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Home My WebLink About0338 PLEASANT PINES AVE - Health 338 Pleasant Pines Ave,, A= _bye o _ a TOWN OF BARNSTABLE vC ON 3 ?Ar"j .. t-4� � - SEWAGE #�aC—6S 2 VILLAGE Aft, (Al- 99'01 S-6r,,(-& "" ASSESSOR'S MAP & LOT Z/y-07 d INSTALLER'S NAME&PHONE NO. llVrkR A..G---V SEPTIC TANK CAPACITY X 1 D� LEACHING FACILITY: (type) 2 /°''f@T-s (size) t�^�i�i� #`E X I/X 7 NO.OF BEDROOMS 41 �T BUILDER 0 OWNE PERMIT DATE: 1' Z 9- 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) . ;,j, Feet Edge of Wetland and Leaching Facility (If,any wetlands exist within 300 feet of leaching facility) Feet Furnished by LOT, NO. : ADDRESS : OWNERS NAME: SEWAGE PERMIT N0. :Z401 NEW: REPAIR: DATE ISSUED- DATE INSTALLED: iNSTA.LLERS NAME INSTALLATI0'1 OF,: WATER_TABLE:.-" FINAL INSPECTION BY: DRAWING OF INSTALLAT,fON ON REVERSE SIDE : ;: , �f..y R• _ r,` - C Ovf�f` S,T` i TOWN OF BARNSTABLE LQCA'I'ION �0 f,4-"A4 PV';VC.S 4VSEWAGE # VILLAGE (�, T�A f"r/ ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO. d2IN SEPTIC TANK CAPACITY O LEACHING FACILITY:(ty (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 4 1lr9-/ y") DATE PERMIT ISSUED: y DATE COMPLIANCE ISSUED: �� '' L 5-� VARIANCE GRANTED: Yes No TOWN OF F STABLE II `.00r�TIO,N, 1 C� 11"CISEWAGE # _ vILL;AGE d&� SSESSOR'S MAP & LOTZI�I'O�o . t INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACIL=: (ty. ) (siz l 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 C l q L 33 to s� °LSD C ION S E W A.G E PERMIT NO. 'VILLAGE I STA LLER'S NAME i ADDRESS y R U I L D E R OR OWNER 41IJ�; )"K3 DATE PERMIT ISSUED ' DAY E COMPLIANCE ISSUED i r � � a I - � c f - , /J /J r: 4 d, 3 Town of Barnstable Regulatory Services TIME r � Thomas F.Geiler,Director Public Health Division • BARNSTABLE, MASS. Thomas McKean,Director ��lFn 039. A 367 Main Street; Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 31,2001 Mr. John Veveiros Department of Environmental Protection 20 Riverside Drive Lakeville, MA 02347 RE: 338 Pleasant Pines Avenue, Centerville Dear Mr. Veveiros, Pursuant to our conversation on the telephone today, attached are the following: a copy of a brief report prepared by Health Inspector Donna Miorandi, R.S., a copy of the as- built card, disposal works construction permit, and a copy of the septic inspection report completed by John Graci. As we discussed on the telephone today, please schedule a review of this matter at your next available committee review meeting. If at the conclusion of the review, the committee agrees that the inspection was deficient, I request that you take appropriate action against this septic inspector. Sincerely Yours, G as A. McKean cc: Alan Burt,338 Pleasant Pines Avenue,Centerville,MA 02632 January 30,2001 Mr.Alan Burt 338 Pleasant Pines Avenue Centerville,MA 02632 Dear Mr.Burt:. This letter is being written as a result of Mike Leary's inspection and subsequent phone call to this department on Friday,January 26,2001. Mr.Leary,a licensed septic installer,called to state that there were septic problems at 338 Pleasant Pines Avenue,Centerville and requested an inspection for that afternoon. Donna Z.Miorandi,R.S.,Health Inspector for the Town of Barnstable,inspected the system at 338 Pleasant.Pines Avenue. The whole system had been exposed(as shown in Exhibit A)by Mike Leary. The infiltrators(installed 3/18/94)at the time were full to the top with sewage effluent. Exhibit B is the completed permit for the installation of those infiltrators. The distribution box that was exposed was down a depth of 5 to 51/2 feet. It is clear that the d-box had an inlet and three outlets. Two of the outlets led to the existing leach pits and the third outlet goes to the trench of infiltrators. Exhibit C is a copy of a PASSING septic inspection report performed on January 13,2000 by John Graci. It is quite obvious to me that Mr. Graci did not locate the trench of infiltrators installed in 1994. This is duly noted in his report by the absence of the trench in his diagram(p.10 of Exhibit Q. On page 8 of Exhibit C Mr. Graci did not indicate that he opened the distribution box(d-box);just n/a is noted. Due to the depth of the d-box and the lack of disturbance of the soil I must believe that Mr.Graci did not open the d-box. If the d-box had been opened Mr.Graci would have seen the three outlets and located the trench of infiltrators thereby exposing the failure of this trench. If you have any questions please feel free to call me at the Town of Barnstable Health Department,(508) 862-4644. Sincerely, Donna Z.Miorandi,R.S. Health Department Enclosures I No. �`°"` �� Z Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE., MASSACHUSETTS Zipprtcation for Dizpaar *pg em Construction Vertu Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.. ECjsC /� Owner's Name,Address and Tel.No. Assessor's Map/Parcel 2 N Q 7 ® `!w 6U t Installer's N(a�me,Address,and Tel.No. 7 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size G A sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow c 1 9 0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank _( 0 Q Type of S.A.S. �='t eL 0<j`_5 t cD rt e Description of Soil r ��- '^Ca� ��OLV,$' dy` -e- ez l Nature of Repairs or Alterations(Answer when applicable) v G r Gt 60, ` 1 XL CT 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 Certifi- cate of Compliance has been issued y th' Bo f Health. Signed Date Application Approved by Q A Date Application Disapproved for the following reasons Permit No. '��_�� — Date Issued Z9 b er: ✓ No. S Z '_� Fee v i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: , -- `" Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migpoal *p5tem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. elrS4K �� Owner's Name,Address and Tel.No. Assessor's Map/Parcel ( r,( 0 ? C) �U Installer's Name,Address,and Tel.No. O -• S t Designer's:dame,Address and Tel.No. Type of Building: / G Dwelling No.of Bedrooms �l Lot Size Q A sq. ft. - Garbage Grinder( ) Other Type of Building No. of Persons - Showers( ) Cafeteria( ) Other Fixtures Design'Flow (1 9 gallons per day. Calculated daijy flow gallons. Plan Date Number of sheets Revision Date Title, A Size of Septic Tank O Q d Type of S.A.S. w 4, �-5 'tO n e- Description of Soil 3Q Nature of Repairs or Alterations(Answer when applicable) v G r it xL L T Gr 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 Certifi- cate of Compliance has been issued by thi B oarol Health. C Signed Date Application Approved by C .r Date Application Disapproved for the following reasons ti t Permit No. Z-'L/ oS Date Issped 7- d THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIF ,that t e On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded(I-le Abandoned( by '�L e- 4 n, at f f e 4'h , o t has been construc ed in 4ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No._Z-1W•1-0-57 Zdated Installer M r k P L f'G►"Lf Designer The issuance of this peppi�t ss all not be construed as a guarantee that the cyst m ill fuaicti'-r�as desrg ed.'