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HomeMy WebLinkAbout0240 CARRIAGE LANE - Health 240 CARRIAGE LANE;- ,_ _ r. ,: � .. � .. ... }, a ,r. , • - r v. • p a t : er ry s n • a ' tl : a M 0 • u + 'i. r 1.� •,. a 7 t ' F'.. ,y v x Y � .. '1 r '1. x. p r. �� } J r .. ,+L_ •l .� ri , „ v ' z y : r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M '< 240 CARRIAGE LN Property Address BRAILEY Owner Owners Name information is required for BARNSTABLE MA 7-21-14 - every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection,forms,may not be altered in any way. Please see completeness checklist at the end of the form: Important: A. General Information When filling out forms on the - computer,use . only the tab key 1 Inspector. to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone'Number license Number B. Certification I certify that I,have personally inspected the sewage disposal system at this address and that the information reported below.is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local,Approving Authority 7-21-14 , Inspectors Sofature Date. The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies'sent to the buyer, if applicable, and the approving authority.- ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection"does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:S.WuSewage Disposal System• age 1 of 17 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M s 240 CARRIAGE LN Property Address BRAILEY Owner Owner's Name information is required for BARNSTABLE MA 7-21-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check ,A,B,C,D or E/a/ways complete all of Section D A) System Passes: ® I have not found any information which`indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria,not evaluated are indicated below. " Comments: SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION, S.A.S WAS INSTALLED IN 2008 ' B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced'or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass... Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20'years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System-Form -Not for Voluntary Assessments M s ' 240 CARRIAGE LN Property Address BRAILEY Owner Owner's Name information is required for BARNSTABLE MA 7-21-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. i B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in.the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass,inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ,.❑ Y ❑ N . ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): E ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s): The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N [:]' ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑` ND(Explain below): C) Further Evaluation is Required'by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 6 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM , 240 CARRIAGE LN Property Address BRAILEY Owner Owner's Name information is required for BARNSTABLE MA 7-21-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1'of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other.. D) System Failure Criteria Applicable to All Systems: You must indicate."Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or El ® 4 clogged SAS or cesspool E ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 17 f Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 240 CARRIAGE LN Property Address BRAILEY Owner Owner's Name ' information is required for BARNSTABLE MA 7-21-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No 0 ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary-to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet, from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis 1 and chain of custody must be attached to this form.]. ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 90,000gpd. 0 ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply, ❑ ❑ F the system is'within 200 feet of a tributary to a surface drinking•water supply El . El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. e t5ins-3/13 f Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 240 CARRIAGE LN Property Address BRAILEY - Owner Owner's Name information is MA 7-21-14 required for BARNSTABLE ' every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been-done. You must indicate"yes"or"no as to each of the following: Yes No r ® ❑ Pumping information was provided by the owner, occupant, or Board of Health' ❑ ® Were any of the system components pumped out in the previous two weeks?., ® ❑ Has the system received normal flows in the"previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ; ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ' .® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes.uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ' ® Was the facility owner(and occupants if different from owner) provided with _ El information on the proper maintenance of subsurface sewage disposal systems? . The size and location of the Soil Absorption System(SAS)on the site has t been determined based on: ® ❑ ' Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] _ D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 330 bESIGN flow based on 310 CMR,15.203 (for example:�,110 gpd x#of bedrooms): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 CARRIAGE LN Property Address BRAILEY ' Owner Owner's Name - E= information is required for BARNSTABLE MA 7-21-14 - every page. Citylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO ASBUILT CARD SYSTEM CONSISTS OF A"1000 GALLON SEPTIC TANK, D- BOX AND 2 500 GALLON H-20 CHAMBERS i - Number of current residents: " • Does residence have a garbage grinder? ❑ Yes ❑- No Is laundry on a separate sewage•system?