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1095 PHINNEY'S LANE - Health
1095 PHINNEY'S LANE, HYANNIS A= 273018 , ,I o t ` TOWN OF BARNSTABLE tLVT�& _ S �r �. .� G/\ SEWAGE# U9�GE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY d 0(3 ux G©( q LEACHING FACILITY: (type) a p G, t— (size) NO. OFBEDROOMS f . Deer OWNER C—C 0 W �. PERMIT DATE: r 1 I et L COMPLIANCE DATE t € Separation Distance Between the: "Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private.Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY < ;6, Q `O jug Li Li M} Ll TOWN OF B STABLE LOCATION ��� SEWAGE # VILLAGE SSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type 01F�f�Azle (size) NO. OF BEDROOMS BUILDER OR OWNER , PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility A Feei 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 ( any wetlands exist within 300 feet of leaching fac'.:ty) Feet Furnished b fJ! ap � x � - CP Li oe 'y \ \ N I N P _ J � " L �'J' Fee ! ©O No. J 11 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pphtation for Misposar 6pstrm Cunstruttion 3permIt Application for a Permit to Construct( ) Repair(V'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. L OCi %nrl S w..ei Owner's Name,Address,and Tel.No. Assessor's Map/Parcel —)213 Q Gcow 1 G�/ Installer's Name Address,and Tel.No. Desi er's Name Address,and Tel.No. �+ O�d Ywf�a�" 0 V�car P"`c'���ee, ��.(, Se �� �� oacovl Ci vo s� co Type of Building: Dwelling No.of Bedrooms �� Lot Size —sq.ft. Garbage Grinder Q� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1 �3('� gpd Design flow provided 3 q K 7 gpd Plan Date 1 l L, Number of sheets Revision Date Title Size of Septic Tank ['�6- Q u kro Type of S.A.S. iA acs 6x : Description of Soil Nature of Repairs or Alterations(Answer when applicable) v v �S�C7 K io 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 OVealth. Signe Date 0 1 a Application Approved by Date Application Disapprov y Date for the following r asons fl 1 Permit No. Date Issued l No. Fee /DO 1X_ THE COMMONWEALT -OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[pplication for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(tf Upgrade( .,) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. dCi Wk r n". Owner's Name,Address,and Tel.No. Cr?s� �.� �CdWIGy I Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Desi er's Name,Address,and Tel.No. e C�t�SS�ve�•d R Scoff C'��rc�.V�. 1�3 v� d yc. rr�ov �' c.r McEn�ec, \2w S vc.n^Cti �� QaSOOI .10Y DU SfCC�G� Co Type of Building: Dwelling No.of Bedrooms Lot Size `1) ,���0 sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures r- Design Flow(min.required) 230 gpd Design flow provided 3 gpd Plan Date Number of sheets Revision Date Title i Size of Septic Tank Type of S.A.S. Description of Soil Zfo Nature of Repairs or Alterations(Answer when applicable) C_ o ST d e-� c�,. 1�crs / S�o�L a s x 1 a x a, 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 Boar�o[-ReaIth. ��. Signed - Date 0 1? Application Approved by Date D i Application Disapproved by Date for the following reasons iiJJ Permit No. tom . Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by CO(-( M -C- at (GCS �J ,�V S L_C, - C.\I1\LQ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N /&—q 4 c1 dated Installer -Ci1..�� Designer ise= T'Y)C <�,A #bedrooms Approved design flow A? gpd The issuance of this permit shall not be construed as a guarantee that the system will functi3 as designed. Date 11 � t / 6 Inspector 1 --------------------------------------------------------------------------------------------------------------------------------------- No. l cl U )_ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MispoSal 6pstetn Construction 3permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at (� t'^, (_ S ` o C.QJ-_(f U 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must a com leted within three years of the date of this pe it. Date /mil a'ZM 2 Approved by �''\ Town of Barnstable Regulatory Services Richard V. Scali,Interim Director MASS.