The URL can be used to link to this page

Home My WebLink About0903 PHINNEY'S LANE - Health 903 Phinn.ey's Lane Centerville A= 252 — 172 m o OPendafie)C a Esselte 4210113 0RA 100/6 K r a { Commonwealth of Massachusetts CP1 01 .: (.,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c / ; � � 903 PHINNEY'S LANE r Property Address JOEL COOPER _ Owner Owner's Name information is CENTERVILLE required for every MA 02632 6/24/2020 page, City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When e A. Inspector Information filling out forms p on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Ca a Cod Se tic Services use the return -- p-- key. Company Name 350 Main St. Company Address W Yarmouth MA 02673 City/Town State Zip Code retwn 508-775_2825 � SI-14423 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting inspection this ins I have determined that the system: p ned 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails L - - %1:7i�c� ` 7/17/2020 Inspector's Si ture 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE required for every MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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 IS IN WORKING CONDITION 2) 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, Ni 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 • Commonwealth of Massachusetts - Title 5 Official Inspection Form j^ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE required for every MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in 9 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 • Commonwealth of Massachusetts x - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE required for every MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is every CENTERVILLE required for eve MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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. 0 ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 Lmins�.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form = Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE required for every MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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. ® 0 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE required for every MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): '19-24 GPD Detail: '18 - 19GPD Sump pump? ❑ Yes ® No Last date of occupancy: SEASONAL Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 7 of 18 Commonwealth of Massachusetts — Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE required for every _- __ MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: — — Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r c 4 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name isrequired for every very CENTERVILLE MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 LLN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE required for every MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 211 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain) If tank is metal, list.age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLONS ' Sludge depth: 211 Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 2" BELOW GRADE I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts � - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is required for every CENTERVILLE MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 y ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts -, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is _ required for every CENTERVILLE MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert EVEN 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE required for every ____.__ MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6X6 PIT ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 N Commonwealth of Massachusetts --11 Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE required for every MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6X6 PIT WITH STONE FOUND DRY DURING INSPECTION WITH NO EVIDENT STAINING. COVER IS 5" BELOW GRADE 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , �• 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information isequired or every CENTERVILLE MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): i I 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name -- information is CENTERVILLE required for every _ MA 02632 6/24/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 1 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts --� Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 903 PHINNEY'S LANE V Property Address JOEL COOPER Owner Owner's Name required for is y CENTERVILLE required for ever MA 02632 6/24/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +11, 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: ASBUILT CA_ RD ON FILE AT BOH DATED 10/5/2007 ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: ASBUILT CARD ON FILE AT BOH SHOWS MAXIMUM ADJUSTED GROUNDWATER TABLE TO THE BOTTOM OF LEACHING FACILITY AT 44 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 903 PHINNEY'S LANE Property Address JOEL COOPER Owner Owner's Name information is CENTERVILLE __ required for every MA 02632 _ 6/.24/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached . For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System Page 18 of 18 deck A g3j.,a PST' • t