(Include laundry system inspection ❑ Yes ❑ .No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): , , Detail 2012--------309 2013------298GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310'CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: • t5ins"3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 7 of 17 r : Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 240 CARRIAGE LN Property Address F BRAILEY Owner Owner's Name information is required for BARNSTABLE MA 7-21-14 every page. Citylrown State Zip Code' Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: _ gallons " How was quantity pumped determined?.' r Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑. Shared system (yes or no) (if yes, attach.previous inspection�records,'if any) . ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M sa 240 CARRIAGE LN Property Address BRAILEY Owner Owner's Name information is required for BARNSTABLE MA 7-21-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Approximate age of all components, date installed (if known)and source of information: LEACHING SYSTEM INSTALLED IN 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: 5:. ❑ cast iron ❑40 PVC. ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 - feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years ' Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: MODERATE t5ins-3113 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 CARRIAGE LN Property Address BRAILEY Owner Owner's Name information is required for BARNSTABLE MA 7-21-14 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness CLUMPING MODERATE Distance;from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural_integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 240 CARRIAGE LN Property Address BRAILEY Owner Owner's Name information is required for BARNSTABLE MA 7-21-14 every page. Cityrrown State, Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,, liquid levels as related to outlet invert, evidence of leakage, etc.): t Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan)-.- Depth below grade: . Material of construction: , ❑ concrete. ❑:metal ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No 'Alarm level: Alarm in working order: ❑ Yes ❑ No '- Date of last pumping:' Date f Comments(condition of alarm and float switches, etc.): . *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 CARRIAGE LN Property Address BRAILEY Owner Owner's Name information is required for BARNSTABLE MA 7-21-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL'NO SIGNS OF LEAKAGE OR SOLID CARRY OVER Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(note condition'of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass.' Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 ', 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 CARRIAGE LN ' Property Address BRAILEY Owner Owners Name - information is required for BARNSTABLE• MA 7-21-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type ❑ a leaching pits number: • • ® leaching.ckambers number: 2' - ❑ leaching galleries- number: ❑ _ leaching trenches - number, length: ❑ leaching fields number, dimensions- , ❑ `overflow cesspool number: ❑ innovative/alternative system J Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): e CHAMBER WERE FUNCTIONING PROPERLY AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE OR SOLID CARRY OVER r t Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration f Depth—top of liquid to inlet invert Depth.of solids layer , Depth of scum layer Dimensions of cesspool Materials of construction Indication`;of groundwater inflow ❑ Yes ❑ No t5ins°3113° Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 240 CARRIAGE LN . Property Address BRAILEY , Owner Owner's Name information is required for BARNSTABLE MA .7-21-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic'failure, level of ponding, condition of.vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids , Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 6 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 240 CARRIAGE LN . Property Address BRAILEY Owner Owner's Name information is required for BARNSTABLE MA ♦7-21-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System♦Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s ' 240 CARRIAGE LN Property Address BRAILEY Owner Owner's Name information is required for BARNSTABLE MA 7-21-14 every page. CitylFown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar. ® Shallow wells Estimated depth to high ground water: NONE AT 11 feet Please indicate all methods used to determine the high ground water-elevation: ® Obtained from system design plans on record 7-2014 If checked, date of design plan reviewed: Date Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: DESIGN PLAN Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection+ Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 240 CARRIAGE LN Property Address BRAILEY Owner Owners Name information is gARNSTABLE MA . 7-21-14 required for every page. City/Town State Zip Code -Date of Inspection E. Report Completeness Checklist ; ® Inspection'Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached:in 'separate file M t r is t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION J 4U ea.