� Date 71�'1/ 0 Inspector --------------------------------------- No. 7e"?,a -0S Z Fee Z y V 70 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSSACHUSETTS Migpogai *pZtem Construction Permit Permission is hereby grante4 to Co struct( )Re air k )Upgrade( )Abandon( ) System located at 3-36 �� c, S � T t K. le 5 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 in st be completed within three years of the date of this it. G 7 Date: 2 9/Zy Approved by !7� t - 1 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. a CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) L Zte Zp G'' , hereby certify that the application for disposal works construction permit signed by me dated f — 2 j / concerning the property located at �� r'S � �t �� meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within l50 feet of the proposed septic system z' There is no increase in flow and/or change in use proposed -"There are no variances requested or needed. . The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation.jAdjust the groundwater table using the Frimptor method when applicable] 0 If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation (using GIS information) "7 �' 2— B) G.W. Elevation +the MAX. High G.W. Adjustment. _ DIFFERENCE B. WE and B SIGNED : DATE: [Please Ske ch proposed p n of sy on back]. NOTICE Based upon the above information, a repair permit will be issued for_ bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cent i 5 i� �puv ,TOWN OF BARNSTABLE ' I LOCATION 33 Miokt ati; t- 4- SEWAGE #Z-vi<'"61 Z VILLAGE QC�-r 5tr,(0 ® MESSOR'S MAP & LOT Z/S/—d7 0 ' INSTALLER'S NAME&PHONE NO. P41-,kRLeft/ SEPTIC TANK CAPACITY X I d LEACHING FACILITY: (type), / (e)riS (size) ��►��v' �f Xl/X NO. OF BEDROOMS iq :,..D 1�1.LG21 V ViO. W1V�K/ LJv ,� PERMITDATE �'' 9-�� COMPLIANCE DATE: ZLIY/d/ 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 faci14) Feet a Edge.of Wetland and Leaching Facility(If any wetlands exist i within 300 feet of leaching facility)` Feet Furnished by IF 14/ J y P_ H r ,n o r� REPORT FROM HEALTH INSPECTOR DONNA MIORANDI This report was prepared as a result of Mike Leary's inspection and subsequent phone call to the Public Health Division Office on Friday,January 26,2001. Mr.Leary,a licensed septic installer,called to state that there were septic problems at 338 Pleasant Pines Avenue,Centerville and requested an inspection for that afternoon. Donna Z.Miorandi,R.S.,Health Inspector for the Town of Barnstable,inspected the system at 338 Pleasant Pines Avenue. The whole system had been exposed(as shown in Exhibit A)by Mike Leary. The infiltrators(installed 3/18/94)at the time were full to the top with sewage effluent. Exhibit B is the completed permit for the installation of those infiltrators. The distribution box that was exposed was down a depth of 5 to 51/2 feet. It is clear that the d-box had an inlet and three outlets. Two of the outlets led to the existing leach pits and the third outlet goes to the trench of infiltrators. The attached copy of a PASSING septic inspection report(marked Exhibit C)performed on January 13, 2000 by John Graci. Apparently,Mr.Graci did not locate the trench of infiltrators installed in 1994. This is duly noted in his report by the absence of the trench in his diagram(p.10 of Exhibit Q. On page 8 of Exhibit C Mr. Graci did not indicate that he opened the distribution box(d-box);just n/a is noted. Due to the depth of the d-box and the lack of disturbance of the soil,Ms.Miorandi believes that Mr. Graci did not open the d-box. If the d-box had been opened Mr.Graci would have seen the three outlets and located the trench of infiltrators thereby exposing the failure of this trench. � S 31,AV) Donna Miorandi,I a "31� 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 338 PLEASANT PINE AV. CENTERVILLE Name of Owner JANE KOPPEN Address of Owner: SAME Date of Inspection: 1/13100 Name of Inspector:(Please Print)JOHN GRACI ��," I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: n/a ( Jq Mailing Address: nla N 2 Telephone Number: nla >0lyN0F 8 200 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-functirion maintenance of on-site sewage disposal systems.The system: X Passes The inpection Is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:1/13100 The System Inspector sh I submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. revised 9/2/98 Page 1 of 11 • c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nla One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is Imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n/a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced n& The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction is removed revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1113/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla-(approximation not valid). 3) OTHER n& revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 339 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13100 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n&. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 338 PLEASANT PINE AV.CENTER VILLE Owner: JANE KOPPEN Date of Inspection:1/13/00 Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13/00 FLOW CONDITIONS RESIDENTIAL: Design flow:JiQ g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 40 Number of current residents:) Garbage grinder(yes or no):M Laundry(separate system)(yes or no): MQ If yes,separate inspection required Laundry system inspected(yes or no)M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): n1a Sump Pump(yes or no): NQ Last date of occupancy: nla COM MERCIAI JINDUSTRIAL Type of establishment: nla Design flow: n/a gpd(Based on 15.203) Basis of design flow: nla Grease trap present:(yes or no):�LQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):No Water meter readings.if available:n(a Last date of occupancy: nla OTHER: (Describe) n/A Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: 129Z System pumped as part of inspection:(yes or no):MQ If yes,volume pumped Wa_ gallons Reason for pumping: n/a TYPE OF SYSTEM X Septic tank/distribution box/soll absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: ORIGINAL SYSTEM IS 16 YEARS-WITH A REPAIR 1993 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13/00 BUILDING SEWER: (Locate on site plan) Depth below grade: Z.6., Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: Z• Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO n1A Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: Z Distance from top of sludge to bottom of outlet tee or baffle: W 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: ].6" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) Wa Dimensions: n& Scum thickness: n1A Distance from top of scum to top of outlet tee or baffle:j3& Distance from bottom of scum to bottom of outlet tee or baffle nta Date of last pumping: n1A 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.) nta revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1113/00 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n(a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nla Dimensions: n/a Capacity: nla gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:_nla_ Alarm in working order:Yes—No—: NQ Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nla DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n& PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa 4 revised 9098 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number: 2-1000 GALLON LEACH PIT leaching chambers,number: _n/a leaching galleries,number: jiLa leaching trenches,number,length: n1a leaching fields,number,dimensions: n1a overflow cesspool,number: n1a Alternative system: n(a Name of Technology: 11La Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PITS ARE STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE NEW PIT HAD 1'4"OF WATER IN IT. CESSPOOLS: - (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n(a Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) W revised 9/2198 Page 9 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a O� g q i D I aI �G OC RQ �4 ti LP revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1113100 NRCS Report name: n1a Soil Type: Wa Typical depth to groundwater: nla USGS Date website visited: n(a Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 COmmorwveatth of MOSSOChUSetfS ,John Grad a AL Executive Office of Environmental Affairs D.E.P. Title V Septic Itpector Department of P.O. Box 2119 2536 Environmental Protection Te 08) MA 0 R 13 (508) 5G - 7 b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION qPR 2 Property Address: 338 Pleasantf3ifw-Av. Address of Owner: 1991 Date of Inspection:4110197 (If different) Tgg Name of Inspector:John Gracl George Maine �fPT Company Name,Address and Telephone Number: t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection Is based on criteria defined In Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is Needs Further Evaluation B the Local Approving Authority performing at the time of the Inspection.My Inspection does Y PP 9 tY not Impty any warranty or guarantee of the longevity of the Fails ! septic system and any of its components useful life. Inspector's Signature: Date: 4117197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 the 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: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.) _ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Pleasant Pine Av.Centerville Owner: George Allaine Date of Inspection:4110197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _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: _ 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has aseptic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D) SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage in 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 cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 338 Pleasant Pine Av.Centerville Owner: George Allalne Date of Inspection:4110197 D] SYSTEM FAILS(continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers 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] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ 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: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) 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 11115195) 3 I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 338 Pleasant Pine Av.Centerville Owner: GeorgeAllalne Date of Inspection:4110197 Check if the following have been done: x Pumping information was requested of the owner,occupant,and Board of Health. X None of the system components have been pumped for at least two weeks and the 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. NaAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was Inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 I . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 339 Pleasant Pine Av.Centerville Owner: George Allaine Date of Inspection:4110197 FLOW CONDITIONS RESIDENTIAL: Design flow: 550 gallons Number of bedrooms: 5 Number of current residents: 4 Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallons/day 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: n1a Last date of occupancy: n1a OTHER: (Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped tank only 2 months ago. System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution boy/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 12 years original with new pit intalled in 1904 Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) 5 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Pleasant Pine Av.Centerville Owner: GeorgeAllalne Date of inspection:4110197 SEPTIC TANK: X (locate on site plan) Depth below grade: Z' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 10'6'H 5'7'W 4'10" Sludge depth:1' Distance from top of sludge to bottom of outlet tee or baffle: z6' Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle:0 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.) The septic tank and all components are structurally sound Recommend pumping the