealMcptic/Designer CerdScat=Form \ l u*/16fu5 nun 10:07 VAa Ou84444400 • 5/,�5J01 Notice: This Form-Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM �1 Ayl� . tit hereby certify that the engineered plats signed by me dated /Y"1, nWg the property located at 655— �f��N�� � meets AV ofthe following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude,this factor may conduct prelitninary tests at the site without a health agent present. • There is no increase in flow a4or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Srimptor method when applicable] Please complete the following: A) Top of(around Surface Elevatiod(using GIS information) B) G.W.Elevation 30 +adjustment for high G.W. DOFERENCE BETWEW A and B 3IG DATE: vY PI(MCE Based upon the above information,a repair permit wilt be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system 1W 23. 6 q;bc*hb folcur PcratxmP . 7 Commonwealth of Massachusetts Title 5 Official Inspection Form s s Subsurface Sewage Disposal System Form Not for Voluntary Assessments w� 555 Phinne 's Lane — Property Address Larkin Owner Owner's Name information is Centerville MA 02632 April 2 2012 required for State Zip Code Date of Inspection every page. City/Town 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. — Company Name 189 Cammett Road — Company Address Marstons Mills MA 02648 City(rown State Zip Code 508-428-1779 SI 12855 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 disposaly P systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev tion by the Local Approving-,,t"ority v" April 2, 2012 Job# 12-53 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t5ins•11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 555 Phinney's Lane _ Property Address Larkin Owner Owner's Name information is required for Centerville MA 02632 April 2, 2012 - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303.or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank was not in need of pumping at time of inspection. Leaching chambers were empty at time of inspection with no definite sidewall stains. _ 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):- 15ins•11/10 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 555 Phinney's Lane Property Address Larkin — Owner Owner's Name information is Centerville MA 02632 April 2, 2012 required for every page. City/Town State Zip Code Date of Inspection — B. Certification (cont.) 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 15ins•11/10 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 555 Phinney's Lane — Property Address Larkin — Owner Owner's Name information is Centerville MA 02632 April 2, 2012 required for every 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_day flow t5ins-11/10 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 M 555 Phinney's Lane _ Property Address Larkin Owner Owner's Name information is Centerville MA 02632 April 2, 2012 required for — every 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.] ❑ ® 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 555 Phinney's Lane — Property Address Larkin — Owner Owner's Name information is Centerville MA 02632 April 2, 2012 required for 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 CM 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'" 555 Phinney's Lane — Property Address Larkin — Owner Owner's Name information is Centerville MA 02632 April 2, 2012 required for — every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No 3 months prior to Last date of occupancy: inspection 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: l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 555 Phinney's Lane — Property Address Larkin — Owner Owner's Name information is Centerville MA 02632 April 2, 2012 — required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank last pumped in 2009 _ 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): l5ins•11/10 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 555 Phinney's Lane — Property Address Larkin — Owner Owner's Name information is Centerville MA 02632 April 2, 2012 required for — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date: 12/16/05 — 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): 4" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 10.5' long x 5.8'wide- 1500 gal. Dimensions: 1„ Sludge depth: l5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 555 Phinney's Lane — Property Address Larkin — Owner Owner's Name information is Centerville MA 02632 April 2, 2012 required for — 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 31" — 0" _ Scum thickness 6" Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle 14" _ Measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert and tees were intact. _ 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-111110 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 555 Phinney's Lane — Property Address Larkin — Owner Owner's Name information is Centerville MA 02632 April 2, 2012 required for — every 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 ❑ 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 l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 555 Phinney's Lane — Property Address Larkin — Owner Owner's Name information is required for Centerville MA 02632 April 2 2012 — every page. Citylrown State Zip Code Date of Inspection — D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert — Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present liquid level at bottom of outlet pipes. — 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11110 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 w 555 Phinney's Lane Property Address Larkin Owner Owner's Name information is Centerville MA 02632 April 2, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Two 500 gal drywells. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers were empty at time of inspection with no definite sidewall stains. 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•11/10 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 555 Phinney's Lane — Property Address Larkin — Owner Owner's Name information is Centerville MA 02632 April 2, 2012 — required for every page. City/Town 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.): l5ins-11110 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 w, 555 Phinney's Lane Property Address ----------- --.------------ --- ------ Larkin _ Owner Owner's Name -- —--- -- information is required for Centerville _ __ MA_ 02632 April 2, 2012 every page. Cityrrown 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 / r•i f ! r f•? ? ? ? �� �r r f f ! \ \ \ \ ♦ \ \ \ \ Patio 47 31 i Commonwealth of Massachusetts _ Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 555 Phinney's Lane Property Address Larkin Owner Owner's Name information is Centerville MA 02632 April 2 2012 required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20+ _— Estimated depth to high ground water: 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el 30 and topo map shows property at el. 50. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 t5ins-11/10 s Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 555 Phinne 's Lane Property Address Larkin Owner Owner's Name information is Centerville MA 02632 April 2, 2012 — required for State Zip Code Date of Inspection every page. City/Town 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 17 of 17 t5ins-11110 r _ COMMONWEALTH OF MASSACFIUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION w V1w. 2`3 DEC 1 5 2004 TOWN OF_ U.. -- ABLE HEA,"H UEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM r PART A /CERTIFICATION Prop.p,Address: SSA r Owner's Name: Owner's Address: Date of Inspection: (0- 7 -D cA Name of Inspector: (please printp�nlac A-Srpwri Company Name: ❑nug s n Septic Inspections Mailing Address: Telephone Number: A 02632 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 inspdction.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: Section Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature• Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Co�m}ments ors/5/0(.rJ� pv✓� / p ****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: Owner's Name: , <S Owner's Address:. Date of Inspection: 7-p L-1 Inspection Summary: Check A,B,C,D or E/AL WAY 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: rt M B. in Conditionally Passes: one o re system components as described in the"Conditional Pass"section need to be replaced or repaired The sys ,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not det (Y,N,ND)in the following statements.N"not determined"please explain. The septic tank is metal and 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration exfilhation or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying 'c tank as approved by the Board of Health. *A metal septic tank will pass inspection if it structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old vailable. ND explain: Observation of sewage backup or break out or high c water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distnb 'on box System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or repla The system required pumping more than 4 tunes a year due to broken or obstru ed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 'l ev \ Owner's Name: P Owner's Address: . Da of Inspection: //� - 7 — O C. her Evaluation is Required by the Board of Health: Conditions hick require further evaluation by the Hoard of Health in order to determine if the system is failing to protect public sty or the environment. 