-ll f Q 2 SEWAGE# IL009-Z'9$ VILLAGE 0 an n S 1zb U ASSESSOR'S MAP&PARCEL 99 7-Ir INSTALLER'S NAME&PHONE NO. C ,)td e C4_ 97 y0a€ SEPTIC TANK CAPACITY /000 /f/0 » LEACHING FACILITY:(type) W 5-du & O z o (size) i Z X Z S NO.OF BEDROOMS 3 OWNER 1��1 LmvC4 (�cr PERMIT DATE: 7- I/- Z 4 COMPLIANCE DATE: '7-1` -Z o4 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and L:aching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY C-��ew�iQ� lc�Qn3e� LL C --v A 31 toz 41.0 it 3 4 7,o 64 eta s A y� s 31 a3.0 4 http://www.townofbamstable.us/Assessing4lMdisplay.asp?mappar=297035&seq=1 7/3 0/2014 TOWN OF BARNSTABLE c V)C:ATION `� ��� SEWAGE # � LAGE �' C1S ASSESSOR'S MAP &LOT � L �( 'Q. INSTALLER'S NAME&PHONE NO. q7 0 3S- SEPTIC TANK CAPA= LEACHING FACILITY: (type) Oc C to 5 1�1`�" (size) ( 0 0(j NO.OFBEDROOMS U < BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) e . Feet Furnished by c 656 _ 1 Ao Pg 7� r' TOWN OF BARNSTABLE LOCATION ;?4U ealu i0gf CgA,t SEWAGE# VILLAGE aA h S�r-6( ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. Ccp.uxdo- -�12.8 Yoaif SEPTIC TANK CAPACITY (000 ff/0 LEACHING FACILITY:(type) 03 5-ou ('..0 U (size)Nc X 7,r NO.OF BEDROOMS 3 j OWNER - 1� i L Van yr 2 PERMIT DATE: —7 COMPLIANCE DATE: �7— 1 ` - Zaa Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). // feet FURNISHED BY C��?.uJll.�Q C1CA�r11Qs (ALL A -Z 0.0 . ►�3 4700 � 4a.s' ILZ I A yf.5 PrLe 1 149,0 3 3i d3.d 33 , o gs 3� 5-t' ° No. 2-0Y75 Fee 6© THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplicatton for �Diq;poaY 6p.5tem Con5trurtton Vermtt Application for a Permit to Construct( ) Repair(-y) Upgrade( ) Abandon( ) ❑Complete System ®Individual Components Location Address or Lot No. 2Lj o C q('('I A4 a LAn.c. Owner's Name,Address,and Tel.No. t3Ar"s'v,-bt.Pd It.41 lems, ItJ Assessor'sMap/Parcel 2gj-7 3 C!e e.� lk"'jt"rs OH Installer's Name,Address,and Tel.No,��p �i�r ��{�/�3�f Designer's Name,Address and Tel No. 5 _ S611-1 L� YO`L� Pam. '3oC �E3 7frsY�q-�stM it,�, 2?3-- e-3-7 1 Type of Building: Dwelling No.of Bedrooms Lot Size 35, S-2 o {-- sq.ft. Garbage Grinder ( ) Other Type of Building ( ,, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33-o gpd Design flow provided 33 1 gpd Plan Date 1"10 P 7-009 Number of sheets Revision Date Title 2 40 Size of Septic Tank 1 o®O qaA 6Ad Type of S.A.S. ( 2) W —2,o si !/ yf Description of Soil 5e L 01✓� L Nature of Repairs or Alterations(Answer when applicable) Date last inspected: A.' ZOOS Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed I Date .7 _t i — ZO� Application Approved by E Date Application Disapproved by: Date for the following reasons Permit No. 2� �,_ 2 459 Date Issued -7 Z-o o 8 ._ �,_. ...... .;. ,�..-�.;.r: .� ,.,,,-mow�. ..y .J:.:,.:,,,�.�<�.�.• No s Fee 6 0 k' 9 Entered in comuteri THE COMMONWEALTH OF MASSACHUSETTS p � s J PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes TippYication for aigpogal 6p5temc Congtruction Permit Application for a Permit to Construct O Repair Upgrade O Abandon O ❑ Complete System;®Individual Components, Location Address or Lot No. ?.4 0 C A f r t A 0 e LA.,c„ Owner's Name,Address,and Tel.No. 124 I f!.tw e AIA-,,ei' t3AfnSi 35To Cole., /4r/e, , /tJ Assessor's Map/Parcel 2 IT-71 73 S� C(e v 'e�✓�*r �� f L+rS 0 q Installer's Name,Address,and Tel.No.e,ja ,',� �@/ Designer's Name,Address and Tel.No. Z 9 S'{ Jr. mt„z e 2 r(C- .449 2 "7 3 n 7.7 C. r.w.2�c rF6aos, Type of Building: Dwelling No.of Bedrooms 3 Lot Size 3 S. S�0 } sq.ft. Garbage Grinder ( ) Other Type of Building S;A t�e h No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _4>34 gpd Design flow provided �J j ( . 'S gpd Plan Date 3"10 - ZC>69 Number of sheets Revision Date Title ?.40Glur, Size of Septic Tank 1 Ooo qak _eYA, Type of S.A.S. ( 2) 14 '20. Sow S A'( Description of Soil 5e.0— 014e^ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Zoog Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. f Signed - Date _ 1 1 Application Approved by a Date Application Disapproved by:17 Date for the following reasons t` Permit No. ZUD�j- Z Date Issued 7- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance . THIS IS TO CER�TIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by C C1?,,), �h�-c. S e-S LA,c., at Z�r J C-+lkdd; 1.dl a. mat,,-, r cae. has been-constructed in accordance o - with the provisions of Title 5 and the for Disposal System Construction Permit No. '°� dated Installer CpSe ,-). A Designer 'v - 1t:2'Lt i i' #bedrooms I Approved design flow t ,*?&_T gpd The issuance of this its aooegstrued as a guarantee that the system will function assrdes'gne� 0 u ? Date / Inspector //� © , 11. />� ,� ,j) •� No. ,?6>0.5- 285 Fee /D O . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE,.MASSACHUSETTS W5pogar *pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair ( yO Upgrade ( ) Abandon ( ) System located at 1,4 " a r and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: rConstruction must be completed within three years of the date of this r�mit. Date ` �' 2 y O Approved by / ors n, of naristable; Regulatorv'Services '" x q wnMrdr�►s , : Thomas E Geiler, Di�,ectoir TbNbft Health I iv siol�Mc e oinas , K.an,iDirector K. a 200 M in Street,$yannfS,MA 020�01 F y Offre: 508-862-4644 Fax: 508.7410•630 Installer�t Desi, ertific on oriri {_ Date: Desigper: _E011 tneec�n, Installer Address. 