HomeMy WebLinkAbout0246 PINE STREET - Health 246 PINE STREET,s,.4,,
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No._i p__-�-' j 03 / Fee------� ----
BOARD OF HEALTH
TOWN OF BARNSTABLE
ion rVe1Y �lCon�truction permit 0���[uat ,�'o � >i
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on is hereby made for permit to Constr ct ( ), Alter-(`"),or Re�air ( )an adi3i ual Well at:
Application y
Location — Address Assessors Ma cel
caner Address
al!1 r-1,11-5
--- -
Installer — Driller Address
Type of Building
Dwelling-����-s5 -------------------------
Other - Type of Building------------- - No. of Persons----------------------------
Type of Well _--- —--- Capacity---- -- - ------- -——
Purpose of Well----- a - --—-------
Agreement:
g The undersigned
ndersi d agrees to install the aforedescribed individual well in accordance with the provisions of The
gr
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
ne --- — --- date
Application Application Approved By — ------------— 3 c�
date --
Application Disapproved for the following reasons:--------- - - -- -- -----—-----
--------- -- ----- ----------------------- --
' 1 date
_ ___ Issued--- _-!`- � e
Permit No. --- - -----------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired
� L
I�
Installer
at- - r- _ }�, cJ�— -- ------- ----- -- ___ ----— -_
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. ------------------Dated---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------------— — - —-- Inspector—-----------------------------------------
4 No.— --- ---r�- 3 / Fee----- --------
BOARD OF HEALTH
TOWN OF BARNSTABLE
ApplicationArVell CootructionPermit
Application is hereby made fora permit to Constr ct ( ), Alter'(" ),-or Re air (4)an individual Well at:
w- — '1 ti--- 4! -c l to
Location —Address _..-.., Assessors Map_and-mil J
N/
_—— ------ ---«----- - -fir Address
Installer --�--- ---_
Owner _
{ Installer - Driller
--_- — -- -- Address ---
'! Type of g
Dwelling -��1� ��-— - ---------
—
�
Other - Type of Building -- -- —- - No. of Persons -- — — -------- -
i Type of Well ---== - ------ Capacity--- -- —---—- —— ---—
Purpose of Well s- --- --------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in acco dance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
S'gne
date /
y. Application Approved By ----——— "'' -
date
Application Disapproved for the following reasons: --------— - - —---— - ---— -----
1 date
CJC` q—emu -------- Issued---- --`
Permit No.- - -----------------------------
date
BOARD OF HEALTH
fTOWN OF BARNSTABLE
Certificate Of Compkiance
/fr 1A , W�u�
THIS IS TO C/ERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) /� �1
bY—------44 f_7 `-�L 6—' -k h /j— Installer
- -= -- — - — --------
at
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. --------------------Dated------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
4 SYSTEM WILL FUNCTION SATISFACTORY. _
i
DATE--------------- —-- - -- Inspector-- --- — - - - -------——
BOARD OF HEALTH
TOWN OF BARNSTABLE
Verl Con5truct ion Permit
t.�
I
No. ------- ---- Fee
Permission is hereby granted
to Construct ( ), Alt,e�(` ), or Repair ( ) an I dividual Well at:
to ___ ?� _ 5; W , r. ,,-- ------- —--- - ----------------------------------
Street
I as shown on the application for a Well Construction Permit
WO5 031 ate -- - --- ----- —-------------------
F � Board of Health
DATE— c—J1— --
i
Page: 1
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
tY Y
Report Prepared For:
Report Dated: 5/19/2003
Order Number: G0319638
David E.Clough
246 Pine Street
West Barnstable, MA 02668
Laboratory ID#: 0319638-01 Description: Water-Drinking Water
Sample#: 19638 Sampling Location: 246 Pine Street;West Barnstable Collected 5/5/2003
-ollected by: David E.Clou Received 5/5/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 6.0 J; mg/L 10 EPA 300.0 5/7/2003
LAB: Metals
Copper 1.3 mg/L 1.3 SM 3111B 5/9/2003
Iron 0.2 mg/L 0.3 SM 3111B 5/9/2003
Sodium 20 mg/L 20 SM 3111B 5/9/2003
LAB: Microbiology
Total Coliform 11`resenf 7 P/A Absent 307 5/5/2003
I
LAB: Physical Chemistry
Conductance 397 umohs/cm EPA 120.1 5/5/2003
pH 6.1 pH-units EPA 150.1 5/5/2003
Note: Recommended maximum contamination level exceeded due to Coliform Bacteria.. Retesting is recommended. Nitrates are,
- higher than average.Monitoring is recommended(2-3 times per year)to establish any upward trends.:
Approved By: y I
RECEIVED (Lab Director)
MAY 2 7 2003
TOWN OF BAR'NSTABLE
HEALTH OEPT.
