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HomeMy WebLinkAbout0088 LONGVIEW DRIVE - Health 88 Longview Drive Hyannis II I I Commonwealth of Massachusetts F Title Official Inspection Form r; Subsurface _Sewage Disposal System Form Not for Vol untary luntary Assessments TB �,•, Property Address n® Owner Owner's Name WS® information is ®'aby� /� /9 ., required for every page. City/Town �wS State Zip Code Date of I pectin 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 A. General Information filling out forms on the computer, use only the tab 1 Inspector: key move your cursor-do not use the return key. Name of Inspector ® TCG Company Name o �o aC Company Address City/Town State Zip Code 0? ) C;�� glc;4— Telephon&Wumber 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 approve_d system inspector pursuant to Section 15.340 of Title 5�01R 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspecto 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 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 LO f.� VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is �� �kv0 A4 0a G 3� ®� ® � required for every - �/� '�- 41 page. CitylTown State Zip Code Date of Insp ction Be Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System P sses: I have not found an information which indicates that an of the failure criteria described Y Y in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: IB) 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. El Y ❑ N ❑ ND(Explain below): t5ins.doc-rev.6/16 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 Property Address J " Owner Owner's Name cjeN /T9��_'°®, / �� /� / information is � ,I// required for every e A ®aa Y� page. City/Town State Zip Code Date Anspeition Bo 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.doc•rev.6/16 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 M Property Address y Ownerinformation is Owner's Name required for every page. City/Town State Zip Code Date of Insifection Bo 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 ❑ 2/1" 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 ❑ tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ElLiquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow t5ins.doc-rev.6/16 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 Property Address Owner Ct w information is Owner's Name required for every �w {0'/ o�4 N 4 Sd- page. City/Town State Zip Code Date of I pecti n Bo Certification (coot.) 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. ❑ E?< ny 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.] ❑ e 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M �V Property Address �i I� 1✓0 . Owner Owner's Name information is ` e A14 /�fi required for every b page. City/Town State Zip Code Date of Inspe tion Co Checklist Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes o - ❑ 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? ❑ s the system received normal flows in the previous two week period? ZHave large volumes of water been introduced to the system recently or as part of its 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)] Do System Information 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). �eovl 1.9/4 V7 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 t5ins.doc-rev.6/16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M Sye e Property Address Owner G Owner's Name information is required for every page. City/I own State Zip Code Date of Ins ectio Da System information Description: g0 00, Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ 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 Last date of occupancy: C" 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.doc•rev.6/16 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 M ®P11i PWO �✓ Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Ins ction D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: C;t0 Was system pumped as part of the inspection? ❑ Yes If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sys 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -Z Property Address information is Owner Owner's Name required for every ` i' z// page. City/Town State Zip Code Date of inspfction D. System information (cont.) Approximate age of all components, date installed (if known) and sore