1Fi.jy Cccnlciacr tii i►w � �1ddr - i C)n is _ " was issued 41�e s all a 0 rI»lt to in t f (datu)R (insltaller) i . septic system Ott^ _ GucrccrcGa y, . I based 'on a design drawn by dated s (designer) { _ 1 cexkify that the septic system referenced above was install ed substantially according to the: design, which may include:; m►nor;approved 'ehanges such as lateral relocation of he t. distribution box and/or septic tank i I certify that the septic systewi refe:.evnced above'was installed with major changes ().e. greater than 10' lateral relocation;of the SAS or any.vertical relocation'of any component of the septic system):but in' aciJordance with ,state;& Local Regulations. Plan revision or certifiedp as-built by designer tar fs llow: i aller.'s Si akurc) ' JR (Designer's . tamp Here? r P E S U ARN LE L l[ SI T CAND AT B ANK Y U. � i ,`� � 4 Q HealwSeptia/Designer Cer ification Worn, - g. 1 0 'd Lqi0 2LZ a 0 9 ON I d33N I 01133f Wd a2: £0 soot-L I-inn �SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY � ■ Complete items 1;2,and 3.Also complete A.anaT:W Item 4 if Restricted Delivery is desired. Agent ■ Print your name and address on the reverse X Addressee so that we can return the card to you. 13. Received by(Printed N ) C. Da f D liv ■ Attach this card to the back-of the mailpiece; /;, or on the front if space permits. F' D. Is delivery address different from Item 1? Eles 1.Article Addressed to: If YES,enter delivery address below: ❑No rno re I 3. Service Type t 'ww(J ll 41•V(-l(•,�►1 � ❑Certified Mail ❑Express Mail I ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. '] Y 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number _ _--�• (Transfer from service Wei 11 700. , 21'S 0 0'0 0 2; 11 41 9 6 9 3 ► t PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE Firs s Mail tage 44 ,��.. � .mow..:.• ..n�°.: �ti. Sender: Please print your name, address,ARi-ijP r Town of� Barnstable 4� �a,„,,,a„•: Public Health Division 200 Main Street Hyannis,MA 02601 I I I I 1.ii ii tt ttyy fii ` 11t t jiit `yy fill HIM IAiIII IIIiSy►i,1I111IIII{IIIIIiIIIIfif117111{11IIfill11 Town of Barnstable P# Department of Regulatory Services pFIHE, Public Health Division Date ovX 200 Main Street,Hyannis MA 02601 �j sewrsreere, � r � Y V EDtr1Ar�059. Date Scheduled Time Fee Pd. Soil S ' ability Assessment for Sewage Disposal Performed By: Witnessed By: ,.,.,!. ,.!.... .......:.._.._...... ,,..,,..!.na..,::w,...N _ ! '.!il" 'i ...i.. a.i.. !:.:!..:.. .r.. ...:.:.,...:., / ................... ..._.... .....,:..,!. .I. T '.�"%. .. ,�F�..... ...y;.:. .,..; .: ,...L.a.. Location Address i f f 4 Owner's Name Address I_q0 C.OWi'l ,4�_, pp t Assessor's Niap/Parcel: 294 7/t g J / Engineer's Name If,gevew;ay, Q'1'7�✓��'ae� NEW CONSTRUCTION REPAIR V Telephone $ads tt2$ I+p2 Land Use he1A1.- Slopes(%) 2-s'16 Surface Stones NowB Distances from: Open Water Body >eSo ft .Possible Wet Area >e5o ft Drinking Water Well >150 ft Drainage Way 'e0 ft Property Line 1, e0 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test.holes&pert tests,locate wetlands in proximity to holes) Ito.3t� Wq �Z.KD If 2. J Parent material(geologic) OurwftA Depth to Bedrock 3Z" e'3•G. p g egg 3.G.5. Weeping from Pit Face ' �3L., g•� 5 De th to Groundwater: Standing Water in Hole: Estimated Seasonal High Groundwater 13z•- 6.Co.S. n::cvc rr.n::-m:e.::r:::::::a::��:.-:•:�,r:,:::::.ca,,:::--.n:nn:en,r..-.n:nc.-::e:v.:r:ann:n,n:y,::�.::,,n.a.:,:aa;�:ii:E,iiiiE�iET:6!ein,ldii:i!ICi!ni?,:ii,.:'3!,!!iii!anhl'I::;r:a,:_ .:..: _•._:ac-.__.._........_';^:;.;.._.,...cy�an:.-..:r:ma::_x-_^:-,-:,n:an.,t.rn. , :_r.,,xn ca.::a::::y.., ,..a..,...,..:-:-s-Y:L:,:•::!t_+I,::DLs.:,L:!L'J. :: � ����,�::::�:�,L3._�J.J.��:��,�]_::!�� ,:::.:::.:: ....................... .___.........,:.::.._,...,:-..:......................__.. Method Used: 'begr acx oaaeR.tAn-J Depth Observed standing in obs.hole: >13t, 8.G.S• in. Depth to soil mottles: 132 $.0.S: in. Depth to weeping from side of obs.hole: 1;L"8.0•S _ in. Groundwater Adjustment N/A ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level .........:....:.:.::.;;;:;;:::.:.-_::::>:,:.:.:,,...,..:.. -,::.:.::y:::..........:.:,n::.::::::,.:::nn:a::a::a:............_:_.._.._:............:..:..:._::... ..........................._._.......__.............. :......,,...,. , .::,,:::..:.:......r:. Observation r Hole# Time at 9" Depth of Perc 3L- Time at 6" Start Pre-soak Time @ 10:10 ArA Time(9"-6') End Pre-soak 10;'ba AM Rate Min./Inch ' 2�'"'• ent• Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-----�— Q:HEALTHNVP/PERCFORM » :..................:<:>::..:.:..;............................................:............. DepthfromSoil Horizon S T $ot Co or Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. '1-b E LoANK SAND ley( 3 3Z LOAM N* to Y( 5 t, 32-t3i C MeO. SAND 2.ejY o- . S-. fjourneRs is Depth from Soil Horizon Soil Texture. Sol l Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. FRLL ti-b- A L.OAMY ND 10Y a( . b=3y "At»Y S NJO 90Y 3 �32=13ti C MEp. sANO -3.J S%CPu - SoN+E Bo�we•�s Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. ° Gravel) - O s f L :.;::::.....:•..:;•;:•:•:.::::::.:.::::::::.::.::::.:.;.::.... ..:.:.:..:: ..........:..............:. . Depth from Soil Horizon . Soil Texture � Soil-Color Soil, Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. %Gra e Mood Insurance Rate Man: ` -�c. rr rr A S`C h ve 00 year flood boundarys No - Yew Above 5 y Within 500 year boundary No . Yes Within 100 year flood boundary No Yes c Depth of N,gturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? -(eS If not,what is the depth of naturally occurring pervious material? Certification I certify that on &a.27}°M9 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis Was performed by me consistent with the required training,expertise and ex.berience described in 310 CMR 15.017. Signature __._ Date —1—to-Ob M • 0" -0 r-R Q Postage $ , 0 Certified Fee a -?0 0 ru ' ' .�� Postmark Q Return Receipt Fee r Here 0 (Endorsement Required) U i O Restricted Delivery Fee JUN 4 O (Endorsement Required) rr-1 Total Postage&Fees s s. 3 c-: �Sc ni P.7 T 1 n'1cn%e � Street,Apt.No. -- ----•----- -- ----------------- -•--•....