• sniexs�aBt,e. Public Health Division �+ A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: l2 f 2 J Gt, � Permit#g Sewa a 11a `�� ��Assessor's Map�Parcel Designer: fir•.?:�n ti.r ri`� Etc:rUl t Y. ,�,_ Installer: 5e_e— `- .n,14 Address: 1 Z 0j, Address: f) '3-- 0 04_ ao •i-�.���t.�a l� lVt/� ci`zi�`i.� ��O1 yywl-S � /i'tA- C?2(,'(�� On N.a \a (9 � ' � was issued a permit to install a -(date) (installer) septic system at R) "n^--kV"S &"' ""e, based on a design drawn by (address) ( r t le�. yv1 L V-CC f L5 dated (designer) i f 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than']0' 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. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in co liance with the terms of the 11A approval letters(if applicable) PETER T. G� (Installer's Sib e re) o M v LEE f No. 35109 fS i� Designer's Signature) (Affix Desi . Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASepticV)esigner Certification Form Rev 8-14-13.doe s� Town of Ba rnstable P# �. ,�,''° ►'�; Department of Regulatory Services I I Public Health Division Date---/ I lqll& MARS. �m1!? 200 Main Street,Hyannis MA 02601 C rE[►tom" ' Date Scheduled• 10 Time— Fee Pd._ ty Soil Suitability Asswm�jent for Sewage ,Disposal Performed-By: 1 ('� v� C.-�n' �� t� 12-Witnessed By: (/i V/d 5 4* fYI e 1. e5 C CATION&.GENERAL INFORMATION Locatlon Address �� 1 �"Vx k(w f e y J 1,c je, Owner's Name 1rlyt,n•-� • Address Assessor's Map/Parcel: V , Engineer's Name gene, Mr G\R/AtX, NEW CONSTRUMOONQ REPAIR J Telephone# O 6' Land Uso Slopes(96) [ Surface Stones Distances ftnm: Open Water Body Possible Wet Area N A ft Drinking Water Well ��tt Dralhage Way + , f ft Property Line i tt Other g SKETCH:(Street name,dimensions of lot,exact locations of test holes&Para tests,loettfe wetlands-in proximity to holes) 2 . Parent matedei(geologic) �y, yV S Depth to Bedrock � Depth to Groundwater. Standing Water In Hole:_ 00 r1k. Weeping fy olA Pit Fnea a�� Estimated Seasonal High Groundwater �d W DETERMINATION FOR SEASONAL•HIGH WATER TABLE Method Used: Depth Observed standing in obs,hole: _ In, Depth to loll mottle9: In.' Deilth to weeping from side of obs.hole: in, Groundwater Adjusttrtent ft. Index Well-# Reading Dato: Index Well Isvol Adj4hotor.,,,,._.,Y Adj.Groundwater.1evel-..,-. PERCOLATION TEST bate- Timr,.�, Observation Hole# Tinto at 9" Depth of Pero 2` Mi. Time at 6" Start Pro-soak Time @ /t 7, Time(9"-6") End Pre soak Rate Min./Inch G Z Site Suitability Assessment: Slid Passedt�� Sitp Failed: Additional Tesdng.Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--- ***If percolation testis to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTIMERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# i Depth from Soli Horizon Soil Texture Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucturc,Stoned;Boulders. • o rsiskcncy.%'Oravell • Z ZD —3 Z S L Lb' iolq • Er; ' DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Solt Texture .Soli Color Soil Other Surface(in.) _ (USDA) (Munsell) Mottling (Structure,Stones,Boulders. .z,s'� �( ------------- DEEP OBSERVATION HOLE LOG Holt;# Depth from Soil Horizon -Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistency, ( t` t • DEEP OBSERVATION HOLE LOG Hole# Depth from Sall Horizon Soil Toxture Soil Color Sall Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, i C Flood Insurance Rate Map: Above 500 year f lood boundary No_ Yes ... Within 500 year boundary No Yes Within 100 year flood boundary No.X Yts I)epth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material's Certi�on I certify that on l., (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required tr ,expertise and experience described in�10 CMR 15.017. • Signature DateV� Q-.WHF TICVERCPORM.DOC i Town of Barnstable Barnstable . Regulatory Services Department lAEN,SfABM _ - � 0" Public Health Division m fD"" A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO . CERTIFIED MAIL# 7012 1.010 0000 2847 8261 November 17, 2016 CROWLEY, JOSEPH W &MARIE R 1095 PHINNEY'S LANE HYANNIS, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1095 Phinney's Lane,Hyannis,MA was inspected on 11/03/2016 by Sean M: Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of l995 TITLE V (310 CMR 15.00) due to the following: , • The garage was built partially over block cesspool and sewer line partially collapsed. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\I095 Phinneys Lane Hyannis.doc y i .- ` "� Town of Barnstable + w • HARNSTABM=X 6 9.ih,,�� Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA•02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water.supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is,free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <12" below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER 6c�Nge DV2� lU1oC�C Ce1I0t1u / Gi✓iU, 3evver ft'/12 Repair deadline: alf Q:\SEPTIC\DEADLINES TO REPAIR FAI ED SYSTEMS.doc 0?7 - 07&q Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1095 Phinneys Lane c Property Address cr) Crowely Owner ►-� Owner's Name information is required for every Copter e V11 Mh1 s Ma 02632 11/3/2016 s page. City/Town V State Zip Code Date of Inspection i1 CA CJ1 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 U 1# l aal on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection,, Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority - �-i—,-/3/20116 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or :has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ";""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �� VS �D� f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is Centerville Ma 02632 11/3/2016 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑" broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,_ safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh . t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1095 Phinneys Lane Property Address Crowely Owner Owners Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is Centerville Ma 02632 11/3/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M , 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2000 gallons How was quantity pumped determined? sight gauge on truck Reason for pumping: cesspools 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 co of the DEP approval. 9 copy pP ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original 1958 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ❑ 40 PVC orangeburg ® other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Sewer line runs under detached garage and paved driveway. Line was video inspected from cesspool back towards house and was found to be partially collapsed. This pipe is not accesible to repair 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: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1095 Phinneys Lane Property Address Crowely Owner Owners Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 112 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): Overflow is a large block cesspool with 1 inlet and no outlets. Cesspool was found to be full to approx 3' below inlet with a stain line 1' higher. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction concrete block Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main cesspool is accesible but is 25% under the garage. System fails because a block cesspool cannot have a structure built on top of it. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below drawing attached separately �eA-0- a 1 P�V Ji;WA^'I 9� r 1 r rr � r l6 r r'' �l 6 r F' �2 ZYtb .to l Z t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation not established Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1095 Phinneys Lane Property Address Crowely Owner Owner's Name information is required for every Centerville Ma 02632 11/3/2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L_ e t I2 ' DATE : 4,379/98 " PROPERTY ADDRESS : 109 Ph ' nn w I�1��/��n R MAR ,class. 2 4 1998 02632 ^ `'AtTtl pTrAe(E On the above date, I Inspecte-d the "ptic system at the above aC_, e55. Tnls system conslats of the following; 1 . 