1. System will pass unless Board of 199&4etermines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner w rotect 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 we r a salt marsh 2. yytem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste unctioning in a manner that protects the public health,safety and environment: _ the syste a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supp butary to a surface water supply. The system has a septic tank AS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS an AS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is 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 certiii ratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollu from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,PlbW that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other., OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: r �✓ rv! G Owner's Name•_ Wj/bv,-' SIa rs Owner's Address: Date of Inspection: AP- 7-G`'/ D. System Failure Criteria applicable to all systems: You pud indicate"yes"or"no"to each of the following for all inspections: Yes No V"backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool v ischarge 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''/z day flow _Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped t/Xny 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. _6,4iiy 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 N the well water analysis, 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.] (Yes/No)The system f1 .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 Hoard of Health to determine what will be necessary to correct the failure. E, arge Systems: To onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must 'cate either`yes"or"no"to each of the following: (The followin 'teria apply to large systems in addition to the criteria above) yes no the system is wi ' 400 feet of a surface drinking water supply _ — the system is within 200 t of a tributary to a surface drinking water supply — _ the system is located in a nitroge five area(Interim Wellhead Protection Area-IWPA)or a mapped I, Zone R of a public water supply we If you have answered"yes"to any question in Sectio the system is considered a significant threat,or answered "yes"in Section D above the large system has failed, owner or operator of any large system considered a significant threat under Section E or failed under Section upgrade the system in accordance with 310 CUR Page 5 of I 1 OFFICIAL INSPECTION_FORM-NOT FOR VOLUNTARY ASSESSMEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / CHECKLIST Property Address: ��v�t✓vr /I�fG Owner:�i ✓� L o Date of Inspection: /p— 7 — D Check if the following have been done.You must indicate"yes"or"no"as to each of the following- Yes Now ri Pumping information was provided by the owner,occupant,or Board of Health ere any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ���e 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 brepk out? Were all system components, e 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? _ 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. 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(3)(b)] F 5 • Page 6 of 11 OFFICIAL INSPE CTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner's Name: Vol Owner's Address: Date of inspection• RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):.,Z Number of current residents: 7— Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):,4, j[if yes Separate inspection required] Laundry system inspected(yes or no): AV Seasonal use: (yes or no):.8,V Water meter readings,if available(last 2 years usage � y/,G� y� g Sump pump(yes or no): ( )): �t3�yy,oov�a Last date of occupancy: Cof IE4 COMMERCIAIANDUSTRIAL: e of establishment: gn flow(based on 310 CMR 15.203): p,t Bast design flow(seats/persons/sq%etc.): Grease ent(yes or no):— Industrial w lding tank present(yes or no): Non-sanitary waste ed to the Title S system(yes or no):—Water meter readings,if ay Last date of occupancy/use: OTHER(describe): Pumping GENERAL INFO TION p g Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:,gallons--How was quantit�poumped determined? t Reason for pumping: x1� TYPE OF SYSTEM Septic tank,distribution box, soil absorption system Single cesspool Overflow oesepeel 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 froth system owner) _Tight tank _Attach a copy of the DEP approval ____,Other(describe): Approximate age of all components,date installed(if]mown)and source of information: 0 AI Were sewage odors detected when arriving at the site(ves or no): v Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address:. <-,�5� Ito Owner's Name: r Owner's Address: Date of Inspection: t b - '7 —D L( ILDING SEWER(locate on site plan) Depth ade: Materials of co on:_cast iron 40 PVC_other(explain): Distance from private ly well or suction line: Comments(on condition of jo venting,evidence of leakage,etc.): SE C TANK:_(locate on site plan) Depth Belo ade: Material of co edon:_concrete_metal fiberglass_polyethylene other(explaui If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee baffle: Distance from bottom of scum to bottom of outl or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and ou t tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREAS TRAP:_(locate on site plan) Depth below e:_ Material of cons 'on:_concrete metal_fiberglass_polyethylene,other (explain): Dimensions: Scum thickness: Distance from top of scum to top oNleakage, e: _ Distance from bottom of scum to b;off or baffle: Date of last pumping: Comments(on pumping recommenutlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMEEN fS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .SS`S I1n-,cmNexr, LAtg- Owner's Name: Owner's Address: Date of Inspection: TI T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth belo Material of cons 'on: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: o Design Flow: gallonst y Alarm present(yes or no): Alarm level: Alarm in working order(yes or no). Date of last pumping. Comments(condition of alarm and float switches,etc.): DI UTION BOX: (if present must be opened)(locate on site plan) Depth of liquid lev outlet invert Comments(note if box is leve 'stnibution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): P CHAMBER:__(locate on site plan) Pumps in wor r(yes or no): Alarms in working order no): Comments(note condition of pump r,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: SS S:�y Owner's Name: Owner's Address: Date of Inspection: 10 - "7 ^ c9�1 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Typed� t/Ieaching pits,number: i 1040 6 C � f l 0" t.v b�1 e leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Typelname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): ` � , ` X, `K 14 �-�M O i 1 S cn tU{11 t lHA S�caA� 1.1 N ( 1/�, ltap F�ti� CESSPOOLS: (cesspool must be pumped a``s``part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Cot( Depth of solids layer: 12�� Depth of scum layer: NK2 Dimensions of cesspool: Materials of construction Indication of groundwater inflow(yes or no) Comments(note condition o sq�' sighs of h draulic failure,level of ponding,condition of vegetation,etc.): 1,�n) cep r) t eG C T1 t�1T n..R ► !c �(4�C� p (locate on site plan) Materials o trucdon: Dimensions: Depth of solids: Comments(note condition o s ' s 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: tiNN '(xj t- �P Owner's Name:_0)%jbq( S 1c K Owner's Address: Date of Inspection: 10 - 7 `O 4 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate when public water supply enters the building. A 6G1. 13 e�ssP�) r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: - , C Owner's Name: Owner's Address: Date of Inspection:_ ID- '7 - o L SITE EXAM Slope:. Leo P1 Surface water%&,,)(7 Check cellar: A,)0 Shallow wells ,J� Estimated depth to ground water-k)_feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Hoard 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: Ac,.90 A-,9 Vv- loci c 1 c X&O kcv ko ►30 G w i=Ncc;kD-J-k-C-1 Q 6 AS LOT 117 6 59 Nw�. LOT 2 LOT I �\✓SHED c9 ,r 9 LL �►s��o� \ o,�w N 2�0;:'3:;:; �. � 18 �03 0Plan ? RES. ZONE.- "RD-1" This MORTGAGE INSPECTION Bank 'UseoOnly FLOOD ZONE.- "C" THE DISTANCES AND MEASUREMENTS ON THIS PLAN SHOULD BE VERIFIED BY AN INSTRUMENT SURVEY. TOWN: — REGISTRY OWNER: _EBjC N1YILVG 9di DEED REF: __,5_Z09 37_ _ BUYER: _XSER-5— DATE: _4Z1 QZ_00_ — _ PLAN REF: 402 —m SCALE.V' S0 _FT. I HEREBY .CERTIFY TO STEi74.EY_�L_ FVL------ YANKEE SURVEY ___THAT THE BUILDING SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS CONSULTANTS SHOWN AND THAT ITS POSITION DOES _ CONFORMr� TO THE ZONING LAW SETBACK REQUIREMENTS OF THE 40B (SUITE 1) TOWN OF ---RARVfZA�.�'_____________AND THAT "+O INDUSTRY ROAD IT.:DOES_NOT_ LIE WITHIN THE SPECIAL FLOOD HAZARD . MARSTONS MILLS, MA 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED_8f�,1_6j__ TEL• 488-0055 unit —Ranel 11 250001 0005 C w FAX 420-5553 _____ THIS PLAN NOT MADE FROM AN INSTRUMENT SURVEY 28789 CB L A MERE PLS� NOT TO BE USED FOR FENCES BUILDING PERMITS ETC. .......... ....... • COMMONWEALTH OF MASSACHUSETTS .. .::... . .. . EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ' Property Address: 555 PHINNYS LANE CENTERVILLE Name of Owner ERIC CUNNINGHAM Address of Owner: SAME Date of Inspection: 8/26199 ` p Name of Inspector:(Please Print)JOHN GRACI I SF�y "ee lama DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) 1 Company Name: n/a T 'O,c ° r9y9 Mailing Address: n/a Telephone Number: n/a Z CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Eva on By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:9/2/99 The System Inspector,shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. f 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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY ONE TO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2198 Page 1 of 11 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 555 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/26199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced n/a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 555 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/26/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nLa_(approximation not valid). 