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Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
TOWN OF BARNSTABLE BAR-w 4106
Ordinance or Regulation
WARNING NOTICE
A V 10 01-o0re). 14
Name of Offender/Manager dob
Address of Offender Pll5 MV/MB Reg.#
Village/State/zip 91t,"; A �f_, IPA l/iAh? S S#
Business Na-me am o: 1 �
/pm,
n (491 2 00
Business Address
S'rgnature of Zffforci'n�g_Officer/
Village/State/Zip
Location of Offense tom' ',P7,'0Nr
QV o r0rol LIt'S
E 4 ,01
ALF
101,.(Mr' -ro nforcing Dept/NA
Offense
�Facts ',' 8_z V A A Lr, WP Im"r -A Ph,/061 rlul, / 7 Col�Pl-�9"1
Ar-D P-6-rVAV �V 71RM,
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This will serve only as a war"nin" At this time no legal action has been taken.
9- ,
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempt:s�,, to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
o
,-, CONMIOXWEALTH OF MASSACHLSETTS
EIMCL-M E OFFICE OF EN'VIROXAMN-TAL AFFAIRS
-DEPARTMENT OF ENVIItONMENTAL PROTECTION
O%%7 %"L\_=STRE•E'.DOSTON MA 0210i 161' 292.9b1n,
MMY COL
Secrets-Y
ARGEO PAIL CELLLCCI D4110 B STP_yc
Gm-ernor Commuss:one-
SUBSURFACE SEWAGE DISPOSAL SYSTUA NSPECTION FORM -
PART'A
CERTIFICATION
Property Address:2 4 6 Pine S t. Nartte of Ownar 4jejdi nonce
W B�rn s t ab 1 e Address of Ownw.-
Date of Inspection: / b —er-co—
Name of Inspector:(Please Prinu Wm. E. Robinson S r. -
1 tiro a DEP approved s err!InspectorIf to Section 16.34O of Title 6 9210 CUR 15.000)
Company Name: Wm. E. Robinsonetic Service
Mailing Addre ls: PO Box I0 9. Centerville MA O EC 29
Telephone Number: R 7 7 20
00
CERTIFICATION STATEMENT
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:
_� Passes
Conditionally Passes
_ Needs Further Evaluation By the local Approving Authority
Fails
Inspector's Signature: 26 L b Din: O—f-)
The System Inspector shell submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty 130)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 VW
system owner and copies sent to the buyer.if applicable. and the approving authority.
NOTES AND COMMENTS
Poor I of n
Stec,(Kd Parr
SUBSURFACE SEWAGE DEPOSAL SYSTEM NSPECTION FORM ,
PART A
CERTIFICATION leonsearadl
N*perty Address: 246 Pine St. W M'a n�std. e
,3",: moss
Date of 6tspaabon
NSPECTION SUMMARY. Cheek B, C, of D:
AL YY�TEM PASSES:
�//1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
SYSTEM 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.
Indicat yes.no. or not determined(Y. N.or ND). Describe basis of determination in sp instances. If 'not determined'.explain why not.
_ The septic tank is metal.unless the owner or operstor has provided the system inspector with a copy of a Certificate of
Compliance lattechad)indicating that the tank was installed within twenty 120)years prior to the date of the inspection: or
the septic tank, whether or not metal,is cracked.structurally unsound.shows substantial infiltration or exfihration. or tank
failure is imminent. The system will pass inspection R the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pips(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if Iw0h approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
=�•�sec 9;2!5c
Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Iconbnued)
Prop"Add►ess: 246 Pine St. , W Barnstable
Owner: Moss
Date of Inspeeoon:
C. RTHER 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
ublic health,safety and the environment.