2-6 'x10 ' concrete bloc cesspools. r Base-0 on my Infn-actlon, I certify the following coridltlone: 2 . This is not a title five septic system. 3 . This—is a sewage system that is in proper working order at the present time'. • "SIG NATUR'" : Name : J . P . Macomber Jr... ---------------------- Company:J_ P_Macomber &- Son_Inc .. __Cencervi11e `Ma99__02632 Pnone : 5Ca__775__3338------- • i THIS CERTIFICATION DOES NOT CONST[TUTE A GUARANTY OR WARRA,,iTY .fOSEN P, MACOMBER & SON, INC. Tanks-CeupoolYl.e.chfleld+ Pump+d L lnitallO Town Sower Connoctloni P.O. Box 66 ' Centerville, MA 02632.0066 COMMON WEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617.292.5500 µ'ILL1AXt F.VELD TRUD1'COX Govemor Sccreta ARGEO PAUL CELLUCCI D.A\ID B STRUIr Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission PART A CERTIFICATION Property Address: 1 095 Phinneys Lane Centervillegddress of Owner: Date of Inspection:3/9/9 8 (if different) Name of Inspector: Joseph P.Macomber Jr. I am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.?.Macomber & Son Inc. Mailing Address: BOX 66 Centerville,Mass. 02632 Telephone Number: 5 0 8—7 7 5—3 3 3 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 iunction and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the local Approving Authority _ Fails Inspector's Signature: 4k Date: The System Inspector all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tf,e system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: S I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 Crv(R 15.303 Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: &)o 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 deLermined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. /1,t4dX, Th septic tan s 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 exfiltranon, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic Eank as approved by the Board of Health. (revised 04/25/97) Day• 1 of 10 DEP on the Worid Wide Web: http:/Avww.magnet.state.ma.us/Oep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1095 Phinneys Lane Centerville,Mass . Owner: Marie Crowley Date of Inspection:3/9/9 8 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of (he Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced dza The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A6 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. tv The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. 9 The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indica(es that the well is free from pollution from that facility and the presSnce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance AI (approximation not valid). 3) OTHER -a-te X/0 -� � . (revised 04/25/97) Page 2 of 10 "1\ J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 095 Phinneys Lane Centerville,Mass . Owner: Marie Crowley Date of Inspection: 3/9/98 D] SYSTEM FAILS: You must indicate ei;-.er "Yes" or "No" as to each of the following: —All) I have determined that the system violates one or more of the following failure criteria as defined in 310 CN1R 15.303, The bans for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to Correa the failure. Yes No -K/ Backup of sewage into facility or system component due to an 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. _A10AJ 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 112 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 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. 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" as 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 the system is within 400 feet of a surface drinking water supply i 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 095 Phinneys Lane Centerville,Mass. Owner: Marie Crowley Date of Inspection: 3/9/9 8 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 components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZAs built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, Oluding the Soil Absorption System, have been located on the site. 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: 4 4The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. 