3) OTHER nLa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 555 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/26/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n(a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 666 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/26/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 565 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/25/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-M g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: 220 Number of current residents:Q Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):JLQ Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): n/a Sump Pump(yes or no): NO Last date of occupancy: 811198 COMMERCIAL/INDUSTRIAL Type of establishment: n!a Design flow: Wa gpd(Based on 15.203) Basis of design flow: n/a Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):MO Water meter readings.if available:n/a Last date of occupancy: nLa OTHER: (Describe) Wa Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: 1996 System pumped as part of inspection:(yes or no):MQ If yes,volume pumped n/a_ gallons Reason for pumping: n/a TYPE OF SYSTEM X Septic tank/distribution boxisoil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n/A APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM.IS OVER 30 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 565 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/26/99 BUILDING SEWER: (Locate on site plan) Depth below grade: IE Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: n& Comments: (condition of joints,venting,evidence of leakage,etc.) n& SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No nLa Dimensions: 676'BLOCK CESSPOOLS-EMPTY Sludge depth: nLa Distance from top of sludge to bottom of outlet tee or baffle: Wa Scum thickness:jVa Distance from top of scum to top of outlet tee or baffle:ltLa Distance from bottom of scum to bottom of outlet tee or baffle: Wa How dimensions were determined: MEASURED 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.) MAIN CESSPOOL AND ALL COMPONENT ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM FOR MAINTENANCE EVER YEAR. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) D& Dimensions: Wa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:ji& Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: n& 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.) Wit revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 555 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/25/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n& Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) Dimensions: n& Capacity: nta gallons Design flow: nLa gallons/day Alarm present: NO Alarm level:jita- Alarm in working order:Yes—No—: NO Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 666 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/26/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: 11111 Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: _nLa leaching galleries,number: 111a leaching trenches,number,length: n/a leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: Wa Name of Technology: _i/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION PIT HAS NOT HAD MORET CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: Wa Depth of scum layer. n/a Dimensions of cesspool: n& Materials of construction: n/a Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)nta Comments: (note condition of soil,signs.of hydraulic failure,level of ponding,condition of vegetation,etc.) Wit PRIVY: _ (locate on site plan) Materials of construction:n/a Dimensions:Wa Depth of solids: WA Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n1A revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 555 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/25199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a R O .rp q� revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 555 PHINNYS LANE CENTERVILLE Owner: ERIC CUNNINGHAM Date of Inspection:8/25/99 NRCS Report name: xi& Soil Type: n/a Typical depth to groundwater: n(a USGS Date website visited: Wa Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers XUsed USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 I TOWN OF BA.RNSTABLE LOCATION PI % t W GE # Vr�IULAGE ASSESSOR'S N & ��� �— INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACIL=: (type) 01 (size) fed NO. OF BEDROOMS BUILDER OR OWNER `Co PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by \J I} 44 y� � g LOCATIO SEWAGE PERMIT NO. ks,6,, -IN1 ro n FBI I-5 kan VILLAGE �-Q-�pf -0t.j�� 1 STA LLER'S NAME & ADDRESS P f-ffqOOfnbeL+ R U I L D E R OR R 4��o + DATE PERMIT ISSUED -rc7- � DAT E COMPLIANCE ISSUED - 27�7�, c!+ `s 1V0 .. �-t--.. 1-- Fss............. ............_. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ,0-low� /3�.a�v.s ... _...................OF............ T9 jGG liration for Uigpoiitt1 Workii Cnonianu#inn Vamit Application is hereby made for a Permit to Construct (,,—) or Repair ( ) an Individual Sewage Dis System at: 5i gas Z v :'-G-�'TL72 V/GG&' ........:<. ....... . ........................................................................ ......� ....•----.........---. ...-•------------....... -._........---•--------- Location-Address or Lot No. q M' TGs72✓iC LG.... - .................. ...... _._.. ........------...._....•...._..._..._...... Owner P b'0�Gam/ Address.................. ..........••••--.............................•....... W Installer Address Type of Building Size Lot...