of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi�40 ❑ cast iron �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: feet Mater 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: ®� Sludge depth: t t5ins.doc•rev.6116 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 Property Address Gi 89 Owner Owner's Name information is B required for every i�iL� �Y/�-� ® O°a' ®� page. City/Town State Zip Code Date of In ectio Do System Information (cont.) Septic Tank(cont.) L? � ®� Distance from top of sludge to bottom of outlet tee or baffle ss Scum thickness Distance from top of scum to top of outlet tee or baffle l -F Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? �e Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tit s�''► o N �, AV Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 9 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.doc•rev.6/16 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 GMC7 or 2 Property Address Owner 09 2 information is Owner's Name 0�6�� ®� required for every eo A'4 page. CityrFown State Zip Code Date of Insp tion Da Systems 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 'e 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.doc•rev.6116 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 4M 00 ®_ • ® i v III Property Address /4 — e tj °`- � - y--- - -- ----'---- Owner Owner's Name OO �y information is 114- / �required for every � G __ page. City/Town State Zip Code Date of Ins ction Do System Information (cont.) Distribution Sox(if present must be opened) (locate on site plan): 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.): &0 -st 4-�l s® / 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.doc•rev.6/16 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 Property Address P Y Owner 04 Owner's Name information is required for every n IL:�-�S�tate page. City/Town Zip Code Date of Ins ction Do System Information (cont.) Type. ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields CIO �RC V number, dimensions: El 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.): god � r 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.doc•rev.6/16 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 Property Address -Z404l 14C Owner Owner's Name k information is required for every page. CitylTown State Zip Code Date of Inspe tion 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of ll assachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments zo AM ille C4/ 12v Property Address Owner Owner's Name information is 62N � 6�� /az„ q A required for every page. City/Town State Zip Code Date of Ins ectio ff 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: ❑ d-sketch in the area below drawing attached separately Title 5 official Inspection Form:Subsurface sewage Disposal system-Page 15 of 17 t5ins.doc•rev.6/16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner _ Owner's Name information is AV C9(oXx Id- ;g ®7 required for every ��� �� "� page. City/Town State Zip Code Date of Insp ction D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Av j�/� 6 4J c 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 ❑ bserved site (abutting property/observation hole within 150 feet of SAS) Checked w local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the hig g d water elevation: rou Ito k"- � .o I`J-�� o . Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Aa- Property Address Owner Owner's Name Y� information is 04C. 1C required for every _ �(i1 �� .� (�-� page. City/Town State Zip Code Date of Inspq6tion E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked VIn ection Summary D (System Failure Criteria Applicable to All Systems)completed S stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 AsBuilt Page 1 of 1 TOWN OF BARNSTA13LE LOCATION �S L0nq McVV �� `—SEWAGE# Zo/Z — D 3 Y VILLAGE Cr3 n te�,a'1�,� ASSESSOR'S MAP&PARCEL 7� i INSTALLER'S NAME&PHONE ONE N0. Gc, P SEPTIC TANK CAPACITY /5n® 6� 1 77- 3117 ' LEACHING FACILITY:(type) 1,d6 (size) L20 3/5 4- NO.OF BEDROOMS •! OWNER n �-r a /? r. c✓ nn PERMIT DATE: Z-Z-- Zc r 2.- COMPLIANCE DATE: i Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N,G eet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within Feet 300 feet of leaching facility) / Feet / � FURNISHED BY U 1 -I= aa` 6 6 A-7-3�:d� 13-7=36 y' 3 a A -?