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) (15.302(3)(b)J it (revised 04/25/97) Pegs 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION Property Address: 1095 Phinneys Lane Centerville,Mass. Owner: Marie Crowley Date of Inspection:3/9/98 FLOW CONDITIONS RESIDENTIAL: Design flow: p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):Aa Laundry connected to system (yes or no):Xj Seasonal use (yes or no):J& .. Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):&12 497 Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: .U/¢ Design flow: j), gallons/day Grease trap present: (yes or no)&Ik� Industrial Waste Holding Tank present: (yes or no)&2d Non-sanitary waste discharged to the Title 5 system: (yes or no). Water meter readings, if available: oVA 1VX Last date of occupancy: A}& OTHER: (Describe) Last date of occupancy: 42 c GENERAL INFORMATION PUMPING RECORDS and so��rffe of information: System pumped as part of inspection: (yes or novik If yes, volume pumped: �A//P gallons Reason for pumping: .f/iQ TYPE OF SYSTEM ti Septic tank/distribution box/soil absorption system / Single cesspool Overflow cesspool _Ve Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) _ I/A Technology etc. Copy of up to date contract? Other 4,44 APPR� O)(IMATE AGE of all components, date installed (if known) and source of information: *,P 7- Sewage odors detected when arriving at the site: (yes or no) (revimed 04/25/97) P&9. 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 095 Phinneys Lane Centerville,Mass. Owner: Marie Crowley Date of Inspection: 3/9./9 8 BUILDING SEWER: I (Locate on site plan) it Depth below- grade: /P Material of constructio cast iren _ 40 PVC _ other (explain) CrP 1-1 - Distance from privy a water fulpl7wJell or suction line Diameter Comments: (condition of joints, ven ing, evidence of le kage, etc.) SEPTIC TANK:,Qbw— (locate on site plan) Depth below grade:_&e Material of construct ion:AAconcrete.y�metalN,&Fi berg IasW Polyethylen&Ct�other(explain) AIX If tank is metal, list age d& Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth: �� = Distance from top of sludge to bonom of outlet tee or baffle:�,� Scum thickness:, 4.1,4 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 dimensions were determined:Comments: (recommendation(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.) j A JQ�r- &e5,e e,7 GREASE TRAP: /e— (locate on site plan) Depth below grade: Material of construction4V concrete4(8metal4 Fiberglass4A/ Polyethylene�t other(explain) Dimensions: AJA Scum thickness:IA Distance from top of scum to top of outlet tee or baffle:.,qZj Distance from bottom of scum to bottom of outlet tee or baff1e:8jd- Date of last pumping: 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.) Z/--"S Lo rA (revioed 04/25/97) Pag• 6 of 10 I - - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1095 Phinneys Lane Centerville,Mass . Owner: Marie Crowley Date of Inspection:3/9/98 TIGHT OR HOLDING TANK:AeeV must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:.(/-7 Material of construction: J�concrete�v, netal�ilFiberglassVAPolyethylenetf�other(explain) ti4 NA Dimensions. AAW Capacity: AM gallons Design flow: .U14 gallons/day Alarm level._Alarm in working order,,i Yes;dA No Date of previous pumping: Comments. (condition of inlet tee, condition of alarm and float switches, etc.) �L i Ode G1 � 1rC1!' �iDT DISTRIBUTION BOX:, bve- (locate on site plan) Depth o: hQuid level above outlet inven:�/ Commer':s: Incite if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) L S TY�L L LDA? D oC J S A"j' �OJ'1B�'C✓yT PUMP CHAh1BERAA&�F— (locate on site plan) Pumps in working order: (Yes or No)lfW Alarms in working order (Yes or No),&XV2 Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r.vi..d 04/25/97) P.g. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION (continued) Properly :.ddress: 1095 Phinneys Lane Centerville,Mass. Owner: Marie Crowley Date of inspection: 3/9/9 8 SKETCH OF SEWAGE DISPOSAL SYSTEM: :;uae ties to at least two permanent references landmarks or benchmarks ccate all wells within 100' (Locate where public water supply comes into house) ?h►nne j5 Io, Cexho-ryfk 110uSo" � I f>7� C^O���e 8�,10 IL I Page 9 of 10 SUBSURFACE SEWAGE DISP,. L SYSTEM INSPECTION FORM 1. C SYSTEM INFOL :. 