system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle:n1a 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.) nla (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Pleasant Pine Av.centervllie Owner: George Maine Date of Inspection:4110197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of con struction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee, condition of alarm and float switches, etc.) rda DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) D-box Is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Pleasant Pine Av.Centerville Owner: GeorgeAllalne Date of Inspection:4110197 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: nla Type: leaching pits,number: z$x4•leach pits leaching chambers,number:nfa leaching galleries,number: nfa leaching trenches,number, length: nfa leaching fields,number,dimensions:nfa overflow cesspool,number:nfa Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The overflows are structurally sound and functioning properly. CESSPOOLS: (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: nfa Depth of solids layer: nfa Depth of scum layer: nfa Dimensions of cesspool: nfa Materials of construction: nfa Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection) nfa Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla PRIVY: (locate on site plan) Materials of construction: nfa Dimensions: nfa Depth of solids: nfa Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nfa (revised 11115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 339 Pleasant Pine Av.Centerville Owner: GeorgeAllalne Date of Inspection;4110197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' U � g � A f) cG.1 AA A 3,AC A� 51 (A �D �3 DEPTH TO GROUNDWATER Depth to groundwater:11 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 339 Pleasant Pine Av.Centerville Owner: George Allaine Date of Inspection:4110197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � D AA AC `I7 51 OA i� DEPTH TO GROUNDWATER Depth to groundwater:11 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9 I Ai COMMONWEALTH OF MASSACHUSETTS e EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector `•`�` ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 s • Tea i icke� ivia. (508)564-6813 /* C TRUDY COXE Secretary " ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 338 PLEASANT PINE AV. CENTERVILLE Name of Owner JANE KOPPEN i Address of Owner: SAME 7 � Date of Inspection: 1/13/00 .'. Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Secdon 15.340 of Title.5(310 CMR 15.000) Company Name: n/a ✓ EY Mailing Address: n/a A N Telephone Number: n/a ft , ip;1NCF D CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below is trueracAgrate 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-sfte sewage disposal systems.The system: X Passes The inpection Is based on criteria defined In Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date: 1/13100 The System Inspector sh I submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of comoletina 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 the system owner and copies sent to the buyer,If applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1113100 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310.CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nla One or more system components as described in the`Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination.in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13100 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15:303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has.a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER nLa E revised 912/98 Page 3 of 11 I L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART A CERTIFICATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE P Y Owner: JANE KOPPEN Date of Inspection:1/13/00 _, You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high ground%rater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design now of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13100 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with NIA, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13/00 FLOW CONDITIONS RESIDENTIAL: Design flow:—M g.p.d./bedroom Nu..-Zci,Ai 4 Num.,.ai CA ;aCivaij:1 Total DESIGN flow: 44Q Number of current residents:) Garbage grinder(yes or no):YES. Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):MQ Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): n& Sump Pump(yes or no): MQ Last date of occupancy: n1A COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: r Ca gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):.iM Industrial Waste Holding Tank present:(yes or no): 1LQ Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:DLa Last date of occupancy: n/a OTHER: (Describe) DLa Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: 1997 System pumped as part of Inspection:(yes or no):MQ If yes,volume pumped nla. gallons Reason for pumping: nla TYPE OF SYSTEM X Septic tankidistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nla APPROXIMATE AGE of all components,date Installed(if known)and source of information: ORIGINAL SYSTEM IS 15 YEARS-WITH A REPAIR 1993 Sewage odors detected when arriving at the site:(yes or no) MQ revised 9/2/98 Page 6 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13/00 BUILDING SEWER: (Locate on site plan) Depth below grade`. 2 6" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of Joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: Z Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nla Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: Z Distance from top of sludge to bottom of outlet tee or baffle: 3 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: I How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) aLa Dimensions: Wa Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:jiLa Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping: nLa 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.) nLa revised 9/2/98 Page 7 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13J00 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nta Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: nLa gallons Design flow: nLa gallons/day Alarm present: NQ Alarm level:-nLa- Alarm in working order:Yes—No—: NQ Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.). nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) llLd PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nla revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13100 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type. leaching pits,number: 2-1000 GALLON LEACH PIT leaching chambers,number: j3La leaching galleries,number: _nLa leaching trenches,number,length: nLa leaching fields,number,dimensions: nLa overflow cesspool,number: n& Alternative system: nla Name of Technology: _oLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PITS ARE STRUCTURALL SOUND AND F UNTIONIN PROP R Y THEN W PIT HAD 1'4"OF WATER IN IT. CESSPOOLS: _ (locate on site plan) Number and configuration: nta Depth-top of liquid to Inlet invert: nLa Depth of solids layer: nta Depth of scum layer. n(a Dimensions of cesspool: nta Materials of construction: nta Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)nta Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) DLa PRIVY: _ (locate on site plan) Materials of construction:nLa Dimensions:n& Depth of solids: 19a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla revised 9098 Page 9 of 11 i L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1/13/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a n �I � q ❑ f oI �G oL OC � 14` j4 LP L revised 9/2/98 Page 10 of 11 v o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 PLEASANT PINE AV.CENTERVILLE Owner: JANE KOPPEN Date of Inspection:1113100 NRCS Report name: nLa auii Type. Li.$ Typical depth to groundwater: nLa USGS Date website visited: Wa. Observation Wells checked: MQ ' Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 I 4 APPROVED THE COMMONWEALTH OF MASSACHUSETTS e sta. Copse BOARD OF HEALTH TOWN OF BARNSTABLE IS nod Oeto Appliration for 3 i oott1 ork,i Towitrnrtion Prrmit Application is hereby made four as Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System ate. � iC__.._.. 5� � Location-Address or Lot No. C � . s Owner Address , 1272 � Installer Address UType of Building Size Lot.............................Sq. feet Dwelling—No. of Bedrooms....... ----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type 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........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..................... Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._-__-----_-_---___-_. a ................................................. ........................................................................................................... 0 Description of Soil........................................................................................................................................................................ x U •--•--••--•-•••---••-------•••-••----------•--------------•--------------------------•--------•---------•-••••-••--••-••••-••-•••---•---•---...•---••---•---••-----••-•-•-••-........---•-•----•-----••• x •---•-••--•-----------•------------------•..........._ - -----�-------------------------------------------%.....•---...... ............... U Nature of Repairs or Alterations r � � � f r e a�� ____. _-----•-- r ---------------------------------------------------------.-C-------!------ 5 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complyes been issued b the bo rd of health. Signed .... ..�h ............ Q ---.::. J�.'.._.....� ..Y.. Application Approved BY .. . .................. ----....---..........Application Disapproved for the following rear ............................... . .................... ............---------- --- .... .................................. . . - Permit No. ..... ................ � Issued ...... .. .................. .... ice...... ace +. 100, Z�7 No....q....... Fps......:::...'.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE � f pliration for ioiaooal Morko Towitrur#inn 11rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location Address or Lot No. --•-•--•.. .�/.. a-< rt2 . . , + S/...lj ... .. ..... ........ ............ . .. . ----.... ... Owner Address v a -••...� .--•�•--- 1°�fa 2 ...�.-- --•--f-`---------------------•--•------ ---`------��f..�C G�_..-.... .. ..h...... / Installer Address Type of Building _ Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ............................ No. of persons---.-__-_-___-__-____-..---_ Showers ( ) — Cafeteria fixtures --------------------------------------------------------------------------------------- ------------------------------------------------•--•--------- W Design Flow............................................gallons per person per day. Total daily flow..........................:.................gallons. W Septic 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 ( ) 0-4 a Percolation Test Results Performed by.......................................................................... Date...................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Deptli"to"ground-water..................... ... f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•-•---•....................•-•••••---•---•----•-----••---------••----•--------.....--•----•-•.............•---•---------•--------......................... Description of Soil............................ ___a -- U --•----------------------------------------------------•-------•---•------•------•------------------------------------------------------•---------------•--•------------•----------...........---------- W ----••---------------------------------------------•---•-•----------------------....-•--•------•-------•--..... '............................................ Nature of Repairs or Alterations—Answ�er`r wh/en/a/p licable _._�'ar _ � r.__ . 3__._ �1� ✓ �7i2. r?S Ali Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ( J — Signed ........` / .................................... �� ..% ......./.�` ...:.. ...... `_. ...... ram/"�L Approved /�.Jit "i v/�.� �7 .I�• EG /��1 I �7 ApplicationBy ,....._............... _ 1 - -;........-..:....................:.. ----��---_--------------------- 'Dare Application Disapproved for the following rear ....... . ........................................................................ ................ . ...................................................I..........Z-----------------------------------.......----'--------"--------'------------'--.........................................../........./-_ry --/ J.. �� l Dace- Permit No. .. [.."1......".".....1...