https:/itownofbarnstable.us/Departments/Assessing/Property Values/HMdisplay.asp?mappar=252172&seq=1 1/2 l J q TOWN OF BARNSTABLE LOCATION 01 ?4,N4e-V%1 IAJ C SEWAGE# 2o07— 9 ti VILLAGE CC=N�,�►.,L.L ASSESSOR'S MAP&PARCEL 2SZ 72- INSTALLERS NAME&PHONE NO. PvL 19-Am', 2 3 7 516 SEPTIC TANK CAPACITY (000 LEACHING FACILITY:(type) pi r ask�irw�� (size) 6 k NO.OF BEDROOMS Z. OWNER v L S PERMIT DATE: (O- COMPLIANCE DATE: Separation Distance Between the: , Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility y t Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) 100 Feet Edge of Wetland and Leachi (If any wetlands exist r c within 300 feet cility /°y Feet FURNISHED B Z deck A 3�.q, .o' d� c y • , 30. �� C,F,ac,K C�cw, V No. 7 Fee L THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _•�� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for atgoar 6p9tem Corgi%truction Vertu Application for a Permit to Construct( ) RepairW Upgrade( ) Abandon( ) ❑.Complete SystemA!'Individual Components Location Address or Lot No. q03 �F}��N�,`S LAJ£ Ow is Name,Address,and Tel.No. Cel.rlfk H�.�G- S Ht-A Assessor'sMap/Parcel 252— Nox -70 (,PjT94_v1". O26�Z Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. RVL rj�,,R7bj �5.:r SaZ okt-tgNvs ou'53 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 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) 99AALc b.—i'm,,Y RrP�a.� ��}}�,p 3o _ P.o,�t,. CC7W_�J �N�.Ifti �,.1� w� ,f c.►-�-,e �� P1P1.�4.- 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 t s B ard o ealth. Signed Date 0c.107 Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. , )- 4K(-i 9 Date Issued J " r No. ..260 71_K Fee t/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Apprtcatton for attpozar *pttemc Conslructton �Oermtt ' Application for a Permit to Construct O RepairW Upgrade O Abandon O EJ Complete System-P<l Individual Components Location Address or Lot No. . ' Owner's Name,Address,and Tel.No. i Cen+ K✓i'.t.0 A 4. SHto Assessor'sMap/Parcel 252- 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 ( ) I Other Type of Building No.of Persons Showers( ) Cafeteria( ) u Other Fixtures Design Flow(min.required) gpd Design flow provided d gp Plan Date Number of sheets Revision Date . Title Size of Septic Tank Type of S.A.S. III Description of Soil", Nature of Repairs or Alterations(Answer when applicable) 11`f CA L E" -04ax c..t �A n --•p,P94b- ZIC> PIP11-4r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in jaccordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of s Compliance has been issued by th s B rd o -ealth. Signed Date Oc% -7 Application Approved by V /l _ - Date- Application Disapproved by: Date for the following reasons ti Permit No._�� e y V Date Issued o THE COMMONWEALTH OF MASSACHUSETTS A,� t l Q t1 BARNSTABLE, MASSACHUSETTS Certtftcate of Compliance THIS IS TO CERTIFY,that the_On-s�.te Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( ) Abandoned( )by ?Ajkd�_ at 1?P73 p}tk,"I,V'S (.We has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 24;u-7 - y Y& dated 13JO Installer Avg. �tn,.J Designer #bedrooms Approved design flow gpd I The issuance of this permit shall not be construed as a guarantee that the system will functio as desig ed. I' Date Inspector42 XY ——�-—————————————————————— . -- No. Fee THE COMMONWEALTH OF MASSACHUSETTS i PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS t� 'gal 6p5tem Con5tructton V ermtt Permission is hereby granted to Construct ( ) Repair O Upgrade ( ) Abandon ( ) System located at 103 r-v `3 C A�cf and\as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Con truction must be completed within three years of the date of th p i Date /V7 Approved by I r' (7) 213/ � LO CATION SEWAGE PERMIT N0. VILLAGE ��,�� INSTA LLER'S A i ADDRESS B U I L D E R OR ;ea f'. 1,4�, DATE PERMIT ISSUED DATE COMPLIANCE ISSUEDr � -- �' �' f ct; �9 No.--...................... Fas..... 5..-'...... t THE COMMONWEALTH OF MASSACHUSETTS i� BOARD OF HEALTH _.... . .............OF.....I, . i��..:.............. ................... Appfiraliun -fur M.ipuutt1 Workii Tonstrurtiutt Vrrmft Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: .1SA L.:o.c onde t7. W —ri-LAOw er y -----------'---------- .. N ....... A � _ Installer Addressf.{ ' Q Type of Building !C` Size Lot8/J_S�q±Sq. feet Dwelling—No. of Bedrooms --------------------=--Ex Expansion Attic ----- p ( ) Garbage Grinder (X,) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ----- ....................* Design Flow--------7. 7t�.............___gallons per person-p�r dy. Total daily flew...----__2v _._______....--... 1�lons. N W Septic Tank—Liquid capacit�r792-gallons Length! __..�!_.. Width _ -�}_._ Diameter_-- -____ Depth.._.__. 47 - x Disposal Trench—No. .................... Width�__..__y-----__--- Total Length--__-___T_...._..._ Total leaching area--------------------sq. ft. Seepage Pit No._47PA...... Diameter__ 0__:' -------.Depth belo inlet_(..: .' __ Total leaching area._4So_7---sq. ft. Other Distribution box ( ) Dosing tank ( �/ o�se> Y �: Percolation Test Results ZLTf&w=d b Av4-.__ 4.ylleDate a Y �------------------- ---- r 7 Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water..-.--_.--_---.-_.------ f14 Test'Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_.--.----._---.---_---- W ------------- -- 4 - - . ..._- O -- -- ------ ------ ----------------- - ....