10N (continued) Property Address: 1095 Phinneys Lane Centerville,Mass. Owner: Marie Crowley Date of Inspection:3 nspection:3/9/9 8 Depth to Groundwater � Feet 4boe;1: Please indicate all the methods used to determine High GroundwaW Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, bservation hole, basement simp etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High GrounciWaterElevation. Must be completed) Used Water Contours Map. Gahrety & Miller Model 12/16/94 I I (revised 04/25/97) P&c 100f 10 i -•rrn r•+.-rtrs--rr-ern:arrr•nr.ernrnrs rsrrrer�r:-.r++vnr+.r�n+•n mr.v na-srTer.r+r .. .rn-rrr- r—r-:._--.r... TOWN OF Barnstable BOARD OF HEALTH + SUI)SURFACF SF.WACF DISPOSAL ,SYSTEM INSPECTION FORM - PART. U .- CEKT IFICATION I `- �•••T••••T•••••t-T.t.:^.-.rnr rll-rt.T.nTtrtC stir T•'.T7:�-z9+--tVf+C•smmrTRtlRv+�RTTR1:RtfeT1+.'e7 . rsmn7mrnr-ere-T-.+rr.r.•.:r r.-•r--., �..A -TYPE OR PRINT CI.EARL1'- PROPERTY INSPECTED STREET ADDRESS 1095 Phinneys Lane Centerville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Marie Crowley PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Irre. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City State tIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 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 complete as of the time of :inspeetion . 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 ne : System 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 ticted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE C1ITERIA of this inspection form . r Y Inspector Signature Date - -y- �.- One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF IIEALI'll. * If the inspection FAILED, the owner or"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 . 305 . partd . doc r t l�J 7 P7 ti THE COMMONWEALT H OF MA.SSACfrCTSLTTS DEPARTMENT OF ENVZRONIENTAL PROTECTION BE IT KN OWN OWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CER + + D TITLE S SYSTEM INSPECTOR as provided M 310 CMR 15.340 and Section 13 of Chapter 21 A of the General Laws_ Issued by The Department of Environmental Protection. Acting Ohector of t2rc i toll of w2tcr Pollution Control q�? 1 97--EXISTING CONTOUR N x 100.98 EXISTING SPOT GRADE F9-71 PROPOSED CONTOUR W EXISTING WATER SERVICE LOCUS wy -e H, W-- OVERHEAD WIRES TEST PIT off°o< 06 LANE Sfot� BENCHMARK LEGEND tk yv�o O„ a 3° N LOCUS MAP NOT TO SCALE 104.96 x TP-1 EXIS77NG CESSPOOLS 104.52 1 TO BE PUMPED, FILLED �1 WITH SAND & ABANDONED 10 .51 N TP :J GARAGE 103.92 �,, SLAB it 4.16 103,62 PROPOSED SEPTIC TANK 103.69' N 103,19 N: LTI QGlbh 0 103.43 w PAVED DRIVEWAY:-;.: ti� 23 BENCHMARX �102.93 010 O .: rvi 102.85 BULKHEAD COR. EL.=103.35 rn ° 102.21 PATIO ° x x � x 1 3.01 02. a 102.79 EX. SEWER 1D N EXISTING/ 102.56 m HOUSE(#1095) T.O.F.=103.`35f rZ '0 x 102.35 102.19. 101,87 ' 102.63 J LAMP 10241 --� a 1 I 102,68 x 10 88 / rn ` 02.45 U � , 101.21 -�� 101.48 LOT 2 p � 17,300 ±SF 10` 101,5 5ARCEL ID: CB 17.5 _ x 100 6 I 99. S'-- I - L-80.51 :% y N 5.4 'S0" � .;. 100.55 xl WSJ 9,9 ---- R=548.50'- 99.72 _ -- - CH BASIN ��---------- 9 99.60 9.55 r edge of pavement 99.51 99.30 99,12 - LANE PHINNEY9 S ��P��� OF Mgss9�yG o PETER T. McENTEE PROPOSED SEPTIC SYSTEM UPGRADE PLAN o CIVIL No. 35109 1095 PHINNEY'S LANE, CENTERVILLE, MA pr RE IS1ER �2 Prepared for: Scott Frank, 113 Old Yarmouth Rd, Hyannis, MA 02601 FI OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO. CROWLEY, JOSEPH W & MARIE R Engineering Works, Inc. 1"=20' P.T.M. 242-16 �,7 G 1095 PHINNEY'S LANE 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. CENTERVILLE, MA 02632 (508) 477-5313 12/7/16 P.T.M. 1 of 2 f; NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:101.0 FOR A DISTANCE OF 15' AROUND THE SEPTIC TANK PROPOSED D-BOX PERIMETER OF THE S.A.S. INSTALL RISERS & COVERS OVER INLET & OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & COVER PROPOSED S.A.S. SET TO 6" OF GRADE INSTALL RISER & COVER OVER EACH CHAMBER AND T.O.F.