(.d'.(.:.!... ......_ Issued a l--�LL.�G�..�.............. ------------ -------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �L !!��'QrttftCatQ of CritII liala t~E THIS IS TO CER IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired U` / t c.�l �J r by ...----- 7..............._.......... ......._................-------------------------1� = �� v - �, at ................................... . ._�j,en2ev :.........rf-�,z1�s------ ---------------------- -�'/.....Instakr /,C`/.--..1�� -----i_.......... ----------------------------------- has been installed in accordance with the provisions of TITLE 5—of The State E vi•ronmental Code as described in the application for Disposal Works Construction Permit No. ..._ -. .....''.C. C� dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ...`....f..�✓.... 7.....- - ------- Inspector J ._...... .... ----------- ---------------------- -------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE N .............. FEE... ............. Diopnoal Workv Tono#rudion "ami# Permission is hereby granted•-.._._•-._._T ........................... to Construct ( ) or Repair (- k an Individual Sewage Disposal System at No.----•-..;ff + /�..� Art/-f-•--------••-�_. i2J s r w .fi42f�................................. -- --- --- ••••-= ............... street n�� as shown on the a717 lication for Disposal Works Construction Permit Bayted_.:.------____ l_________________ ....... Board of Healhh DATE ...... r ----- ----------------------------•--•- FORM 36508 HOBBS✓k WARREN,INC..PUBLISHERSC zz TOWN OF BARNSTABLE ,J LOCATION 4SEWAGE # VILLAGE ASSESSOR'S MAP LOT I INSTALLER'S NAME & PHONE NO. ./ l - �lok//Tj 3 2- Sp(—p SEPTIC TANK CAPACITY �U U LEArRlM(: RAOTT TTV./r....ol NO. OF BEDROOMS y� PRIVATE WELL OR PUBLIC WATER C�j? BUILDER OR OWNER . G e D DATE PERMIT ISSUED: '3 f �/ DATE COMPLIANCE .ISSUED: --� '— Z .. VARIANCE GRANTED: Yes No fL� ....__.. r o �XN � i 1 .�_ ` e-._ i No...5�. �.�.tb 7q Fss. a THE COMMONWEALTH OF MASSACHUSETTS - -, - BOAR® OF HEALTH .................. . ...............OF.-.............-......... Applira#ion for Dispaii al Workii Tonotrurtinn famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: . Y.. ..__......_.......... ------------------------------------- 7....- - - --- Location-Address or Lot No. 1.11d... Z. lltil..V j u/....d?R.r...C' € l/./.CLEF^91 Owner Address .......................................... ... 1...fool�h` .�f..... - A._ .! !�{1...1r Installer Address Type of Building Size Lot. _,5_9b........Sq. feet Dwelling—No. of Bedrooms.................. ----------------------Expansion Attic ( ) Garbage Grinder a`4 e of Building r. (/) Other—T yp g ........:��______.__. No. of persons.______!�'__________________ Showers (�„) — Cafeteria 0 Other fixtures -----•......--••••-••-••--•-•-••. ....•-•••-------•••••-••••--•---•--•••••----•--••---•--•---------•••••••-••-•••------••--•...............••---- W Design Flow............ ..............gallons per person per day. Total daijy flow........... W.......................gallons. W Septic Tank—Liquid capa it Q gallons Length___._......... Width----- ....... Diameter________________ Depth_.._Lltt........ x Disposal Trench—No. ......��...... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------:Z------- Diameter___...4�.._....._. Depth below inlet................ Total leaching area...? i�...sq. ft. Z Other Distribution box (f ) Dosing tank ( ) aPercolation Test Results Performed by----A1 44&2 ', ..............•................... Date. �_Z !_ - ...•..•...... I.Test Pit No. ....5_-----minutes p er inch Depth of Test Pit... t ........ Depth to ground water_._'! i..______.__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •--•-------•---•-----••......-•••••......•...�........----•-.....-••••--•.................................•------•----•-•----......._......-----..._....... 0 Description of Soil------- ! .-- ?- Q--- W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..------•-------------------------------•--•------------------------•---------------....---•--.....-----••--------------------------------------------------.........-------------------•--•---......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b i ued by t board of health. igned-• Cry- .... ........ ................................ �t'�/�j •i�' �/ Dat Application Approved By---.....—�_�� .... a----......- r --•••-••..�Ir Da e Application Disapproved for the following reasons:-------•------••----•---•-----------------------•------------•------- ...................................... .........................••--•--------•-----•------�........-•---•------.....-•------------...._...------•-••---•-•---•------••-••••.........-••--•----•---• ........................................... Permit No..--S:!_._.^ `U� .-----.. Issued_....................................................... -----.........----.._Date--•--- Date No.-_ . I.-._........ FEs............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....--" --....... ................OF................................_.....----------•-----..........---..__..._... Appliration for Dispas al Works Tonstrur#inn truth Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_........_...........................................................•-----_.... ........_....•••-•-•••------•-----........-•-•-•-----------•-•--•---------•------............--••- Location-Address or Lot No. ......................—.......................................................................... .........._....................................................................................... Owner Address W ...••... .. ........F PQ Installer Address d Type of Building Size Lot............................Sq. feet V g— .....Expansion Attic ( ) Garbage Grinder ( ) Iwellin No. of Bedrooms...................................... pal ,Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) p-' F-, Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid ca.pacity._...__.....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........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-___-__-__-____.•____.. fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------------------------------•---------•----...........-------------•-----•-•••••.----••........................................................ 0 Description of Soil----------------------•------------•------......------..............