1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES N ACCORDANCE WTTH 310 CMR 15.303(1)(b)THAT THE SYSTEM
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a tone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3' OTHER
Page 3or11
xY
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION lcondmiied]l
PropwtyAddress: 246 Pine St. , W Barnstable
Owner: Moss
Date of lnspeebon:
D. SYSTEM FAILS:
You ust indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure
Yes No
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 of
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 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 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. 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. LA GE SYSTEM FAILS:
You mu t 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
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)
The o net or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional
office f the Department for further information.
Pdgt 4 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
kopeny Address: 246 Pine St. , W Barnstable
Owner: MO S S
Date of Inspection: /—G—o a-u
FLOW CONDMONS
RESIDENTIAL:
Design flow: Sb-0 g.p.d.fbedroom.
Number of bedrooms Idesign): 4 Number of bedrooms Isctusl):�
Total DESIGN flow S6 a
Number of current residents: 7
Garbage grinder Iyes or no):A- 0
Laundry(separate system) lye.or no):/,, If yes,separate inspection required
Laundry system inspected (yes or no;
Seasonal use (yes or no):-61—p
Water meter readings, if available (last two year's usage Igpd): well water
Sump Pump(yes or nol:-&-0
Last date of occupancy:
C MMERCIALIINDUSTRIAL:
TV p of establishment:
De—g- flow: dpd 1 Based on 15.203)
Basis f design flow
Grease trap present: Ives or no)_
Industr I Waste Holding Tank present: lyes or no!_
Non-sa itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available.
Last d to of occupancy:
OTH : (Describe!
Las of occupancy
GENERAL INFORMATION
PUMPING RECORDS and source of information:
/ Cl!i
System pumped as part of inspection: (yes or no)�d
If yes. volume pumped: gallons
Reason for pumping
TYPE OF YSTEM
Septic tank-distribution boxisoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system Ives or no) (if yes, attach previous inspection records,if any)
VA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif known)and source of information: •C+' � O—•
Sewage odors detected when arriving at the site: Ives or no)
SUBSURFACE SEWAGE DISPOSAL SVSTW INSPECTION FORM
'ART B
CHECKLIST
Property Address: 246 Pine St. , W Barnstable
Owner: MOSS
Date of Inspection: 6-4-0
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 an&the system has been receiving Vimmal 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 N;A.
_ Tne facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrialwaste flow.
_ The site was inspected for signs of breakout.
All system components, excluding 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:
v _ Existing information. for example, Plan at B.O.N.
_ 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 land occupants.if different from owner) were provided with information on the propermaintaname"f
SubSurface Disposal Systems.
Pagc3of31
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Ieatiewd)
'ropenyAddress: 246 Pine St. , W Barnstable
Owner: MOSS
Date of Inspection:,,,`
BU ING SEWER:
ILoe to on site plan)
Depth below grade:_
Materi 1 of construction:_cast iron_40 PVC_other(explain)
Distan a from private water supply well or suction line
Dia er
Cam ents: (condition of joints, venting, evidence of leakage.etc.)
SEPTIC TANK:_
Ilocate on site plan)
Depth below grade:
Material of construction: ✓concrete_metal_Fiberglass _Polyethylene_otherlexplain) .
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions:_ r!o A?- O
Sludge depth: ' v
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: Ar�,•
How dimensions were determined: 6 Pr,-Ae'r- dZ
-omments:
(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.) /4r6--t] T''A- ,y
G R�AS
TRAP:
(Iota a on site plan)
Depth below grade:
_
Materi I of construction:—concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimen ions:
Scum hickness:
Dista ce from top of scum to top of outlet tee or baffle:
Dist nce from bottom of scum to bottom of outlet tee or baffle:
Dat of last pumping:
C mments:
Ir commendation for pumping, condition of inlet and outlet lees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
vidence of leakage.etc.)
Page 7 of 11
. SUBSURFACE SEWAGE DISPOSAL SYSTEM iuspECTION FORM v
PART C
SYSTEM INFORMATION lounertwd)
aropertyAddress: 246 Pine St. , W Barnstable
Owner: Moss
Date of lnspmbon%,
TIG R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
Iloeate n site plan)
Depth b low grade:_
Material f construction:_concrete_metal_Fiberglass_Polyethylene otherlexplain)
Dimensio s:
Capacity gallons
Design fl w gallons 1day
Alarm pr sent
Alarm 1 vel: Alarm in working order: Yes_ No_
Date o previous pumping
Com nts:
Icond tion of inlet tee, condition of alarm and float switches.etc.)