__...-.,..Z. .....Sq. feet Dwelling—No. of Bedrooms............ 3............................Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Type of Building ............................ No. of persons-_----___-__-_•_-•-..__-__-_ Showers ( ) — Cafeteria ( ) a Other fixtures ..------•----•---••-----•--•-.---- W Design Flow................ ...........................gallons per person per day. Total daily flow.....................3-`-'__ ............gallons. 04 Septic Tank—Liquid*capacity.lo4a.gallons Length__B"K Width__46_,'I.. Diameter---------------- Depth...-3- Disposal Trench—No. -------1.......... Width....... e!�� Total Length..... ...... Total leaching area----3ei.....sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area............--....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ Percolation Test Results Performed by._..c�..?!��......_G.:.._. �'Z-�-GY............. Date--- �;t_ �� .. ,tea Test Pit No. 1... .. ...minutes per inch Depth of Test Pit.... .. Depth to ground water........................ Test Pit No. 2... _._minutes per inch Depth of Test Pit......!2-6..... Depth to ground water....../!8........ Q+' ---•----•------------------••-•---.................. ------ `�j�S o�G 4 :n.v4 4a/ s C ' /f o ............... ... .. _. .....r ......................................................................... W ........................................................................•.--••--•-•--_............._.._.........__---------_...._................_...._.............._........_.._........._.__..._..... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •--------------------------------------••...-••-••-•----•-••--------------••••-•---......----•--------------------••----••------•••••-••---•----••--•--••••--•-•-•-••---•.............................. Agreement: The undersigned agrees to, install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLr: 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until .Certificate of Co pliance has b issued by he board of h t . � Z igne � k........... D e _APP-icati�n`'Approved By...................... Q 4 / D to Application Disapproved for the follo i g reasons:................................. ..............••----...........----•--------•-----•--------...................-------•••-••••-------•---•-•-••--•....---•••••-•-•••-•--••---•--•-•--------•-•-•--••••---•--••••--•-----••----•--•-.----- Date Permit No.---...... -_ Issued Date ---------------------------------------------------------- - z THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... OF...... - f�•, ��y,Zc-' ----------------------------------------• Appliratiun for Disposal Works Tonst.rudiun Prrutft Application is hereby made for a Permit to Construct (--) or Repair ( ) an Individual Sewage Disposal System at: l/ 1�/GCS............. ...................... .. ..Location-Address ............ ......................................_.. or Lot No. G �C/rti /emu�� �" TC 71v/LC G W •- .....__... _ -.--------.-'Owner...... ................................. .......... ......._......Address......................._................ ............................................................... �:� tr........-• ----...---••---------------...................----......--•---.................................--- Installer Address Type of Building Size Lot.... �-`-/2..--.Sq. feet U Dwelling—No. of Bedrooms..............3...........................Expansion Attic ( ) Garbage Grinder ( ) a'14 Other—T e of Building ....... No. of persons............................ Showers YP g ..................... p ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------....---....---------........------......---------------- ...... W Design Flow................. ........................... per person per day. Total dail� flow..........--........_..._......._.........gallons. WSeptic Tank—Liquid capacity..Iej? gallons Length... ......._.. Width...`....... Diameter................ Depth................ x Disposal Trench—No......_./........... Width.......�O,_._.. Total Length...... r'....... Total leaching area...................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. ZOther Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b ._... '' "'?��..__L.:... �:-LLG1` f /.S"- �7��_ aY . . - /....--.._... Date ......,................ ,_a Test,. Pit No. I....<..z-..minutes per inch Depth of Test Pit.....` �...... Depth to ground water........................ (i Test Pit No. 2.... .. _..minutes per inch Depth of Test Pit.......1z........ Depth to,'ground water....../!.°'`'.... ....-------•----------------------------------•--.........-----.....-••••-...._..---..............VD Description ...of A '_- /L" ..... /. .,"S//cy. -- ..........................r..�...i.�.�... �.......•-u---¢--•-'•-°-----�--o--.l-.-.-�.-r.-�---�...�......-s-•-,..�.-.-..,...�...--.�-.-- �-•-• u4"- / " 2 i_..S&2 ---------------------------- •W ---------------- --------------------------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------------------------------•--•----------------•---------------------------------------------•----------.......