---- --..... M or.PO Box No. � St t� ----Y- . -• -. Certified Mail Provides: a A mailing receipt a A unique identifier for your mailpiece a A record ofdelivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class Maile or Priority Mails. a Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.,Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. n For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Town of Barnstable Barnstable Regulatory Services Department ;er1C8C j BARNSI'ABLE. 1639. Public Health Division �ArEDMa+A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO June 2, 2008 Philmore Hart 3580 Glen Allen Rd Cleveland Heights, OH 44121 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 24.0 Carriage Lane, Barnstable, MA was last inspected on May 5, 2008,by Robert Paolini, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the.guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Stain line was over invert, solids observed in side holes of pit. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH ma McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL# 7006 2150 0002 1041 9693 Q:\SEPTIC\Letters Septic Inspection Failures\240 Carriage Lane.doc Pd a-- Commonwealth of Massachusetts - W Title 5 Official Inspection FormCOP Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Carriage Lane - -' 'G^M Property Address Philmore Hart f Owner Owner's Name information is Barnstable Ma. 02630 5/5/2008 z required for every page. City/Town State Zip Code Date of Inspect'-n Inspection results must be submitted on this form. Inspection forms may not be altered in any way. . Important:When filling out A. General Information 035 forms on the computer,use 1. Inspector: �- only the tab key to move your Robert Paolini cursor-do not use the return Name of Inspector key. Capewide Enterprises,LLC Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 reran City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of ( 7- Title 5 (310 CMR 15.000).The system: o ❑ Passes ❑ Conditionally Passes ®. Fails ❑ Needs Further Evaluation by the Local Approving Authority h y 5/5/2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 L r . i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which'indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more:system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as.approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The'septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND.Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced } ❑ obstruction is removed 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 ti Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.3,03(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption-system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. r ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form = Not for Voluntary Assessments c�M 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 1 Commonwea.ith of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cwM 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No [� ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ®. Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified . laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is Barnstable Ma. 02630 5/5/2008 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ElWere all s components, the SAS located on site? system p onents 9 excludin ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:80,000 g ( y g (gpd)): 2007:60,000 Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 240 Carriage Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 I - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage; etc.): Joints appear tight.No evidence of leakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gallon Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 0 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? Measured 240 Carriage Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appear to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection e D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm,present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of_liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution Box not present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is, required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 gallon ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): San K soil.Leaching-P-i#was-dry-was time of inspection.Heavy solids observed on bottom of pit�tain line--- over Invert.Solids observed In side holes-of-pit. 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 240.Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth,of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 f Map. Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map' Abutters Map Size ® Zoom Out J „ ? In P I amig } 10 - a z Y U 4Ili ——•— — i i_ --- I 5 I 20 Feet Set Scale 1" = 20 I Aerial Photos rr,,.,,,H h+')nnr-')nm Tn...n a Ra•nefnF In UA All r;nhl..ono,,,, http://www.town.barnstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=297035&mapp... 5/9/2008 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 240 Carriage Lane Property Address Philmore Hart Owner Owner's Name information is required for Barnstable Ma. 02630 5/5/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 70' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 Plate#2 Annual ranges of groundwater elevations. 240 Carriage Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable Op THE T regulatory Services ELUMSTPABLE, z Thomas F. Geiler, Director MAM ArFo .