DISTRIBUTION BOXIII
(locate on site plan;
Depth of liquid level above outlet invert:_
Comments:
Inote if level and distribution is equal. evidence solids carryover, evidence of leakage into or out of box, etc.)
0 6�
PUMP HAMBER:_
llocate n site plan!
Pumps n working order: (Yes or No)
Alarms in working order (Yes or No!
Comm nts:
Inote onditron of pump chamber. condition of pumps and appurtenances.etc.)
1
` Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART C
SYSTEM WFORMATION Icondrawd)
top"Address:246 Pine St. , W Barnstable
Owner: Moss
Date of Inspection:
16--'1-
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:_
leaching chambers, number.
leaching galleries, number:_
leaching trenches, number, length:
leaching fields. number, dimensions:
overfiow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condn on of soil. signs of hydraulic failure, level of ponding. damp soil, condition of vegetation, etc.)
L
C POOLS:_
(local on site plan)
Numbe and configuration.
Depth•t p of liquid to inlet invert:
Depth of Solids layer: `
)epth of cum layer:
Dimensio s of cesspool.
Materials f construction
Indication of grounowater.
nflov. (cesspool must be pumped as pan of inspection)
Comme s
(note c ndmon of soil, signs of hydraulic failure. level of ponding, condition of vegetation, etc.)
PRI _
Irocat on site plan!
Materi Is of construction
Depth of solids: Dimensions:
Com ents.
Inote condition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Pap(9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION feentinred)
Nop"Address: 246 Pine St. , W Barnstable
Jwnw:
awe of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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Pakc10ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM
PART C
SYSTEM WFORMATHM leortderredf
ropertyAddress: 246 Pine St. , . W Barnstable
Owrw: Mo s s
Data,of Inspection:
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 Cehir
Shallow wells 1
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
-Obtained from Design Plans on record
served 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)
/c- C�c Fv l9 9
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Pace11of11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
F DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 246 PINE ST. WEST BARNSTABLE, MA 02668
Owner's Name: HEIDI MOSS
Owner's Address: 161 PARKER RD. W BARNSTABLE MA.
Date of Inspection: 6/19/01
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: if P.O. BOX 2119 TEATICKET, MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditio Ily Passes
_ Needs F -t er Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 6/19/01
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
Notes and Comments a�
SYSTEM PASSES TITLE V INSPECTION AS PER BARNSTABLE BOARD OF HEALTH. THE STAIN LINES IN THE
FLOW DIFFUSERS INDICATE THE FIELD HAS BEEN FULL OVER PIPES,THE INSTALLER OF FIELD, ADDED
NFW STONF; AND SYSTFM APPFARS TO BF, FUNCTIONING PROPERI.N.
.r
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This
inspection does not address howlthe system will perform in the future under the same or different conditions of use.
a
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 246 PINE ST. WEST BARNSTABLE, MA 02668
Owner: HEIDI MOSS
Date of Inspection: 6/19/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D .
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSES TITLE V INSPECTION AS PER BARNSTABLE BOARD OF HEALTH. THE STAIN LINES IN
THE FLOW DIFFUSERS INDICATE THE FIELD HAS BEEN FULL OVER PIPES,THE INSTALLER OF FIELD,
ADDED NEW STONE AND SYSTEM APPEARS TO BE FUNCTIONING PROPERLY.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined" please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
broken pipe(s)are replaced
_ obstruction is removed
_ 'distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
;t
Page 3 of I l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 246 PINE ST. WEST BARNSTABLE, MA 02668
Owner: HEIDI MOSS
Date of Inspection: 6/19/01
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(l)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has 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 n/a
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution fi-om that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this.form.
3. Other:
n/a
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 246
PINE ST.WEST BARNSTABLE MA 02668
Owner: HEIDI MOSS
Date of Inspection: 6/19/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times
pumped Wa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. IThis system passes if the well water analysis, performed at a DEN
certified laboratory,for,coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.l
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
I
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.
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)
yes no
_ X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
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 lies failed, The owner or operator of any large System cunsiddCLl a sighilictait thl°edit
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.