-----------......_.....---_.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in oo ern ation until ar Certificate of Co pliance has been issued by the board of health. at - .......... Application Approved By.............. 4 ..ee ''.L��. V�_ .. ....� `��..Q Application Disapproved for the folio * reasons:........................•--•----.........---•--.....---•-------••-----•-••-......--•--••••D••.........___ .............................•---------------•----....---------------------•--------------.....-----.........•........---------•------------•----------------------.......-----.....------........---Daft - Permit No........... ... . -r�-4 ....___ Issued............................................ .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............TO t,��/ O F.........: �/rac NSlis7 G3 G& . ......................... ................................................................. Tatif rate of Tamplianrr THIS IS TO)CERTIFY, Ttat (th�vidual Sewage Disposal System constructed ( L-6r Repaired ( ) by..........--•-...--••••.... . S.�SI L. ..... ...........Installer ........................................................•...-.................. ._...._ at.............................. ©------.-.L..r�.l_.iVN _.. - L►U..1 r...`!�I�' ................................................. has been installed in accordance with the provisions of TIT F of The State Sanitary Code as�iesc bed in the application for Disposal Works Construction Permit No.--._._]L- F.G. .---z-`{---.-.-.. dated___......-1";.!_((-J�--- ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA TO Y. DATE.......................................... ....1...6 --47�_•---_. Inspector.................................................................................... W 01fHE COMMONWEALTH OF MASSACHUSETTS GAME P-V'5f_ 2-.'V5-rtIIfi'1.o ov BOARD OF HEALTH I cocR-rtll wn -rP(iE w�Rk walt�$tJ-g.du G .........................................../ / OF...............!�'��%?../......? C�G t`' j cac Disposal orks onu tu#ion "rrutif Permission is hereby granted.............: . ...ralSewage .:......._.._.. --................-----..................---................___.. to Construct ( t,?or Repair ( ) an Indivi Disposal System atNo............. ........ Street as shown on the application for Disposal Works Construction Permit No....a3-�:�'�... Dated.......... 1 o...-:;?C............ :_... DATE.............. of Heal FORM 1255 A. M. ULKIN, INC., BOSTON 4% z '— IN �. .- PApO,00sea Ao 1 No7� EZ�wATto•✓s l3As�a oh/ `S'/7-er /�1�9N S�`791 LaWdL .f" LOCATION .C&-A'i0r4'o:ViGG� SCALE . e. its o i . . DATE PLAN REFERENCE -V G. S.4bw•v o.v .f�. .B�. �z E- = . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CD �� EY E., p . 26100 1 CERTIFY THAT THE ... ....:. . ...... . �fClSTiR�� ' SHOWN ON THIS PLAN iS LDCATED ON THE AROUND ` L'�N� � AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF . . . . . .. . . . . . . . . . . .. . . . . .. WHEN CONSTRUCTED. DATE � . . . . . . . . . .. . L,4v G?: t§'E�9t��'fo.c�T_ ,��TiTio•t/�:�' REGISTERED LAND SURVEYOR z 5 TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 4"CAST IRON 2"MAX '7nn17pJ1 , OR SCHEDULE 48 4��SCHEDULE 40 P.V.C.(ONLY) 12 MA_—" ° X. P.V.C. PIPE PITCH I/4"PER.F PIPE - MIN, • T PITCH 1/4"PER.FT. 7KWC# c �o•X 3a PRECAST ,'. INVERT w• V •. F4.w- • 7 e&e DiG1'uso2s •e EL. SEPTIC SEPTIC TANK INVERT DIST. INVERT ? Few 4:; (3 9 .) °l' EL.... :GG. EL..$ ; DiCFvsoas INVERT BOX •e; EL. 8,3, /oe�o••• GAL. INVERT¢ INVERT ' 'is 3/4��TO I I/2 EL`i . I E Of,.o. WASHED /D 1 , ;� STONE s2.9fio7 •• .., Az f 3-3,87 PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE 9�e� iis.p lo'BEyo"o To SOIL 'LOG WITNESSED BY : DATE 1NGY !S TIME. for 34.�7 T'`�!> B.• .� `��^! BOARD OF HEALTH TEST HOLE I TEST HOLE 2 �'a`/ /� /LL-ZG�/ ENGINEER ELEV. . . '�Ic?. . ELEV. Td` O�e/Y+�j woo��oAYj •56,L s� s„ DESIGN DATA : 48 Z4o•90 �' 397o NUMBER OF BEDROOMS -3 �o 46+Y �R,-rSE he. 38,7a TOTAL ESTIMATED FLOW 330 • • GALLONS/DAY SAS D ` Cos►n,5',�-;' BOTTOM LEACHING AREA 30? . . . SQ.FT. /PITIC,RD. bZ. 3 7 90 PquC�n �" Sq�D q� SIDE LEACHING AREA . . . 8a . . SQ.FT./ PIT/zoo �/�iZ3Ls iiB ", L j3B� GARBAGE bISPOSAL AA!`✓.E'. ,(50 % AREA INCREASE) CRAV&L TOTAL LEACHING AREA . SQ.FT &,'' 33,?' /Z�" �Z. 33.Zc PERCOLATION RATE Al -SA 7;11191v 71✓v . MIN/INCH Darr _ _ _ �18 WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .S�.. SQ.FT/G,PP. .... Y. NUMBER OF LEACHING PITS-f�, ? ��1 APPROVED , . . . . . . . . . . BOARD OF HEALTH �q •�i2� ��"/•- D!f vSo2S DATE . . . . . . •AGENT OR INSPECTOR 0 ,. tH OF iF+�ss `-7�' o ED1 / aRv0 os �g GEC// Z- ,.F 1r. •.' V 5 H -o o a1=LLEY y No. 26100 Q ER�IZZ) �s�DH4L i�¢a05 sannAR�a�' PETITIONER B 7— / t j 1 AP— t'f r'f It Is ill, s HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 3 L4-^l99' T�72V/GGG' Lot No. �z Owner: Address: Contractor: Address: Notes: STEP 1 Measure depth to water table 9 8 tonearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..7 date STEP 2 Using Water-Level Range Zone and . Index Well Nap locate . site and, determine: /a_I tN 247 A) Appropriate index well . . . . B) ►dater-level range zone .Z°^.... . fC p:4� L STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well . . _ . . . 