=103.35t SET TO 3' OF F.G. TO SERVE AS INSPECTION PORTS F.G. EL.=101.4t F.G. EL.=103.3t F.G. EL.=104.0t F.G. EL.=104.5t L = 13' ® S=1% (MIN.) p S=1% 2MIN.) L = 5' 4"SCH40 PVCP60 ( S=1% (MIN.) 2" LAYER OF 1/8" TO 1/2" M'mw 4"SCH40 PVC 4"SCH40 PVC DOUBLE WASHED STONE E aaaSaaa (OR APPROVED FILTER FABRIC) 14" B9aa96a INV.=101.25 48" LIQUID aaaaaaa --3/4" TO 1-1/2" DOUBLE LEVEL WASHED STONE �D INV.=100.75 PROPOSED INV.=100.58 4 4.8' 4' GAS D-BOX EFFECTIVE WIDTH = 12.8' INV.=101.00 3 OUTLETS I NV.=100.50 PROPOSED SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN CONNECT TO EXISTING 4" C.I. SEWE H-10 RATED OUTSIDE HOUSE, INV.=101.60t TOP CONC. ELEV.=101.3t NOTES: BREAKOUT ELEV.=101.00 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=100.50 ease ease INVERTS, PRIOR TO INSTALLATION. aaaaB eases 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND BOTTOM ELEV.= 98.50 TRUE TO GRADE ON A MECHANICALLY COMPACTED 4' 2 X 8.5'=17.0' 1 4' SIX INCH CRUSHED STONE BASE, AS SPECIFIED 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0' IN 310 CMR 15.221(2). PERVIOUS MATERIAL 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' (MIN.) ABOVE G.W. LEACHING SYSTEM SECTION 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM OF TP, EL.=93.5 AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. (NO GROUNDWATER) SEPTIC SYSTEM PROFILE SOIL LOG DATE: NOVEMBER 28, 2016 (REF 15,208) SOIL EVALUATOR: PETER McENTEE PE SE#1542) GENERAL NOTES: WITNESS: DAVID STANTON R.S. HEALTH AGENT ELEv. TP-1 DEPTH ELEv. TP-2 DEPTH 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 104.4 A 0" 104.2 A 0" 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS SANDY LOAM SANDY LOAM OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 103.9 10YR 4/2 " 103.8 10YR 4/2 LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: B 6 B 6" -310 CMR 15.405(1)(b): SANDY LOAM SANDY LOAM o, 1 A 4' variance, septic tank to cellar bulkhead for a 6' setback. 10YR 5/8 10YR 5/8 ) P (bulkhead), 101.7 32" 101.8 30" 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR C PERC __- C_ TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 30"/48" DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 4 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN MED. SAND MED. SAND ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 2.5Y 6/6 2.5Y 6/6 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 93.7 128" 93.5 128" 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. PERC RATE <2 MIN/IN. ("C" HORIZON) NO GROUNDWATER ENCOUNTERED 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 12$'26 S' THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS Q IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND v� REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). CIV sr- 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE , INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. Q� �6 / ��? GARAGE 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND / rt• ' SLAB NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. �` 14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC SYSTEM COMPONENTS NOT SHOWN ON THE PLAN o 36.31 23,S' ca DESIGN CRITERIA NUMBER OF BEDROOMS: 3 BEDROOMS SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 330 GPD DESIGN FLOW: 330 GPD GARBAGE GRINDER: NO-not allowed with design LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF BACK OF HOUSE .74 GPD/SF S.A.S. LAYOUT PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 2-500 GALLON LEACHING CHAMBERS IN SERIES , SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 1095 PHINNEY S LANE, CENTERVILLE, MA SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: Scott Frank, 113 Old Yarmouth Rd, Hyannis, MA 02601 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:...................... ....................................... 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 242-16 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD (508) 477-5313 12/7/16 P.T.M. 2 of 2