Page 5 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 246 PINE ST.WEST BARNSTABLE,MA 02668
Owner: HEIDI MOSS
Date of Inspection: 6/19/01
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period
X Have large volumes of water been introduced to the system recently or as part of this inspection
X Were as built plans of the system'obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components, excluding the SAS, located on site
X _ 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 '?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15,302(3)(b)]
i
f -
.,Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 246 PINE ST. WEST BARNSTABLE, MA 02668
Owner: HEIDI MOSS
Date of Inspection: 6/19/01
FLOW CONDITIONS
RESIDENTIAL I _•
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents:3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a N•
Design flow(based on 310 CM 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present.(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the'DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1998 NEW SYSTEM INSTAI1EII
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 246 PINE ST. WEST BARNSTABLE,MA 02668
Owner: HEIDI MOSS
Date of Inspection: 6/19/01
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L 10' 6" H 5' 6" W 5'W"t
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL-COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE
GREASE TRAP: _(locate on site plan) 1
Depth below grade: n/a
Material of construction:_concrete_metal_f berglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc,):
n/a
t:;
Page 8 of 1 1
r _
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 246 PINE ST. WEST BARNSTABLE, MA 02668
Owner: HEIDI MOSS
Date of Inspection: 6/19/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
BOX 1S STRUCTURALLY SOUND.
PUMP CHAMBER: _ locate n '( o site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
n/a
F,
u
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 246 PINE ST.WEST BARNSTABLE,MA 02668
Owner: HEIDI MOSS
Date of Inspection: 6/19/01
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
FLOW DIFFUSERS leaching chambers, number: 5
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: nla
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
CURRENTLY THE FLOW DIFFUSERS APPEAR TO BE FUNCTIONING PROPERLY.SYSTEM WAS
PREVIOUSLY INSPECTED AND FIELD SHOWED SIGNS OF HYDRAULIC FAILURE. INSTALLER ADDED
NEW STONE,AND SYSTEM NOW APPEARS TO BE FUNCTIONING PROPERLY, AS PER BARNSTABLE
BOARD OF HEALTH
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic faihire, level of pending, condition of veg ,jmion,
n/a
Paue 10 of'
OFFICIAL INSI11?CTION FOIIM — NOT FOR VOLUNTARY ASSESSMENTS
SUI3SURFACI+, SENVAGF, I)ISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 240 PINE. S'I'. w1,.S'I' RARNSfAIIIA", MA 112668
(honer: IIEIDI MOSS
Date or Inspection: 6/19/01
SKE'1'CI1 OF SEWAGE DISPOSAL SYS•I EM
Provide a sketch o the sewage disposal system including ties to at least two permanent relerence landnuu l<s or benchmarks.
f
Locate all wells within 100 feet. Locate where public water supply enters the building.
-------------
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o R
I �1
A Is 5`J
ACDA
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C 1 .
in
.Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 246 PINE ST. WEST BARNSTABLE, MA 02668
Owner: HEIDI MOSS
Date of Inspection: 6/19/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12 + feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
d Wm. E. Robinson Septic Service
P. O. Box 1089
Centerville,MA 02632
775-8776
December 28, 2000
Ref: 246 Pine Street, Barnstable
To Whom It May Concern:
On March 12, 1998 we installed a new Title-5 septic system at 246 Pine Street,
Barnstable, for a Ms. Heidi Moss. In October 2000 we were infonned, both by her and
her tenant, that water from the septic was running down her driveway.
We went there but could not see where it was coming from. We brought in a pumper
truck and pumped 800 gallons of water into the leaching chambers. It was coming from
the comer of one of the leaching chambers. We dug this up with a backhoe.
The chambers had been run over by an 18-wheeler from Somebody Else Septic Inc.,
out of Orleans, MA., who was bringing in 30 yards of sand. The driver had driven over
the chambers and pushed them all'down.
We raised the chambers up, restoned them, and brought excess fill to bring grade up in
driveway.
We returned to the site in ten days and it was working fine.
We did not charge Ms. Moss for this, even though it was not our fault. It was done as
a courtesy because we had originally installed the system.
The driver that had damaged the chambers also damaged the house across the street
belonging to a Mr. Jenkins.
Thank you.
Wm. E. Robinson Sr.