= ZZ s� 13-9=43 1 3 A C—Le4n a,, I 'i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=251072&seq=2 12/13/2017 No. ®' v ®,3 � Fee Al 03 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01 pplication for Ziooml *r5tem Congtructton Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. C+n7 Z fiLae Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. '�fs Designer's Name,Address and Tel.No. 1 j'tj L�vw✓w�r�.rc►t Sr !h n-�L e �I 1 I Fk 77 Ceo -i-ecil '(3 ,r,rave �l�c<< 54.,j j,_4_ 3cnq nggty Type of Building: Dwelling No.of Bedrooms 2 Lot Size (I t Z+ sq. ft. Garbage Grinder ( ) Other Type of Building !jA •e Fawn No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Desi n flow provided �`—� Z0 gpd 2 5.u,t Plan Date f-eL. �� Number of sheets �� Revision Date Title 01�) �AYtrVaCy' Size of Septic Tank Type of S.A.S. A,-G 3,6 ac- 1( !A) i/6" '-wh615 p11>t�zp Description of Soil r � C Nature of Repairs or Alterations(Answer when applicable) kl t3rit7 7o o —3a-t Date last inspected: 1 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 Boar Health. Signed Date 2_4F_ 12 Application Approved by Date Application Disapproved Date for the following reasons Permit No.Zo l Z — 03'-( Date Issued 2 Za 1-Z_ No. 20 ` z" —®3 1-( Fee 00 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ., PUBLIC HEALTH. DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplication.for tgpogal *pgtem Congtruction Vertu Application for a Permit to Construct( ) Repair M Upgrade O Abandon O ❑Complete System ❑Individual Components p i 'Location Address or.Lot No. 8 tor9 V i Pr,J t7(;tre Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a t'L l - (2o5�&-#. 4i/j-7 ` "F T 1 r✓Pirf�5 Installer's Name,Address,and TeI...No:•"'' ,�,, Designer's Name,Address and Tel.No. I r'�j ( vv+vru✓u ST "7 11-71, 67o - 1•tG� N3 fje Type of Building: Dwelling No.of Bedrooms Lot Size (/���+ sq. ft. Garbage,Grinder,'( ) Other Type of Building $?j n j-e ;1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) i " gpd 1Design flow provided '3 S 5-, Z O gpd Plan Date r_{•Ls ` 'LO 2i Number of sheets 1 a g i1"�� Revision Date i Title g� Loh�y eni' Size of Septic Tank ( J oa Type of S.A.S-:--W(- 36 14C- �e/�/ �6�`!w✓f��Pil,f�r`�` Description of Soil r � y Nature of Repairs or Alterations(Answer when applicable)' /U" /)�)o S,4 S•T_- Ib 1) t 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 Board-o Health. f / Signed Date - 20 1 r Application Approved by Date { Application Disapproved y: Date for tte following reasons Permit No. Zo(Z - 0.3,4 Date Issued 2 Zo 17- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewa e Disposal System Constructed ( ) Repaired ( -) Upgraded ( ) Abandoned( )by ,�J c 1- a/f ,s es (_C at (©y�Tu i-t.,�� f . �P_,1n (�t(t a has been constructed in accordance with the provt ons of Titl(e�5 and the for Disposal System Construction Permit No.ZO/Z 03� dated Installer �fa f:W�l { �(i1/Qils{f (,CC_ Designer 140 T_ect_% #bedrooms 7 Approved design flow 33(o gpd The issuance of this permit shall n t be construed as a guarantee that the syste lnasm will f c n designed. Date / o Inspector --� _ a THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS ligpogal *pgtem Congtruction ertnit Permission is hereby granted to Construct ( ) Repair A_ )` U(grade,( ) 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 S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this.permit. Date / 2 0 /2- it Approved by Town of Barnstable ors Regulatory Services : Thomas F.Geile . , „ a r,Director Public Health Division Thomas McKean,Director 200 Maio Street,Hyannis,MA 0260l Office: 508-8624644 Fax: 508-790-6304 Installer&Designer Cert fication Form Date: Designer. D. C606H I�tJ O ✓tZ Installer: 1()4 tf► J C V�1h q wo Wy' Address: ¢�J T'i 1 N6 L C C1 R Address: 3 1't',a S(�1JDW lGI-� , !Vl S-IndHII , yn f} On 2-�- ?.®rZ AAW� "Je. was issued a penalit to install a (date) (installer) septic system at (10 4 vi e Lv Or 1 J e based on a deli drawn by n�u tp 60116W WW r<, dated F-f� 201 . / (designer) 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. M OF Mgssgc DAVID yGN 10Q o D. taller s Si ) - COUGHANOWII No. 1093 � o FBISTE�� LWI Z. � 2•S SgN17AR\Pa (Designers Signature) ix Designers Stamp Here PLEASE RETURN TO BARNSTABLE PUBLIC UVAT IM DMSION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BARN STABLE I' BLIC EALTII DXVISION, TH KK-YOU. i Y:�.,: tit"..