�A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY.PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed 'on the "Disposal Works Construction.Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q-ASEPTICOisclaimer Private Septic Inspections.DOC i Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection . • One winter Street,Boston,Ma. 02108 John Grad D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508) 564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor 0.. ( 91 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ^f' CERTIFICATION Property Address: 240 CARRIAGE LANE BARNSTABLE MAP 297 LOT 47 Address of Owner: fCEiwo, Date of Inspection: 11/24/98 (If different) 15 1999 Name of Inspector: JOHN GRACI SUSAN HIGGENS Ta ,o� I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: A111i��,T � 1 CERTIFICATION STATEMENT E y 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 16.303.My findings areofhowthesystemis performing at the time of the inspection.My Inspection does Needs Fur per Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthelongevnyofthe Fails septic system and any of Its components useful lire. Inspector's Signature: `( Date: 11124198 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. COMMENTS: 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. t The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co1hpliance(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 conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 Is Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property AddreSS: 240 CARRIAGE LANE BARNSTABLE MAP 297 LOT 47 Owner: SUSANHIGGENS Date of Inspection:11124198 _ Sew.aae backuD or.hreakout or hioh.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: 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 obstructedpipe(s). The system will pass inspection if(with approval of:the Board of Health): broken pipe(s)are replaced obstruction is removed 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 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 SYSTEWIS 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 , i 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 watersupply 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 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: _ 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. Yes No 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. t SAS is in hydraulic failure. (revlaed 04117)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION (continued) Property Address: 240 CARRIAGE LANE BARNSTABLE MAP 297 LOT 47 Owner: SUSANHIGGENS Date of Inspection:11124199 D] SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 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 coiiform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a public water supply well) The 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. o , (revised 0Q7)97) r I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 240 CARRIAGE LANE BARNSTABLE MAP 297 LOT 47 Owner: SUSANHIGGENS Date of Inspection:11124198 Check if the following have been done:YoU must indicate either"Yes"or"No"as to each of the following: ,c_ _ 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. 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. . _c_ — 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 The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is x — — unacceptable)[15.302(3)(b)] r . I _ I (revised 042797) i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 240 CARRIAGE LANE BARNSTABLE MAP 297 LOT4T Owner: BUSANHIGGENS Date of Inspectlon:11124199 FLOW CONDITIONS RESIDENTIAL: Design flow: 3w g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): Yea Laundry connected to system(yes or no): Yea Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rda sump Pump(yes or no): No Last date of occupancy:7n6ge COMMERCIAL/INDUSTRIAL: Type of establishment: ^�a 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) N� . Water meter readings, if available: rda Last date of occupancy: rda OTHER:(Describe) rds Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rda System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: rda TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date installed(if known)and source information: SYSTEM WAS INSTALLED IN 1982 PERMIT M2.198 Sewage odors detected when arriving at the site: (yes or no) No (revlaed 04121)97) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 240 CARRIAGE LANE BARNSTABLE MAP 297 LOT 47 Owner: SUSANHIGGENS Date of Inspection:17124199 SEPTIC TANK: x (locate on site plan) Depth below grade: V Material of construction:x concreate_metal_FRP_Polyethylene—other(explain) If tank is metal, list age Na . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'6"H5'7"W4'10" Sludge depth:r' Distance from top of sludge to bottom of outlet tee or baffle: 33' Scum thickness:o Distance from top of scum to top of outlet tee or baffle:2' Distance form bottom of scum to bottom of outlet tee or baffle: rda How dimensions were determined: nfa 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: rda Material of construction: _concrete_m eta l_FRP_Polyethylene_other(explain} Dimensions: rda Scum thickness:n►a Distance from top of scum to top of outlet tee or baffle:rva Distance from bottom of scum to bottom of outlet tee or baffle: r9a Date of last pumping�,a 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.) rda T BUILDING SEWER: (Locate on site plan) Depth below grade: r5" Material of construction:_cast iron_40 PVC other(explain) Distance from private water supply well or suction Iine:TowN Diameter. Na_ Qmments: (conditions of joints,venting,evidence of leakage, etc.) (revlaed 0Q7)97) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 240 CARRIAGE LANE BARNSTABLE MAP 297 LOT47 Owner: SUSANHIGGENS Date of Inspection:11124198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Na Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: nre Capacity: r9a gallons Design flow: Na gallons/day Alarm level:_nre Alarm in working order?