Wm. E. Robinson Septic Service
cc: Donna Mirandi Barnstable Board of Health.
Wm. E. Robinson Septic Service
P. ®. Box 1089
Centerville,MA 02632
775-8776
December 28, 2000
Ref: 246 Pine Street, Barnstable
To Whom It May Concern:
On March 12, 1998 we installed a new Title-5 septic system at 246 Pine Street,
Barnstable, for a Ms. Heidi Moss. In October 2000 we were informed, both by her and
her tenant, that water from the septic was running down her driveway.
We went there but could not see where it was coming from. We brought in a pumper
truck and pumped 800 gallons of water into the leaching chambers. It was coming from
the corner of one of the leaching chambers. We dug this up with a backhoe.
The chambers had been run over by an 18-wheeler from Somebody Else Septic Inc:,
out of Orleans, MA., who was bringing in 30 yards of sand. The driver had driven over
the chambers and pushed them all down.
We raised the chambers up, restoned them, and brought excess fill to bring grade up in
driveway.
We returned to the site in ten days and it was working fine.
We did not charge Ms. Moss for this, even though it was not our fault. It was done as
a courtesy because we had originally installed the system.
The driver that had damaged the chambers also damaged the house across the street
belonging to a Mr. Jenkins.
Thank you.
Wm. E. Robinson Sr.
Wm. E. Robinson Septic Service
cc: Donna Mirandi Barnstable Board of Health
John enel rs-T1t1e S Seottc Insoecttons
But 2119
UslAct Me.02536
Phone 509-564-6913
Far 509-564.7270 -
•'r
December IS,2000
Mr.duglt
246 Pine St.
W. Barnstable Ma.02668
Dear Mr.CLugh,
in regards to the septic inspection my company performed for you at 246 Pine St. W.Bamstable,from information
provided by you and from my visual inspection, my finding of your system are as follows:
It is apparent the 5- flow diFTusdrs which make ur your soil nbsorbtion system, have been full to the pipe.There is
signs of break-out on both sides. Your information confirms the break-out.
From information provided by you,the installer Mr. Robbinson who installed the septic in 1998,was notified of the
break-out problems in the leach field. When the system was installed the soil absortion system was not properly
covered,which may have been a factor in the break-out.Mr.Robinson brought in more fill to prevent future
break-ous. From.your Information, Mr. Robinson also came back out and excavated along one side of the system and
replaced the stone.This was done a few weeks before the inspection.
During my inspection I probed the ground in other areas around the leach held,where the stone was not replaced,
and my probed came up black.When I was excavating the cover to flow diffusers the soil and stone was black also.
The soil around the leach field appeared to be saturated,howevd"r the now diffusers were empty. At this time,the
system does not meet Title V criteria due to stains lines in the Flow diffusers,and the current saturation of the
unreplaced parts of the leach field.
There may be other factors like plumbing leaks,or the fact the system is getting to much use from 5 people living
there that might play a factor in the hydraulic failure of the system.
M recommendation would be to due a crc test to determine quality of soil and groundwater,then replace the `- .
Y p 9 Y � P
current leach field.
If you have any further questions on my findings,please call. Thank you �4
Sincerely,
'1
John Graci _l 4 r1 n M 2 L) u i r
(,�,
L,.
'ii ra P
I0 -d 160ti8Zb809 t ^I IS AHIUN Wd 2b: t0 00—OZ-83a
John erecl rs-THIe V Septic Inspections
Tow1rket Me.02536
I'll one 509-564-6R 13
Fax 5094 4.7270
December 18.2000
n7
Mr.dugh
246 Pine St.
W. Barnstable Ma.02668 >•:`
Dear Mr.CLugh,
In regards to the scplic inspection my company performed for you at 2,16 Pine St, W.Barnstable,from information
provided by you and from my visual inspection, my finding of your system are as follows:
It is apparent the S-flow diffusers which make up your soil absorbtion system. have been Rill to the pipe.There is
signs ol'break-out on both sides. Your information confirms the break-out.
From information provided by you,the installer Mr. Robbinson who installed the septic in 1998,was notified of the
break-out problems in the leach field. When the system was installed.the soil absortion system was not properly
covered,which may have been a factor in the break-out.Mr.Robinson brought in more fill to prevent future
break-ous. From your information, Mr. Robinson also came back out and excavated along one side of the system and
replaced the stone. This was done a few weeks before the inspection.