--------------------------------------------------•----....------------............------------.... V W -�----------- -------------- --------------------------- •------ ----------------------- ------------------------------------------------------------------------------------------------ •-••-•-•••••-•--••... -----------------------------------------------------•-------------------•---------------------------•-----------------------------------••--------------•---•-•---•-•----•... V Nature of Repairs or Alterations—Answer when applicable............................................................................................... r.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. _Signed------------•--------------•------------------------- •-----....--------------------- --------------------•---.._..._ Date Application Approved By....... __.._ i��;1�- �!• � s"��« ~"-r f ( -y �`�' Da e Application Disapproved for the following reasons---------------------------------------------------------------•-------------................................... Date Permit No..... --- --�U�. _ ---•--- ^� Issued- ------ --- --------• --------------•--- -- --•-•-----------•--•--•- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............................I.,........OF...................................................................................... TntifirFatr of ToanpliFana THIS S TO CERTIFY, That the Individual Sewage Disposal System constructed (,4-f or Repaired ( ) � t bye r�, ,;. � " --- .......•-•----•----•------•••-•-••---••--•-•-•......................................•-•------•--•..._.. ------` •..._........ } Installer ...'......1 . ...C.. .1 n .... .. �,�I1 has been installed in accordance with the provisions of TITLE 5 of T e Sate Sanitary Cod as .described in the application for Disposal Works Construction Permit No..... .... t dated " �/ �..--'---V.............. THE ISSUANCE F THIS CERTIFICATE SHALT. NOT BE CONST UE® AS A G ARANTEE THAT THE w SYSTEti9 .VlIILL F N TION SAT SF.ACTORY. _... • y C - DATE--•-•-. •-•-••---•--------� .......... ..... .. Inspector.........--- ----------•----•--••-----------•--•------...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... No......................... FEE..... :- .:......... Disposal Vorks4 Ton#rurtion amit Permission is hereby granted.......11.......... �' ':A k. to Construct ( or,Repalr ( ) an Individual Sewage Disposal System at No a '� ------ - - ----�.. -----------------------------------------•-•- " ....._...t _a/°�t Street �l a.w r`, as shown on the application for Disposal Works Construction Permit No "s._-_�17Dated._.._j.1. .:.1__A.................. _.M.,..._._-�--��.-�-� lam:�'!�_�c -_��.- ------•......-••••------ ..... --------------------_ fi' �+, .... Of .............................. Board of Health DATE------ •---_..__. ..�.... ............. FORM 1255 A. M. SULKIN, INC., BOSTON L0 C ION S EW A G E PE R M I T NO. 72�Tr vi E 4),-/, VILLAGE STALL R'S NAME ADDRESS �U NSF CL� i I R U I L D E R OR OWNER �rl ) DATE PERMIT ISSUED I DATE COMPLIANCE ISSUED v � � r cry � C � i y� .{ AX8 1 3 LUT 3s. 6 :Pits V/2' sltdnE;. 10064 EX W 5a0 i 14, . i i , , I 7 . Ir l -7 (N DRIB 2-6ij�4..t. t t 4 ,. .. 44 2 W .. . ..r _. _...... .3 S , Tel G.J . .T:. i f'LAN. SCALE 1''-40: P:Rp FILE DATE '11/8/81 No' �cALE All C2pe Engineering; w j 49 Harbor Road t HyP-nnis, Mes9. 02b01 ! e. f7d. ti footing i, . -.. _. N � i -SKETCH; PLAN' OF LAND1 IN 1344NSTABLE'-'MIA for ; EQRGE AAL}4.IN Being' lbt ;"! as: shows on: a r Trust 8Y'1 i pl h -fo n Realty ' P__ ;rze xS. . ,._E 1msJiuth,.PTass:._- i�e:cor_aed,._z: i book 36$ age: 55 1 . . . ; Elev,at o}z ', showh' ar , on ah'_as wined; .datum. DATE 12A3/82 j `Date: ` j Barnstable- $oara' of, Health E1�G�. W� --1,I `�BJ;';T•;A'TJ -. :- a : .:_,. �.__; j-.- _:__ .. ..; _ .:_ .: __ -._. . : _ T TI T:. J..JA,CO.bI TOP SUB SAi'I) ST0iyT 1 p, FRANK FRANK I oU, COtERY -�, CONERY y NO 8573 - � SU 0 R `s'iATE)� � dCOUI�J.TERED; ;5. NI:N., FE INCH. '$ 4 r< i - 11 I � b"191 1�1 No.-•- t _ Fps.............................. ApPROQ THE COMMONWEALTH OF MASSACHU SETTS a sta 1.:onae BOARD OF H E A L T H 4 TOWN OF BARNSTABLE 1 ne ......W D6-. Appliratinit for D4-11111' tl War1w Tvii ifrttrtitin Funtit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address C or Lot No. .. .. .................... :...:... 1_.lr ---- --•....................... ------ ... -----. ---.-.s� _..........--•--.....---------•.._...-----••-----..........•--- ovncr , Address Installer Address Type of Building _ Size Lot............................Sq. feet ►, Dwelling— No. of Bedrooms........f--------------------------------Expansion Attic ( ) Garbage Grinder ( ) WOther—Type of Building No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ....... ------ --------------------------------------------------•---- ---------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic 'rank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ x Dispos<'.1 Trench— No. .................... Width---.--_---- ...... Total Length.................... Total leaching area.......... ..........sq. it. Seepages Pit No........ ............ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by............. ............................................................ Date----------------....------.. Test Pit No. L...............rninutes per inch Depth of Test Pit.................... Depth to ground water....................... (_, Te:;t Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ------------------------------- ---------------- ------------------------------ ..--._--.......................------.-.-.-.-..-.---------•--------------------- 0 Description of Soil---------------------------------------------------------------------------•---•--------.-------•----••-•-----.................-•-----------••-------.--•---------_..... x U •-----••.........................•-....----•-•-----••-----•-•.....------•••--•--•-......----••----.......-•---•••----------.....---••--•---•---••----•--••••••------•---...............------......-•--- W / U Nature of Repairs or Alterations—Answer 1 e a abl ...! �1..� -----------�t�-r. ( � Q --•----•-----••----------------------------------------•----------..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Complia,ce FibJs been issued by the bo rd of health. lZue Signed ......... �f....- - p.. ..':................. .......-........—... :.. ...... .