_Yes No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na r DISTRIBUTION (locate on site plan) Depth of liquid level above outlet invert: n►a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)_ve: Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) rda (revised 04127►97) SUBSURFACE SEWAGE DISPORT CSYSTEM INSPECTION FORM SYSTEM INFORMATION (continued) _ 4 GE LANE BARNST ABLE MAP 297 LOT 47 Property Address: SUSANH240 GGENS Owner.Date of Inspection:11124198 SOIL ABSORPTION SYSTEM(SAS):x approximated by non-intrusive methods) (locate on site plan,if possible;excavation not required,but may be If not determined to be present,explain: Na Type' 1000 GALLON LEACH PR leaching pits,number: - leaching chambers,number:N= leaching galleries,number: Na leaching trenches,number,length: Na leaching fields, number,dimensions:rda__ overflow cesspool,number:Na _ Name of Technology:_Na Alternate system'. Na condition of vegetation, etc.) level of ponding, Comments: (note condition of soil,signs of hydraulic failure, THE LEACH PR IS STRUCTURALLY SOUND AND FUNCTIONING PROP LEACH PR WAS EMPTY ATTHE TIME OF THE INSPECTION.PIT HAS NOT HAD MORE THAN 4'OF WATER IN IT. CESSPOOLS: (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: rVa Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Na _ Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY'. (locate on site plan) Dimensions: N=— Materials of construction: rtva Depth of solids: Na ulic failure,level of ponding, condition of vegetation,etc.) Comments: (note condition of soil,signs of hydra (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 240 CARRIAGE LANE BARNSTABLE MAP 207 LOT 47 SUSAN HIGGENS 11124198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house). • t (revised04127197) Papa 9 of 710 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 240 CARRIAGE LANE BARNSTABLE MAP 297 LOT 47 SUSAN HIGGENS 11124199 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers i X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revised0=7197) t&141 10 0[ 30 t ;�:O C A T I O N C1qjt21 g6,e 1rd+/, SEWAGE P E n t3 l T 130. (i 'VILLAGE INSTALLER'S gA13E b A0 ONES S• _ r CZ i5 6ao; 5i 11UILDER OR OWNER G SCLL l l S z, t j DATE PERMIT ISSUED .DAT.E COMPLIANCE ISSUED ���, r J o aa .d J� P R CA P-- s;� I No.............j� THE COMMONWEALTH OF 'MASSACHUSETTS BOAR® OF HEALTH ...-.TO �h....--.....OF...../-///yd�.�VT, / L>!G. Appliration for DiipnsFal Workii Tonarnrtinn 1hrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ................ o'.`.'• ,4 M_-/� ; Location-Address or Lot N o. . b ..G.�_l:r��v"` ............. ....... ---- ......................... -•---................._._ • Owner Address --' ......_. .:........................................ ................•-'•..........._............. .............__._......._..---...._____..........._ Installer Address U Type of Building Size -'�- a__Sq. feet ., Dwelling—No. of Bedrooms_________ ______________________________Expansion Attic ( ) Garbage Grinder W4? aa Other—T e of Building No. of ersons____________________________ Showers YP g -------•-------•------------ P ( )--- Cafeteria ( ) Otherfixtures ----------------------------•-- ----------•---•--------- ..................:.------- '•---- W Design Flow__.............f_-_____..................gallons per. n per day. Total dajly flow............. ______...................gallons. W Septic Tank—Liquid"capacity/!A—�gallons LengthO.=-_4k Width.-i_�__:_!_'Diameter________________ Depth__.-_j:._ k x Disposal Trench—No ____________________ Width.................... Total Length.................... Total leaching area.................... ft. r Seepage Pit No......../--------- Diameter_____ D________ Depth below inlet___._........... Total leaching area._:r. ...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results_ Performed by.........---=-----'-----'---•-.....--'--------•"------•'-----•--'-'------ Date---'-------•--_-•'" ----.....---_.. ,.a Test Pit No. L�2-.minutes per inch Depth of Test Pit...1y ...... Depth to ground f14 Test Pit No. 2A� _minutes per inch Depth of Test Pit__.ly `__._ Depth to ground water........... 04 ---sT.............................•----------....-------•-•---'-'-'-___-•....._.._..-_--......................................................... O Description of Soil-.--;----1------- o " rr....,r>s�rsm r6- =........................................ .. % _�. V Nature of Repairs or Alterations—Answer when applicable............................................................................................... .--•------------'------------------------------------•-------------•------•--•-•--------------•--•-•.._......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLIT11-1 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has issued by the boar of health. Signed.........._�5_f.1/I__.. ... � ''�---•-'--"-"'.._...--- -.- Application Approved BY ��. �� / %/'- f �Ie.. Date Application Disapproved for the following reasons---------------------------------•----------------------•------•----------------•-'-------------'-"-'--.....---- ...........................'-----'---.•-..---------------•----------------•-----------•---------------------"---'-"--.._..