During my inspection I probed the ground in other areas around the leach Field,where the stone was not replaced,
w and m robed cam u lack. When i was excavating the cover to flow diffuser t i w y p e p b b she soil and stone as black also.
The soil around,the leach field appeared to be saturated,however the now diffusers were empty. At this time,the
system does not meet Title V criteria due to stains lines in the flow diffusers,anJ the current saturation of the •" '"`t
unreplaced parts of the leach field.
There may be other factors like plumbing leaks,or the fact the system is getting to much use from S people living ,
there that might play a factor in the hydraulic failure of the system.
My recommendation would be to due a perc test to determine quality of soil and groundwater,then replace they
current leach field. �>
If you have any further questions on my findings, please call.Thank you {{'
il,
Sincerely, a.
John GradLi7 r
�k
T0 'd I60b8Zb80S EiA1IS AHION Wd 2b: b0 00-0Z-33a
TOWN OF BA.RNSTABLE
0QCRTION �l'—�//�L 5TAP126 -- SEWAGE # Z
MLAGE ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.tom = /Pd 191eS'OAI- 77j'--.9 7
SEPTIC TANK CAPACITY 4 '
,
LEACHING FACILITY: (type) 5- ��e (size) ,:�S"X A�X-J—
NO.OF BEDROOMS
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 feet of leaching facility) Feet
Furnished by
� f
V
ff
gb
f VI
NS
U
6 -3w 0
No. I Fee $5 Q..0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppfication for Migoml *pztem Conotruction Permit
Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 246 Pine Street Owner's Name,Address and Tel.No. 3 6 2—6 4 4 0
Assessor'sMap/Parcel Wbarnstable, MA Huldah Moss 21 Old Country Wy
W Barnstable MA 02668
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service
P 0 Box 1089 , Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( np
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sandy c-- ay
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic System consisting
of 1500g tank, D-Box and five stonepacked flo diffusers .
5 ' overdig. soil removal .
Date last inspected: 1 10" T07
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sew a disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by t ' o of Health.
Signed Zd-LI .. Date "
Application Approved by Date. - �-� -
Application Disapproved for the ollowing reasons
Permit No. - '1- Date Issued
No. _ Fee $5 0.0 0`
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t ;
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Z[pplication for 33itpaal *pttem (tonttruction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. 246 Pine Street Owner's Name,Address and Tel.No. 3 6 2—6 4 4 0
> 1 Wtarnstable, MA Huldah Moss 21 Old Country Wy
Assessor's Map/Parcel W Barnstable MA 02668
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service '
P O Box 108�, Centerville, MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( n)P
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sandy clay
e — —
Nature of Repairs or Alterations(Answer when applicable) Title `5,, Septic System consistlhgg
of 1500g tank, D-Box and five stonepacked flo diffusers./, r, , /,. ;, 'k�
5,<. overdig so 1 removal. /N j) h C ;
64 .
Date last inspected: rb �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 Certifi-
cate of Compliance has been issued by tWO'Boapdof Health.
Signed i Date
Application Approved by Date
Application Disapproved for the ollowing reasons 1
Permit No. Date Issued
————————————————————————————— ---- - --- -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Moss
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( X)Upgraded'( )
Abandoned( )by
at 246 Pine St, W Barnstable has been constructed in accordance
with the provisions of Title 5 and,the for Disposal System Construction Permit No. -j/ 2 dated
Installer W E Robinson Septic SerV Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date 7 - / I Inspector
---------------------------------------
No. / CK - 1( 1 Fee$5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Moss* lizponl *p5tem Conotruction Permit
Permission is hereby granted to Construct( )Repair(XX)Upgrade( )Abandon( )
System located at 246 Pine Strebt
W Barnstable
Installer: W E Robinson Septic Sery
F
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: 7 '-f - Approved by� 1m
r�
NOTICE:, This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E, Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated 2— concerning the
property located at 246 Pine Street,West Barnstable, MA, meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will nit be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following: ,
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) ld
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED: < J '4"v ` DATE -�)— d2 r/)" ' C�
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
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111 ST A L ER'S I ADDRESS
9 U I L D E R 0R OWNER
0A T E PpiIT ISSU ED
OAT C 0 M ? L I A N C E 15SU € 0
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No.. Fps.... `^.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/�RI ...............0F....A........................A/z..........................................