�... . . .. ..Y A lication A roved B L� pP PP Y ... ..... ..... ,...- - ..-...D...-.- ... ..............-......... .. .. -.,/. .... .... Care Application Disapproved for the following rear n ...................................................................... ................. ..................... . . .. .......... ...........................................fi,......:...........:.:. ., ... ............ C. -. ..Dare Permit No. .................... ........ ............. Issued �...... ..1..51 ..........-.....-...................... i 6XH16 �r THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH I TOWN OF BARNSTABLEFj Gertifica to of C omplinnce '� THIS IS TO CERY7'FY, That the Individual Sewage Disposal System constructed ( ) or Repaired / ^ � - � Installer at ' . ....-/ �C ... has been installed in accordance with the provisions of TITLE f he Sta �Ff�v'r)onmental Code as described in the application for Disposal Works Construction Permit No. ._ / ' (,/ / dated THETHEISSUANCE OF THIS CERTIFICATE SHALL NOT 13 C .�.NSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ .. ............�.......... ....7:............................--.............. Inspector .......................................... /...-................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.4......'......... .••• FEE..`..::== I �i��n��tl nrk� C�1�zT,�trt�iun ��xmit v /rw Permission is hereby granted................--------(-------f ......... ........ ------------...---••-.............................................-•-•---- to Construct ( ) or Repaij ( an Individual Sewage Disposal System at No — -l 1-- �'�::7=�` '/ i i tJ Y '<" C�i/ ... ��`'�(/ ..........n.:.....e............. --....... Strcct as shown on the application for isposal Works Construction Permit No./.... ._`..... : at d. ......... .......... `= Board of c5fth DATE..... FORM 365013 HOaHS d WARREN.INC..PUBLISHERS)'- Log Number: � 4232 Bottle # D154 Date: 11/9/84 Uf BARS 1* s� BARNSTABLE COUNTY HEALTH DEPARTMENT �5 SUPERIOR COURT HOUSE v d/I jam/N BARNSTABLE, MASSACHUSETTS 02630 nsa / DRINKING WATER LABORATORY ANALYSIS PHONE: 362-2511 EXT. 331 Client: Cape, Well-Drillers Collector: •BrianiH. Darakjy Mailing Address: Briar Lane Affiliation: well driller Wellfleet, MA-02667 Time & Date of • • 1 , . Collection: `11/7/84, '10:30 a.m. Telephone: 1-800-352-3187 Type of Supply: well- water Sample Location: ' Pleasant Pine Ave. Well Depth: 32' Centerville Date of Analysis: 11/7/84 PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 ml O 0 d H 53 Conductivity (micromhos/cm) 60 500.0 Iron ( m) 0.3 Nitrate-Nitrogen ( m) 0.05 10.0 Sodium ( m) __ 20.0 I , xx Water sample meets the recommended limits for drinking of all above tested parameters. II . Based only on results of the parameters tested for this sample, the,water, is suitable for drinking but may present the problems checked below: A. Water sample has higher. than average levels of Nitrate. Future monitoring is recommended (2-3 times per' year) .to establish any upward trends. B. The low pH of the water may shorten the useful life of the house's plumbing. C. Water may present aesthetic problems (taste, odor, staining) -due to D. Water sample has High levels of sodium. Persons on low sodium diets'"'should consult their doctor. III. Due to one or more of the reasons checked below, this water sample is unfit for human consumption: A. High Bacteria B. High Nitrates REMARKS: CC: Barnstab% ,e Board of Health CC: Laborator iFector 7/17/F14 �. TOWN OF BARNSTABLE LOCATION �� F�.s��'f Plh'CS 4VSEWAGE # VILLAGE ASSESSOR'S MAP LOT INSTALLER'S NAME Si PHONE NO. J IyIdR//L' 3 2` 3C��0 j SEPTIC TANK CAPACITY �U U j LEACHING FACILITY:(type) d (size) jNO. OF BEDROOMS �}� PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER e 6 DATE PERMIT ISSUED: 73A fjr DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No R: ems} Explanation of Test'Results Total Coliform Bacteria Coliform bacteria are an indicator of the sanitary quality of a water supply. Water supplies may become , contaminated from malfunctioning septic systems,cesspools and surface.runoff. A total coliform count of zero indicates that your water supply is safe and approved for human consumption:A total•coliform count of greater ;than zero is most often the result of accidental contamination of the sample bottle through improper sampling methods. For this reason,it would be advisable to retest any well water that is not approved. .R pH is the measure of acidity or alkalinity of the water.On the pH scale,ttie number 7 is neutral, less than 7 is acidic and more than 7 is alkaline. The pH of water on Cape Cod tends to be acidic in,the range of 5.0 to 6.5 4 -- Conductivity Conductivity is a measure of the dissolved salts in solution. Amounts in excess of 500 micromhos'-m are generally considered unacceptable and may have a laxative effect upon users. . 1 Iron The presence.of iron in water in concentration of .3 ppm or greater may: give the water a bittersweet astringent taste, cause an unpleasant odor, often gives the water a brownish color and cause staining of laundry and porcelain. The average concentration of iron in Cape Cod's water is .2- .6 ppm. Although the presence of iron in water may cause,the problems listed above,' it is not considered deleterious to health_ . Iron may be removed by use of an iron removal system. ,. ._ Nitrate-nitro en The Massachusetts Drinking Water Regulations have set a maximum contaminant level for nitrates at 10 ppm. Excessive concen'tianons may cause .methemoglobinemia'(an infanf disease) and hive been suggested'to.- form potentially carcinogenic nitrosamines. Contamination sources include fertilizers, cesspools and industrial wastes. Copper •_ a r" r' .. ,. r ; f t Due to the acidic nature of the water on Cape Cod, copper tends to leach from pipes. This normally does not°present a health hazard; however, concentrations in'excess of 1.0 ppm may cause a metallic taste and/oi a bluish green stain on porcelain fixtures. Sodium V, A concentration of sodium over 20 ppm is only of concern to people who are on-a low sodium diet. If the water supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source of drinking water or contact their doctor to determine if consuming the water is advisable. Concentrations exceeding 50 ppm indicate that there may be ocean water or road salt runoff water vetting into the well. Cam- i i a we ,