• �p LEGEND - ����MOT 1500 GAL . o 7� SEPTIC TANK a��A VQ� (�®� �� ; EXISTING GP, a �;:, ��� O CESSPOOL LO ® / �i/ D-BOX ❑ PIT T co LOOT 2 / 2' ` POLET y� AREA 99y4l� �0 ¢\ CONTOUR 3. EXISTING MINIMAL ASSR MAP 2rJl PCL 72 GRADING PROPOSED � 73 -40 74 \> //A Fti \ Z 0 � ocs 73 72 om OF F � T®P ,4.9 3 ` \ c3AFt 'GE E 71 \ -A o ®gyp TP-2 10 qe \ TP-1 72 0 GARBAGE GRINDER IS NOT ALLOWED al►RDE WVTH THVS DESIGN. CONCRSTS PATID _ o ` ' O PAINT SPOT ON cork \ /-�/ ®®' (LEACHING PATIO coRNER SYSTEM ELEVATION =71.04 IPLAN � USE ARC 36 HC i BARNSTABLE GIS DATUM( UNI TS - SEE 71 SCALE: 9 §n e 20 fft DETAIL ON REVERSE FL OW ® �® �® NOTE FLO U�l PROFILE 10 20 EXISTING CESSPOOL IS TO BE PUMPED. COLLAPSED 8 REMOVED. TOP OF FOUNDATION RAISE COVERS TO WITHIN EXCAVATE ALL ASSOCIATED EL = 74.93 +- CONTAMINATED SOILS AND ME 6 In OF FINAL GRADE REPLACE WITH CLEAN MEDIUM 720 71.0 SAND PER TITLE 5. /—D=BD BOX 3. INSPECTION -17PORT MAX TEE 68.0 71.05 1500 ����0� __ EXISTING SEPTOC� TANK 70.00 6 >r, Y67. 7 ===-==_=========-=-= ====== STONE == 70.25 -SEE DETAIL ON BACK BASE 6J. 7.82 IBC G°- CCU NG + 10 Ft 6 1n STONE BASE L66.10 SYSTEM nl "7.5 FL m . m b) 5 Ft -SEE DETAIL ON BACK Ln c) 3 Ft NO GROUNDWATER Z4 60.10 'Y^ACL jNOFMgsScjNof s MOTTLING OBSERVED ��' Sqc SEWAGE DISPOSAL o o DAD. G� oho D DID yG� Go-T� � cg• SYSTEM PLAN NOT COUGHANOWR �' t�ii EST. -TO SERVE EXISTING DWELLING N tiT No. COUGHANOWR n ROGER AND MARIE , Sc°E ►sTE o, eNSE° o� �� 1995 HANSON �5 m 3q �P� E� P� ` OWNERISI OF RECORD AR LOCUS �RONN►�� 88 LONGVIEW DRIVE CENTERVILLE. MA 43 TRIANGLE CIRCLE PROPERTY ADDRESS CENTERVILLE. MA SANDWICH MA 02563 THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM DATE: FEBRUARY 8, G01G DPLACEMENT OF EPICTED ON IT.FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING 5 0 8 3 6 4-0 8 9 4 PG.1121 jag, E T E-3 55 6 A L 0 C U S M A P SHOULD CONSULTDWIT O ASMASSAACHUSETTS REGISTERED LAND SURVEYOR SOIL TEST LOG- PERRC # 13544 DESIGN' CALCULATIONS DATE OF TEST: FEBRUARY 7, 2012 SOIL EVALUATOR: DAVID D. COUGHAYVOWRI, LSE-461 DESIGN FLOW: 2 BEDROOMS X 110 GPD = 220 GPO WITNESSED BY: DON DESMARAIS, HEALTH DEPT. SEPTIC TANK: 220 GPO X 2 DAYS = 440 GALLONS NO N SEPTIC TANK TEST PIT 1 PERCRATN 2WnTE 2 MIN/INCH RIND INSTALL C SOILS DISTRIBUTIIONOBOXLOUSE 5 OUTLET O(MINIMUM ALLOWED) MINIMUM +NSI(7Es DIMENSION = 12 1n ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER MINIMUM SUMP = 6 irt. 79 20 (INCFES) HORIZON TEXTURE (MUNSELL) MOTTLUC SOIL ABSORBTION SYSTEM: 0-6 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE INSTALL 20 ADS ARC 36 HC BIOOIFFUSERS (3616BD) 6-26 B SANDY LOAM 10 YR 4/4 NONE FRIABLE 20 UNITS x 5.0 Ft / UNIT = 100 L.F. 100.0 L.F. x 4.80 S.F./L.F = 480.0 S.F. 26-42 Ci LOAMY SAND 10 YR 5/4 NONE FRIABLE 480.0 S.F x .74 G.P.O. / S.F. = 355.2 .GPO 67'70 USE 20 ARC 36 HC BIOOIFFUSERS AS CONFIGURED BELOW 42-132 C2 MEDIUM SAND 10 YR 5/3 NONE LOOSE 80.20 - VL = 355.2 GPO > 220 GPO REOUIREO REFER TO DEP APPROVAL LETTER OF NO GROUNDWATER ENCOUNTERED TRANSMITTAL a W000052 FOR TEST PIT 2 2 MIN/INCH IN C SOILS DRAINAGE SYSTEMS N OF AB OOIFFDUSER SYSTEMS. ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 71.10 (INCFES) HORIZON TEXTURE (MUNSELL) MOTTLING 0-6 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE L Eft CHI NG S YS T EM 6-24 B SANDY LOAM 10 YR 4/4 NONE FRIABLE CONS T RUC T ION DE TA IL 24-40 Cl LOAMY SAND 10 YR 5/4 NONE FRIABLE USE ADS ARC 36 HC BIODIFFUSERS Iir3616BD1. 87.77 GRAVELLESS INSTALLATION - USE DEP 40-1321 C2 MEDIUM SAND 10 YR 6/3 NONE LOOSE APPROVED INSTALLATION PROCEDURES. 20.0 FL 1500 GALLON SEPTIC TAN DI MIIENS/Olnll`S AND DETAIL NOT TO � USE SHOREY ST-9500-M-90 SCALE In P7 9 6� ( v TAPER 0 20 UNITS TOTAL - 5.0 Ft- PER UNIT 0 INSTALL TWO INSPECTION PORTS TO WITHIN 3 INCHES OF THE SURFACE AND INDICATE LOCATION ON AS BUII*T CARD e� CROSS SECTION VIEW RESTORE VEGETATIVE COVER BACKFILL WITH CLEAN PERC SAND TO TOP OF CHAMBERS INLET CENTER OUTLET END COVED END 3 IN DROP —► /( FLOIM LINE FP0114 - —► EXISTING FROM ` 90 in 94 = T® 2.875' SUITABLE MA TERIAL Iw ®-BOX EFFECTIVE WIDTH = 5 x 2.875' = 14.375' 43 In USE 5 ROWS OF 4-ARC-36 HC LIQUID GAS---*' I _ ADS BIODIFFUSER UNITS-NO STONE LEVEL BAFFLE — SEPARATION BETWEEN INLET LAND OUTLET TEES SHALL NOT EXCEED LIQUID DEPTH CROSS SECTION VIEW NOTES 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 2) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). 3) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM, 41 ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES AND APPLIANCES, AND BIANNUAL PUMPING OF THE SEPTIC TANK. 5) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 6) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE HAS BEEN FLACED TO MINIMIZE UNEVEN SETTLING. SEWAGE DISPOSAL SYSTEM PLAN PAGE 2 OF 2 ROGER AND MARIE HANSON 88 LONGVIEW DRIVE - OENTERVILLE. MA F4EB 8, 2812 1 ETE-3556 1 / • _ -_ // Town of Barnstable . .P#_ Department of Regulatory Services F Public Health Division' -Date 2e l Z KAM rE%3 200 Main Street,Hyannis MA 02601 Date Scheduled �- 6 L t s Time 1 Fee Pd. � I i Soil Suitability Assessment for age Disposal Performed By: Ct'VdUl' CoV71vIA•NBWV #`e6 f µ Witnessed By: • J LOCATION& GENERAL INFORMATION Location Address to"ngv�' phr Or Name Owner's �,qe f (�jq hi e 00 ��>Sa CPtd-vt vy I'll P Address. Loklv7e i%l (fir C7V Assessor's Map/Parcel: 2-5-[ 7 Z _ _ Engineer's Naine N Ott d CBY�H elk ow NEW CONSTRUCTION REPAIR Telephone# 909- 3�4 D6f1 S4 Land Use: 1CC' ,ot wol/I f e� _ Slopes(96) ` `6�C -Surface Stones �l-d ke Distances from: Open Water Body (D�• ft Possible Wet Area 160+ ft Drinking Water Well A11+ft Drainage Way �O ft Property Line D ft Other - "ft SKETCH:(Stmet name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)' too - r f i i t ..,,-c�..- �- ,�..,...----...-+.-�;y...v.r+nr..`�-"'..+--ram'-�►..'"�'�,.l+.w..rw"`t+ ;e7'��..-" •.mot__�' _ -_`"_'y..- _ r =..+•a.�--_ �,�......,..;i�-• t J -�j P-z t 00 Parent material(geologic) �Og !C i�I' 60fi f"tiS Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Noe }1 4 Q Estimated Seasonal High Groundwater W10 F-f DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: rvlo•'F"e s Depth Observed standing in obs.hole: '-In, Depth to soil mottles., Ke ft9 "��" "`""`` ""`�'' Dcptli co weeping from side of obs,hold: �'•=-�`'" �(n,"•�`©rouitdwater Atl,Justtrient � f."`�"^'' '"�� Index Well# Reading Date: index Well level- Adj,factor Adj,Groundwater Level PERCOLATION TEST DatpZl?IZtZ Thne L=30P Observation ' . Hole# Time at 9" 7 � Depth of Perc "h . ' Time at 6" Start Pre-soak Time @ G -0 0 Time(9"-6") h R End Pre-soak l•� b Rate Min./Inch Site Suitability Assessment: Site Passed 2 Site Failed: N d Additional Testing Needed(Y/N) 9J o Original: Public Health Division Observation Hole Data To Be Completed•on°Back(--------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICVERCFORM.DOC NO GROUNDWATER ENCOUNTERED TEST PIT ' 1 PERC AT 72 in — 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 71.20 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 0-6 Ap SANDY LOAM 10 YR, 3/2 NONE FRIABLE 6-26 B SANDY LOAM 10 YR 4/4 NONE FRIABLE 26-42 C1 LOAMY SAND 10 YR 5/4 NONE FRIABLE; 87.70 - r 42-132 C2 MEDIUM SAND 10 YR 5/3 NONE LOOSE k 80.20 NO ATER TEST PIT 2 2 MGN /OINCHWIN C SOILSOUNTERED ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 771.10 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 0-6 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE 6-24 B SANDY LOAM 10 YR 4/4 NONE FRIABLE 24-40 C1 LOAMY SAND 10 YR 5/4 NONE FRIABLE 8 7.77 40-132 C2 MEDIUM SAND 10 YR 6/3 ..NONE LOOSE C�Oo�lOo DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA; (Munsell) Mottling (Structure,Stones;Boulders. Consistenev. Gravel) Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout th- area proposed for the soil absorption system? 'fie S If not,what is the depth of naturally occurring pervious material? �. Certification D �4 R I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consis ha: . the required training,expertise and experience described in 310 CMR 15.017. ����H OF Mqs Signature C ---- 'LS Date D Z• of Z-- o� DAD1. yc� U COUGHANOWR �/C E N SEA 4 Q:45.EPTiC1PERCFORM.DOC E�� VA L U P�o TOWMOF RNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & 1,014' �a INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type 09 (size) NO. OF BEDROOMS e BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300;7eteyacng ty) Feet • --Fu.* ,fished b � _ a �l L 4 � \ K ` y DATE 12/6/99---- PROPERTY ADDRESS:—$8_L2ng3_iew Drives_____ Centervi.jjP, U ,______ 02632 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 2-6 ' x8 ' bloc cesspools . Based on my Inspection, I certify the following conditions: 2 . This is not a title five septic system. 