Appliration for Uigpniia1 Works Tomitrurtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (Jan Individual Sewage Disposal
System at
..... � .._ 1� --..-. ---- .................. ------------------------ -ot-N•-. .:.._..- ---
Local n-. ddress or o
...... ` .... ............ ........................................ ..................................................................................................
O / � Address
ao. •--•.............. ... �Yr Y.... ............_.................-•-.....-•-^•---•-..................._.._.......-•--••--••-•-•----•
Installer Address
UType of Buildin Size Lot___________________________S q. feet
,., Dwelling—No: of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures ••-•-•---•--......-•---•... _-
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area....._............sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by--•-••••=................................................................. Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_--___-__-_.-_--.-___.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 - ::-----•---------- ---------•---------------•--------_.______--------•--_____------------___-----_____-----•----•---------••-•-----•------------------
0 Description of Soil...... - -------- ---- -
U Nature of Repairs or Alterations—Answer when applicable......_ "_ +-_. .'?" nr ''WZ
� e-�_________________•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'LU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by t bo Oh ol lie pith. ,f
Signed.. r ` �`w--F�--
Application Approved By_
Date
Application Disapproved for the following reasons:................................................................................................................
...........................•-•---•-•------•-••--•--•-•---•--•--------------••-•-•-------•--•---..............._.....-•..................................................... ......................
Date
PermitNo... .._-...-....•-�••-- ...... Issued.......................................................
Date
FE$.... .....�.......
THE COMMONWEALTH OF MASSACHUSETTS
. BOARD OF HEALTH
�d' .............OF..... �' :> .
Appliratiun for Dispati al Works Tomitrurt uat Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
........... ......Itez, -Ad,..... ....................................................
Locate nddress or Lot No.
y........................................ ---------------•---•--•-•-----•--------.......-----------•-----------------------....-•--•--•----
Address
............••
Installer Address
UType of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other. fixtures ------------------------------------------ ----------------•----------------------•--•---•-•-......---------------------.......------
-------------
W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter...............:.... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'~ Percolation Test Results Performed by---------•-••---••-••---------------------------------.................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------.............
.. ......................-------------------------------------------------
•------------
•.............
--------------
••......
•-----•--•--
DDescription of Soil......... �-------------------•--•-----------------•--------------------------------------------•---------------------------------••--•--•--•---•---
x
W -----------------------•----•..._.......---•----------••-----••-•-•---•-•-------------........................ a r a
x Nature of Repairs or Alterations—Answer when applicable...... "� �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITTIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boad o health.
C'
Application Approved By................... - -- --- ----------"................... -4��-_----------�--
Date
Application Disapproved for the following reasons:................................----------------------•-----------------------••---------------•-•-----------•.
..............................•----•----......_....--------------------.......--------.......-------•----------------------------------•---------------------------------•--------------•---------------
Date
Permit No....4� --7.../-`-/A..2..... Issued.......................................................
., Date
THE COMMONWEALTH OF MASSACHUSETTS
--w- BOARD OF� HEALTH
..... ........ ....................
(Irdifiratr of Tautph atta
THI ^T FRTIFY�1 That the Ind:j+idual Sewage Disposal Slstem constructed ( ) or Repaired
y - -----------
: / In aller t
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as esc ed in the
application for Disposal Works Construction�Permit No..... - "/ _ _. dated...... ?, ' . ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................•S ...�.....`..G•-------•---•----•-----.. Inspector............ .... ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r '
.......
e ... .......:..........OF......:......
N : ..�..... Q FEE . :.............---
Disposal urkii 00unotr ion rrntit
i. � x.! °`n Ural,..✓ ,� zy;..- s. F1�.F'�'f,! .f.. .�//
Permission is hereby granted ......... ..... .......... -- . ..-----.................---....
to Construct (��) or Repair ( A:)'an Individual Sewage Disposal System f
,� /v
Street � /
as shown on the application for Disposal Works Construction Permit No..._AS?'-02-2-bat
?ATE.... ,� . . . Board of Health
. .._ ....
FORM 1255 OBBS & WARREN, INC., PUBLISHERS I