7/8.5' mo yr STEP >a ` Using Table of Water-level Adjustments for index well STEP 2A , current depth to water level for index well (STEP 3) , and water-level zone (STEP 2B) determine - z ; water-level adjustment ' . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . • • . . ' STEP S Estinate depth to high water by subtracting the water- level adjustment (STEP 4) "from measured depth to water G level at site (STEP 1) . . . Figure 3 • r r �7� by , EDWARD E. KELLEY REG. LAND SURVEYOR CUMMAQUID, MASS. 02637 TEL : (617) 362-2266 Town of Barnstable Oct. 15, 1986 Board of Health Hyannis, Mass. Ref; Leo E. Beaumont, lot # 2, Phinney' s Lane , Centerville The sewage system was installed with only a slight variation in location and a slightly- higher grade than the approved plan. It was installed in existing pervious material; therefore the ten foot excavation was not required. It meets all requirements of Title V and the Town of Barnstable Health re ons. .== OF OF MQ No 7 �O EDWARD �Gs 9 E. LL q No,261000 Sghi p Reg. na ian Reg. Pr � ' �rs4 � Land Su LAWb�' APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITSr LOCATION StSa'O�.S N0. VILLAGE Ap DATE APPLICANT FEE �— ADDRESS- . SSS JAI 04 AAIA TELEPHONE NO. - / (Non-refundable ENGINEER TELEPHON NO. DATE SCHEDULED — ' T- (Applicant' s signature.) . . . . . . . 00vooe . o . 0000e . . 00 . . . 000 . 000 . . . . . . o . . . o . . . o . . . . 00 . o . . . . . . . o . o . . . . . . . . . . . . . SOIL LOG SUB-DIVISION NAME DATET TIME 9 ;3Q ,,,9/1-1 EXPANSION AREA: .YE$ NO__.;. _ �/�L/�" % ENGINEER--:!: TOWN WATER A,- PRIVATE WELL Aim ������ BOARD OF HEALTH ALxjee p '41 C71.9 EXCAVATOR SKETCH: (Street name,etc. ,dimensions :')of lot, exact location of test holes and percolation .tests, -locaf-ewetlands .in proximity to test holes) s • NOTES: k j �1 . 6. aTO2 p n a o r y 'S L.�A-0 PERCOLATION RATE: TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: Z 1 I w ovD 2 kj vo 0 2 L o"q� o�/rr . 3 a` 3 Sc.pSo/G g.-'' 4 SGQ So/G �!97 5 0'' �•C,9y ,i 6 fr'/LNG� G 6 �'o t $-4l 00 8 8 C0�92Se 9 9 �BG ,, 12 12 13 13 14 14 15 1 15 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENC, ES7- UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON• PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P . E. AND RETURNED TO BOARD OF HEALTH ' Copy: RETAINED BY APPLICANT .III Uj t i xqk;t4f, Op � � . 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'�..... .. a •, I , ` - .: �. r, x ',x b,.w -,. ` { i ,.:Z..:� ,S-L.�:. -w co.6ta.w a- ..y -.�.--* k sr � z rt / u.'r. � a b f ,`fir 1: S t'k 4 `.n - 'a - 3e -se w i ( µ 4 d j ,, 1. Yx . .. +fir '' f ; f a ASSESSORS MAP : TEST HOLE L OGS \ PARCEL - I c� - - - _ - - SOIL EVALUATOR:—mil MIA ( NOTES: FLOOD ZONE: L 1 V�PPU1VGAtg- - WITNESS : l/3�/ REFERENCE: C-COnF1� � -F DATE: \ - - - 1) The installation shall comply with Title V and Town of Barnstable Board of T4�4zxyl -S�\/ - . PERCOLATION RATE: -L, 6tJt t- ' Health Regulations. Car��5v�7?9kTT� ' t�J 0 l Ni 2) The installer shall verify the location of utilities, sewer inverts and septic wct ___ TH- i TH-2 components prior to installation and setting base elevations. ZDOw"-� 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. Aft. /a �� 4) This plan is;not to be utilized for property line determination nor any other f fl 6*46 purpose other than the proposed system installation. r io �, 0, /D G 1 b,l 5) All septic components must meet Title V specifications. '4-0 I �0 c 1*0 6) Parking shall not be constructed over H10 septic components. LOCATION MAP C ,i,lj, Gr ,�Y� G! �o// 7) The property is bounded by property corners and property lines. F �� r /� d 8) The property owner shall review design considerations to approve of total 0q design flow and number of bedrooms to be considered for design. Receipt of IAAJO payment for;the plan and installation based on the plan shall be deemed ` /b approval of the design flow by the owner. / ! 9) The existing cesspool(s) shall be pumped and filled with material per Title V �q abandonment procedures. Those within the proposed SAS shall be removed 3Z 1 f 3� cJ� I along with con:aminated soil and replaced with clean washed sand per Title V o G�vO. _.� ���- �o ��✓� w�L g P specs. 10)System components to be 10 feet from water line. SEPTI. S I GN 11) If a garbage grinder exists it is to be removed and is the responsibility of the � SYSTEM DE owner to ensure such. i FLOW ESTIMATE ' BEDROOMS AT 1 lO GAL/DAY/BEDROOM - ✓ GAL/DAY o� (0� SEPTIC TANK GAUDAY x 2 DAYS - GAL USE 1L' D GALLON SEPTIC TANK SOIL A3SORPT I ON SYSTEM Lj Al `vTDWc AQ'00�-k-10 SIDE AREA: Z�c �1 1 a X -2 r* /1 BOTTOM AREA: O1� 4, SEPT I C. SYSTEM SECTION ( ,I,S, �► ►� °� -10 °? --XX'.AbrkAq --� 1500 GAL SEPTIC TANK _-ay .�' 1 77ovO"'L � _ k,)4— vc.t -RT fLreV, 671 SITE AND SEWAGE PLAN LOCATION : PREPARED FOR : , M SCALE: DAV 1 D B . MASOW�� DATE: (( I DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA 3 DATE HEALTH AGENT ( 50 ) 833- 2 177 {y Z