3. This is a sewage system with two cesspools in series . 4. The overflow is dry . 5 . Installed new Sch. 40 4" PVC pipe & fittings from the and throuh out the remainder of the sewage system. 7 . Pumped main cesspool as part of inspection . 8 . The sewage system is in proper work ' ngg'' o ad� r at the present time . SfiG N 4f6 E:f N a m e:_,i L,__Kos w Company: L se.2h_P . Macomber & Son , Inc . 01<\R Address: Box 66 "c � � ' Cent_er_ville_L M_a__026_32-0066 - '99 Phone: 508 775_-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY P. MACOMBER & SON,�JOSEIPHINC. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5600 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 88 Longview Drive Name of Owner Sarah S p u r g i n Centerville Mass . 02632 Ad&*"ofOwnw: Date of Inspection: 12/6/9 9 Name of Inspector:(Plea"Print) Joseph P.Macomber J r . I am a DEP approved system Impactor pursuant to Section 16.340 of Tk%6(310 CMR 15.000) company Name: J.P.Macomber & Son Inc . MmTuV Address: Bay 66 02632 Taiephone Number: ;v 8 775—3z3z3 8 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: s� Passes _ Conditionally Passes Needs Further Evaluation By the Local A proving Authority _ Fails Inspectors Signature: / WY Date: The System Inspect all submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wkNn thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner stall submit the report to the appropriate regional office of the Department ofrEnvirorunental Protection. The original should'be.sent to-" system owner and copies sent to the buyer,if applicable,and the approving authority. . NOTES AND COMMENTS I revised 9/2/98 Page IofII ��Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 88 Longview Drive Centerville,Mass . Owner: Sarah Spungin Date of Inspection: 12/6/9 9 INSPECTION SUMMARY: Check A, B, C, o/ D: A.� SYSTEM PASSES: /Z i I have not found any information which Indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: Replaced orangpbprg piping from tho house and thFe3gh oti`r— the sewage system.All new Sch . 40 4" PVC pipe & fittings . S. 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. Indicate yes, no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If "not determined', explain why not. 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. j 16 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipes)are replaced obstruction is removed distribution box is levelled or replaced - The system required pumphig-more than four-times•a yeardue to broken or obabncted pipe(s). The system will-puss-- inspection if(with approval of the Board of Health): -- broken pipe(s)are replaced obstruction is removed E �I C I revised 9/2/98 Page 2orii E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION lcontirwed) Property Address: Owner: Date of Inspection: 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. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.lMLL.PRQTECT THE PUBUC EIMTKAND SAFETY AND THE EP"MORMENTz AA Cesspool or privy is within 60 feet-of surface water 4jo Cesspool or privy is within 60 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: /V 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 60 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 60 feet or more from a private water supply well,unless a well water analysis for collform 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 -V-19 (approximation not valid).- 3) OTHER 2-6 ' x8 ' block cesspools in series . One overflows too the other . The first cesspools arts a cPnt-; r tanlc Contni nC cn1 i rj 1-1-to ' A nl are Ai-16trs waste—we9te—water to overflow to the second cesspool and disperse into the soil . revised 9/2/98 Page 3or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 88 Lonview Drive Centerville ,Mass . owns.: Sarah Spungin Date of Inspection: 12/6/9 9 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: AID_ 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 , Backup of•sewage into faciRtyrer••ryetem component-due an overloaded or■cbgged-SAS-or•ceaspod. _.•- -�- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. .a Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more the 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 1. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 41 Any portion of a cesspool or privy is-within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria,volatile organic.compounds,ammonia nitrogen-and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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 7 _ the system is within 400 feet of a surface drinking water supply the system•is•witWn 200 feetofa-tfibUtarir•toe+urfaoa•ddnhiwg+wator-oupwy, ••• - -- •• -._ ._ 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 15.304(2). Please consult the local regional office of the Department for further inforpation. I revised 9/2/98 Page 4or11 f i , j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST P,.opertyAddre": 88 Longview Drive Centerville ,Mass . Owner: Sarah Spurgin Date of Inspection:12/6/9 9 Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes No ' Pumping information was provided by the owner,occupant, or Board of Health. _ None of the system compoaerus.ha+w heart pr+aMpadiEopaRJeasi tavo•aweeks sad-tbe-rystem has bam1=ceiaiag rsaasal flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this Inspection. As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The site was Inspected for ,�signs of breakout. All system components,40c'luding the Soil Absorption System have been located on the site. rAloe.— 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:- Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)) _ The facility owner.(and.occupanu..1f diffarapi infarmatiomon tha Ornpar MnI^taaaQC&^f SubSurface Disposal Systems. i I M revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddress:88 Longview Drive Centerville ,Mass . owner: Sarah Spungin Date of Inspeoconl 2/6/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow:-/0 g.p.d./bedroom. Number of bedrooms(des I �- Number of bedrooms(actual): ,� Total DESIGN flow�� Number of current residents: Jr Garbage grinder(yes or no):—U Laundry(separate system) !yes or o If yes, sepautaJnspection.required Laundry system inspected es or o Seasonal use(yes or no): Water meter readings,if available(last two year's usage NO): Sump Pump(yes or no): AV Last date of occupancy:mj-9 COMMERCIALANDUSTRIAL: Type of establishment: AL� Design flow: .0 aad ( Based on 15.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present:(yes or no),dg Non-sanitary waste discharged to the Title 6 system:(yes or no).,dA Water meter readings, if available: Last date of occupancy:_ OTHER:(Describe) 11114 Last date of occupancy: �, GENERAL INFORMATION PUMPING R�DSd and�o=i 0 formation: ll�� r System pumped as part of inspection:(yes or no)_ If yes, volume pumped: M,-gallons Reason for pumping: gllY �LIL1117 TYPE OF SYSTEM VD Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool 1,V_ Privy All Shared system(yes or no) (if yes, attach previous Inspection records,if any) Aj,4_ I/A Technology etc. Attach copy of up to dato�operation and maintenance contract AID Tight Tank Copy of DEP Approval Other mix APPROXIMATE AGE of all components, date Installediif known)-and source of4"formation: Sewage odors detected when arriving at the site:(yes or no) -40 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:88 Longview Drive Centerville ,Mass . Owner: Sarah Spungin Date of Inspection: 12/6/9 9 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:2cast iron 40 PVC_other(explain) Distance from private water supply well or suction line Diameter ,r, Comments: (condition of Joints, venting,evidence of teakage,•etc.) - — Joints apnpar tight Nn evi dPnra of 1 nniraoo S C ANK (locate on site plan) Depth below grade: Material of construction:A�concrete44netaVAFiberglassA�PolyethyleneJgother(explain) AVA If tank is Inetal, list age&21 Js.age.confwmed by Certificate of Compliance (Yes/No) Dimensions: AIN Sludge depth: Distance from top of sludge to bottom of outlet tee or tsaffle —' Scum thickness:_ VA Distance from top of scum to top of outlet tee or baffle: Ad Distance from bottom of scum to bottom of outlet tee or baffle:-Idg— How dimensions were determined: 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.) Pump main cesspool pvpry 2-1 3aarc jLutlet tee is in nl are The recennnl s are structurally—sg;ipd .