__ _ -� :_Description of Soil � ::.:.::::.:::-------------------------------------a '=_/� -- •- --- ----- � _-_ : : : W x V 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 Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued b7y�the boar ealth. S• l� igned -•• -----•.......---- --- ------------............................ ,J ) `^ / Date Application Approved BY---------= --- - -- -- - - ---- - -- --�- - --�`�-�----------- Date Application Disapproved for the following reasons----------------------------------------------------------------------- ......................................... Date Permit No..........................................----------- .. Issued.__�`�� .................. Date .. Lf n'' t s � t � __ I ... - 1 ....T.-___Z . Nay.. ••-••- low Fins.............................. THE COMMONWEALTH OF MASSACHUSETTS �0ARD 0 F HEALTH _. _ _..OF..... VyFlolti"= " Apphratiun -for Bitipm5al Works Towitrurtion Vanift Application is hereby'made for a Permit to Constructa�{ or Repair ( } an Individual' Sewage Disposal System at: ----- •-.---U----• t` ----- ----- --•-•-•-•-• �fp.l9 !i � _ .--• ddr�s� 1 12... /......... `� ( / /t � ��,�' Installer f Address Q Type f Builcfir '0 1 O ,` Size Lot_81 ._ Q q. feet U Dwelling —,No. of Bedrooms________ ____ _________ Expansion Attic ( ) Garbage Grinder (x) k p, Other—Type of Building ............._-___-__-_-_- No. of persons...-_-_._-__-_-___---__..__ Showers ( ) — Cafeteria ( ) a' y Other fixtures ______________________ ___ t,Q -------- -•-----------••-•------------------- -------------_.-•------------••-- -- WDestgn>Flow_<_-- _.{ -- -- --------------gallons per person per da . Total dV .Pew_____--__��___Da______-__._-•_------g llonsy �- Septic Tank—Liquid capacit�.Sa�?tllons Lengtl lJ^S�___ �t'idth. ._..... ..... Diameter..`........._ Dept1L�)..� x Disposal Trench , No---------------------- Widtl ------------------- Total Length---------- _ Total leachingarea-.__.--_-_-______s ft. Seepage Pit No C'��r__. Diameter_�O-_. 4t::: Depth below i let_.___ _-_ __-sc ft. p ---•--- Total leaching area 1. z Other Distribution box ( ) Dosin/�� w` >ri4�l•' ., Percolatton Test Results Pub, *---- - f`' ------•----• - Date........ 1 Test Pit No '1'_:__ -__--minutes per inch Depth of Test Pit____________________ Depth to ground water..----.-._.._._---.--..- C� Test Pit No. 2_____ ________minutes per inch' Depth of Test Pit_-.,,,._______------ Depth to ground water-_.-_-,__------.._-_-_ O t 'V.. t . --•--' Description of Soil . *"' � I " J� �-, �` . x -- - U ------------- ---- --- - �47, - 4 ------------------------•__.--_-.._.._._...______-s__-______-_-__-_-,_.____:______-___________,____-._-____,_-_____-_.____-,-.__-__..____--__-_.:__-____-_-__-..._-__.-..__._-____--_.-----___--_-_-... U Nature of Repairs or Alterations—Answer when applicable..t......:..............................................___..__._......___.__...-___.___..... -----••--- :._.._..-•---------------- --•------•----------------•-- -1 Agreement tt The undersigned agrees tp 'install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of.the State Sanitary Code—The undersigned further agrees not to place the system in operatidla,until a Certificate of omplianee has been issued by the board: e Ith. ' x r t . t ---------------- te Apphcattb I Approved BY------------- f' d ----- I r�' '' Date Application Disapproved.,f or the following reasons:----------- - --------- ----------------- ---------•----------------------------••-- ......................`............ .........•_-------------== ----------------------------:%--------------------------------------- --Date Permit No....................... ,/ ` /�° •-----• •--•-_. .•.,•--- Issued !! Date THE COMMONWEALTH OF MASSACHUSETTS . BOARD 1Of HEAL,, H ' t : ,. I}1 . r s ' Trrttfiratr off o,M�V` guar %, T S IF TO `C Y, That the Individual Sewage Disposal.System constructed ( ) or'.Repaired ( ) by ' tj• '- f ' at so jR_ ` �__ ._ _._!�- �sr St1Il _ ; , . Chas been install in a rdance with the provisions of : ti I of TIie State Samtary Coele'as:described in the application fo-r Disposal Works Construction Permit No.,+_ -.____ dated _. t►s r._ + r �/ , 0.y 1 * �SSUAN;CE`OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE FIAT THE SYSTEM'WILL FUNCTION SATISFACTORY. 77 DATE- .................................................... Inspector_.._.__-_./ {� -•--- r THE COMMONWEALTH. OFiMASSACHUSETTS r B9 RD PF HEALTH;' _ filar true iit" rr�tit Permission is hereby granted: ( (�" d --•--- ..._.._....•-•--_-•-•- to to Construct' or Rep a ) an I d' id S e DIs oral ste at No._ --•- as shown on the application for Disposal Works Constructiot Per o Dated_ "'a�� ...... r. Board of Healthy DATE. r f FORM 1255"HOBBS-�& WARREN. INC., PUBLISHERS '- S Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM ' 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Jason C. Ellis, R.S. cursor-do not Name of Inspector use the return key. J.C. Ellis Design Co., Inc. Company Name Q P.O. Box 2152 Company Address Brewster MA 02631 City(rown State Zip Code 508-385-2228 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 ❑ Ne4Furtheraluation by the Local Approving Authority September 22, 2007 pecto 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. Shealnspection-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 1 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. CityTrown 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: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Shealnspection•08/06 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 2 of 2 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA . every page. Citylrown State Zip Code Date of Inspection B. Certification (coat.) B) System Conditionally Passes (cont.): ® distribution box is leveled or replaced PIPI-Xj- AM -Tb ��-- ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water. ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects.the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has aseptic 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. Shealnspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. Citylfown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is.less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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: _. ❑ ® 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. Shealnspection-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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 god. 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. Shealnspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA 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? ® E 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)] Shealnspection-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d '07-27 g.p.d. 9 ( Y 9 (gpd)): '06-101 g.p.d. Sump pump? ❑ Yes ® No Last date of occupancy: Several months Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial.waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Shealnspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 ge Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: none 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Certificate of Compliance dated 8-26-1979 Were sewage odors detected when arriving at the site? ❑ Yes ® No Shealnspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments M 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ® cast iron ❑40 PVC ® other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Good condition -schedule 30 from cast iron to tank. Septic Tank(locate on site plan): 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 --------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gallon Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29 +/ <1„ Scum thickness Distance from top of scum to top of outlet tee or baffle 6"+/- Distance from bottom of scum to bottom of outlet tee or baffle 15 +/ How were dimensions determined? measured Shealnspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 903 Phinney's Lane Property Address Paul Shea Owner Owners Name information is required for Barnstable MA 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.): Good condition. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Shealnspection"08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 10 of 10 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box deteriorated -needs to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Shealnspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is. required for Barnstable MA every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): y 1 6'x 6' leach pit with stone. Top of pit 2' below grade. Dry dry when inspected. 'Shealnspection•08/06 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Shealnspection-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 903 Phinney's Lane Property Address Paul Shea Owner Owner's Name information is required for Barnstable MA every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. "'*.ti A 'g �-1jox Prf SC-raytc- �..� 25 ' Se nc. TA..k oar 2�' , Lk'AGH ?iT y�{.5' 31.y SCPT�c i .A W Shealnspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M. bVy� 903 Phinney's Lane Property Address Paul Shea Owner Owners Name information is required for Barnstable MA every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 4'+ below pitfeet 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 and groundwater maps You must describe how you established the high ground water elevation: USGS topo maps show groundwater at el. 34. Ground level at el. 70. 36'+/-to groundwater from existing grade level. Shealnspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 I owy Y'r „ram' 45+ Y ...-_� ,„ •ram'_• S .,..,./ „I +� x- k �+G/ `"„'r F' „:':: � i C..�-"7".'F �:�•y ji y .� �.�g "`...--�• -.-N+"u .,.�, .Y'�*wr"'. ..,�� .,.,.....�..__..,,_. m "'�'«,-,..�� '+.d„',.�r:,....-.__...... .__ _ , - -- .r,... ,.._._.__"..,-••�-„"" • ,,,,..." w,.roLr �+^"yam , � r ✓'9'^{�' F*,�� 1 > r_ , ........... , m4j r� ,r _ i , 1�} t ., •. -- a .r" L „ J , , a .»,••-.+.'P'� ,, � a..r,Nb.:.,.,,-r-.,^• 1p�ii,, r e �tCip 6,"j �w�i�.'iw � `•. j L " ,. < • « 4 d � iw , „ „ .. a I*4f ,..H,ef'• }, " " , " "ti,.-,.,, ✓ `�, •'' L+'-�r � , ,a^.yS.n. .1�... ._. -,.., � , + P" M" .. , t�' "'r� l,:'b•+['L ry ...r__, _...._ - D ,, Y♦` � am t 4 '1 dp M _ 3 ttzjj, Y 2 w..l .: +1 ', 3 - , , , r F 4p :dam ., 4� f�'r � ,i y' 1JT^^x ;,.ySh.,,,,. � "W�'�� 4� 7 - �!�"� `#^a'�:."'m . Y4'"': � -/�•4 4"'.»,.)y��„A�' SOW or- It X r yy + r n k: y , _... "*. .. ,}�, ..•. -_� ,.. y ♦. a ,. �,,,...._� . .,, � ;., .:�"- � �,, itf M« - 1 i 1 r I 1 , , r H r P { , v ' q e 9 f"# n ' F i y r � "•- k ,.. � v � 1. , • r ' , A i , , r � p[ r'M F ys ` 1 v .. V van zoo NP VIA I IN, - ,. , s .r , KK / Y.. .r- , i L s V r' n ♦ k „t r v 1. , »•x � �, �, r r .uell -4 , p r ON ti W a. >.. .. .. .. ..,. to . A p , ,