-------'•--•--'------"---------'-'-'-------•---'--'-----•------••--'---'-•- Date PermitNo......................................................... Issued........................................................ Date ti I� Fps. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .?a `vAv.....OF...-.- 2...vST...-......1._.....'......................................................... ApplirFation for. Biapnaal 19orkg Tnnitrnrtiun Permit Application is hereby made for a Permit to Construct ( Repair ( ) an Individual Sewage Disposal System at: -- /✓�°Go� .i�i2/vJ SST, �o ................_.. .__............. - ...._..--•••-........_................... ....._..._....•••--•-----....•--•••----•-••----••-•••--•-•-•••---•----••--•--••--__........_•-•-•- Location-Address or Lot No. ...................... Owner Address a ... ......................................•. ---•-----------------------------•---•-------••--•------•--------------•-•----•---•--•••••-•------ Installer Address Type of Building Size Lot___:•3S S :d_Sq. feet is a Dwelling—No. of Bedrooms____.___..-�_____________________________Expansion Attic ( ) Garbage Grinder (/✓p 04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ...................................... O a o i.j ? �� i W; Design Flow................. per p�r3 per day. Total daily flow........... _._._._..................gal ons. � i w WSeptic Tank—Liquid*capacity./a�4tallons Length.f�'=__�"Width_ . ��. Diameter________________ Depth___5 -.� x Disposal Trench—No_ ____________________ Width___.._._._._.__.___ Total Length_________..._.__._.. Total leaching area_:.:1�.............sq. ft. Seepage Pit No........./---------- Diameter._.._. ....... Depth below inlet.......(.......... Total leaching area...��'_�7_.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by_________________________________________________________________________ Date........................................ as Test Pit No. 1__e-::_Z-minutes per inch Depth of Test Pit___- Depth to ground water... __. .-, (Z4 Test Pit No. 2_4n.:::_minutes per inch Depth of Test Pit.__/` y::._ Depth to ground water.............eC�`' P4 -------------------------------•----------------..........................._--�-f-�•---••-•-------•-----------••--•--__....... 0 Description of Soil_...`¢•____.:1� �` - To/ t S G�/3 t"`' 4'••- G4 -./v�0: S G-'-�,' -�• --- •••---- - - ------- `� V �/N.... .. D•-•._._ay...�---•----��..' v " T�Zg:� -sa�<__.. �_- yam..... c. - .. / W .................... /`� (iv ¢..� 7............. GvsvQ------------------------------- UNature 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 been issued by the board of health. Signed...................................................................................... ••••---••••--••••--•-•--•---•-•- D to Application Approved By............._________ -- f ----- ate Application Disapproved for the following reasons:................................................,............................................................ _ ..................-..........................................--.......................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................OF............*............... ........ ....................... �r , riirtt#r of Tantli�anrr THIS 1 TO CERTIF hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............... '............ ..d..-•------------------•----••-•--•••----- -•••--- ...........................--•---...••-••-•---•---•----._.... 0 Installer at.............. = ��--•'>--••--•••�" �. : �1----- - �-•----------------•-----------•----------•------ -- has been installed in accordance: with the provisions of TITL_; 5 of The"State Sanitary Code as described in the application for Disposal Works Construction Permit _______________ dated............_-_________________________-_-_______ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................ �`� Inspector................ ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............................I............OF............................................................ ................. Nd -_,!!._..t�.. FEE._?_�_"............. Diopnsa1' arks CDnnitrnrtion Permit Permissio hereby granted-------- ....... - ----------------------------------------------------------•---__---__-------_____._____------- to Construucc f ) or Repair ( ) an Individual Sewage Dis osal System ' at No... .......... Gx- ....�M a���wG�✓� treet i as shown on the application for Disposal Works Construction Permit No...................._ Dated.......................................... ............................................ oard of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS + 1 4 'I���}i it 14••� � i�h�° it rl, ,, _. � �� '„ ���. i�. ',�I A �. 111. 'Al1y Ilp. i ill � V ° �\ ` � .,�•, \ ,\ I '.t_ ,. `�t t �1 \ i lap- wr II / �,I � t( k�,il � It y I�1.F�Cy' .d/T•" °� p,20©_� � � �1� 1• ,, t '�.�, f M r 1 y1 +, ,t; �, ,,.:1. } ' D/1ST•._ i iViM• �. ,`_ I OG1 N s� .�°, ,. 4 1y1� sf}.°4.. '• `e ��'� _...{� 04rOf� Q 1�'` �7 w•/ �v� ;lD,•rf 4 t {4� N y 5 ) h tip •4 r D[ I r � ., 'i� , t i1 t. /_5779-71.. J ,Crpl�li�GY4NC� !✓/T// LQ'GAL N,1n/6 4WS QY.:BLOG,/NSPEGTd�. fit . n!.4G' G2/aOES" TO'/3 . ,t } Pit N Of �P�tH OF RICHARD RICNAJAMW RD l } 9WARN+i O'MEA1ly'►s .� � O LEGEND EXISTING SPOT ELEVATIONS OwO �! EXISTING CONTOUR--- 0- - - - FINISHEQ SPOT ELEVATIONS FINISHED, CONTOUR o PROPOSED PLOT PLAN APPROVED' BOARD OF HEALTH MASS DATE— AGENTLar4.7 CA��/AGF L:gNE:. R. J. O'HEARN,./NC.,:RL S RS ; 1348 ROUTE 134 EAST DENNIS, MASS. I l DATE,: _ �� e Z SCALE ea-iss3 9:!E. ,2A/ JOB N0. CLIENT I DR: BY SHEET L.,OF 2