—'the nlro_...fI-Qu;—is—ary at the present time . GREASE TRAP: (locate on site plan) Depth below grade: Material of con3truction:4Aconcrete.f�L netaL,&Fiberglasso� Polyethylene4&lother(explain) AA Dimensions: Scum thickness: OR 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: A)d 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.) Grease trap is net nrpApnt _ revised 9/2/98 Page 7oril SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 88 Longview Drive Centerville ,Mass . Owner: Sarah Spungin Date of Inspection: 1 2/6/9 9 TIGHT OR HOLDING TANK(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade: Material of construction 4igconcret%oy2metalMAFiberglass,!Y&olyethylene4&ther(explain) AIA N Dimensions: AlA Capacity: d4 gallons Design flow: d&3 gallons/day Alarm present �f Alarm level: Alarm in working order:Y94/4 N000 Date of previous pumping: AIA— Comments: (condition of inlet tee, condition of alarm and float switches,etc.) light or holding tanks era not ircacnr DISTRIBUTION BOX-4161ri (locate on site plan) Depth of liquid level above outlet invert: IV,# Comments: (note-it level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) - - Distribution box is not !resent _ PUMP CHAMBER: hev- (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No)-do Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) ump chamber is not present , revised 9/2/98 Page 8of11 I f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:88 Longview Drive Centerville ,Mass . owner: Sarah Spungin Date of Inspection: 12/6/9 9 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number: V leaching chambers,number:z leaching galleries,number:_ leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool,number: 1 Alternative system:}- Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of pending,damp soil,condition of vegetation, etc.) Loamy sand to medium fine sand .No signs of hydraulic failurt, or pnnrli ng Soil - are Avy vegetation JB ner-maj CESSPOOLS: (locate on site plan) I Number and configuration: Depth-top of liquid to inlet] yert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of Inspection) 0 Pumpedinflow Cesspool No Pvi dPnrn of wnt-er i ntruRIGA.- Comments: (note condition of soil, signs of hydraulic failure,-level of pending,condition of•vegetation, etc.) ame as above . PRIVY: � (locate on site plan) Materjals of construction: �/Jf Dimensions: Depth of solids:—A&L Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy is not irPgant revised 9/2/98 Page 9orii SUBSURPACE SEWAGE OLSP04AL SYSTEM INSPECTION FORM PI.RT C SYSTEM WFORMATION tcor*d+ti+�E) prop.rryAdd��s+: 88 Lon4yiew Drive Centerville ,Mass . Sarah Spungin on. ofa«+t 12/6/99 SKETCH OF SEWAGE DISPOSAL SYSTEU: Includ# tlss to at I►ast two p►rman#nt rslsr#nc#landmarks or b#nchmarka loc►t# ►II walls wlthln 100' (locst# what#pubUo wat#r supply comas Into houssl m .00, , l i revised 9/2/98 Pstiloof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 88 Longview Drive Centerville ,Mass . Owner: Sarah Spungin Date of Inspection: 12/6/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Collar Shallow wells Estimated Depth to Groundwater . Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record �b3erved.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 Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Model 12/16/94 revised 9/2/98 Page it orii I I I', ]•.T.fSTw rnlTe�.•r.— rnrarrrme.rls-rert renre*rr.•f.`rT'Ir►ITRTYeln nerslY til'�I��rtlPn T7r:Tr.1.r7r^:.rtr.r•t. TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I •••TT'1•T••.••.:.-T.ItT.^.T1TI.T TT11'R.ITI TIT7RT.ff1P'IiT1:Tt•IT'1VnR'�11RA►�R�fit11�1�11r.R'! 7�A1 .+ZI`!rT'TT�1t•-..1 -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 88 Longview Drive Centerville ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # 6 pli OWNER' s NAME Sarah Spungin PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . . COMPANY NAME J . P .Macomber` & Sow Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP I{ COMPANY TELEPHONE ( 508 I 775 - 3338 FAX (508 ) 790 - 1578 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: ' a ISysteui PASSED _ The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con tcted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . . 6 Inspector Signature Date Dn6copy of this certification must be provided to the OWNER, the BUYER where applicable ) and the BOARD OF HEALTH. 1.. * If the inspection FAILED, the owner or,I,operator shall upgrade ' the system. within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 15 , 306 , partd .doc