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HomeMy WebLinkAbout0012 CRANBERRY LANE - Health 12 Cranberry Barnstable A= 234-048 �I f i 0201 Commonwealth of Massachusetts Title 5 Official Inspection Form. w:. �- Y�;,f Subsurface Sewage Disposal System Form,:-Not for Voluntary Assessments ,•, • , 12 Cranberry Ln4' Property Address Dick Sanford Owner Owner's Name information is enteNll L 15 G required for every C1Yn • MA 02632 9-23-20 .. e` 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. . . A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address East Falmouth n s MA, r :,02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number y B. Certification I certify that, am a DEP approved system inspector in full-compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below_ is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and e"*d6nce in the'proper function and maintenance of on-site sewage disposal systems-After conducting this inspection] have determined that the system: 7 • - 1. '® Passes 2. ❑ Conditionally,Passes t 3.. ❑ , Needs Further Evaluation by the Local Approving Authority t r , 4. ❑ Fails 9-23-20 I or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to.the system owner and copies sent to pthe buyer, if applicable, and the approving authority. I Please note: 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. t5insp.doc-rev.7/26/2018 _ r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 a .. c � Commonwealth of Massachusetts r� Title 5 Official Inspection - Form c�li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Cranberry Ln Property Address Dick Sanford - Owner Owner's Name information is Centerville MA 02632 required for every t :;'(9-23-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 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 is in good working order with no sign of failure. - 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I Commonwealth of Massachusetts _,- •:a f . ° 4_ 3 Title 5 Official Inspection Form i� r:, i�l Subsurface Sewage Disposal System Form;=Not for,Voluntary Assessments (' a `r 12 Cranberry Ln , Property Address Dick Sanford ? Owner Owner's Name information is Centerville. . MA 02632 9-23-20 required for every ` page. City/Town t State Zip Code Date of Inspection C. Inspection Summary (cont.) • 2) System Conditionally Passes (cont.): t,r . ,. ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms ar'•repaired: `'' ' • " ` ' + 1 Iw♦ Tr_ .' w a ! �» ..tom _' rt,,.. i.'V ,' . ,� . .. :. El 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 ass inspection if with a �o`val of Board of Health 'h P P C pP )� ' ` ❑ broken pipes) are replaced' ' `❑' Y "❑N 'El (Explain below): �c + 0 ' obstruction is removed 't �{ ❑ Y ❑N i .❑"ND (Explain below): ❑ `' distribution box is leveled or replaced• : ❑Y` '❑' N- ❑ ND (Explain below): At r J r } ❑ 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): 3) 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 environments '= a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r' ,w Title 5 Official Inspection Form !'I r�► Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 12 Cranberry Ln Property Address Dick Sanford Owner Owner's Name information is required fog every Centerville MA 02632 9-23-20. page. City/Town - State Zip Code Date of Inspection C. Inspection Summary (cont.) ' ❑ Cesspool or privy is within 50 feet of a surface water r ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland orr-a salt marsh b. 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. c. Other: r 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No El ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection';Form r "I wa p Ici Subsurface Sewage_Disposal System Form Not for Voluntary Assessments 12 Cranberry Ln Property Address Dick Sanford Owner Owner's Name information is Centerville - t .,�, MA 02632 9-23-20 required for every _ - page. City/Town R,F State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure,Criteria Applicable"to All Systems: (cont.) ; Yes. No.— : T Ej Z' '"i 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 E `'t®3 "€Y��tha. day flow'- ,.- ,, fP Ej ® 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 water supply f ❑ . ®.� .�;. 'well.- El ® f",-�'•-Any portion'of'a cesspool or privy is within 50 feet of a private water supply well. ❑t' ` ® 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.] . 0 4� The system is a cesspool serving a facility with a design flow of 2000 gpd- s -,10,000 gpdr t �, 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 •r - ,- ., =,. .•. „r•system owner should contact the Board of Health to determine what will be necessary to_correct the;failure;,,,,, t 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000'gpd to'16,000 gpd. ' t' - For large systems, you must indicate either"yes".or;`no"to each of the following, in addition to the questions in Section CA., Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply " ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form 01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Cranberry Ln Property Address Dick Sanford Owner Owner's Name information is required for every Centerville MA 02632 9-23-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) -'J, If you have answered "yes"to any'question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall,upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. - 6. You must indicate "yes" or"no"for each of the following for all inspections: 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? ® i ❑ Were as built plans of the system obtained and examined? (If they were not available.note as N/A).. „ ® t❑ + 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, ,t 'dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑, Wasthe 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I' c Commonwealth of Massachusetts Title 5 Official Inspection Form ? r�) Subsurface Sewage Disposal System Form -Not,forVoluntary Assessments 1. >" 12 Cranberry Ln r , Property Address - -Nv Dick Sanford r Owner Owner's Name information is required for every Centerville MA 02632 9-23-20 page. City/Town t State Zip Code Date of Inspection D. System Information V r v 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example-: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage_grinder?. Yes ® No Does residence have a water treatment unit? • , 4 f f., r_ ❑ Yes ® No If yes,.discharges to: w Is laundry on a separate sewage system? (Include laundry system inspection El 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: } ..4 Sump pump? ❑ Yes ® No . , Last date of occupancy: �f, '1 f i„ 2017 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts - rI ,p Title 5 Official lnspection Form ��r F�ll Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Cranberry Ln Property Address Dick Sanford - Owner Owner's Name information is required for every Centerville MA 02632 9-23-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ' Design flow(based on 310 CMR 15.203): , w' Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): , 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 f Commonwealth of Massachusetts e 3 Title 5 Official , Inspection Form. Ji�r Subsurface Sewage Disposal System Form-Not for.Voluntary,Assessments t, 12 Cranberry Ln Property Address Dick Sanford - Owner Owner's Name information is required for every Centerville ,,; _+'� , Lt MA 02632 9-23-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® .`Septic tank, distribution box, soil absorption system,, ❑ Single cesspool $,, ,4., , . 4 •� ❑., ,t 1 Overflow cesspool,; 4 •Y ❑ - 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 rt inspection of the I/A-system by system operator under contract} ❑ . ,-, Tight tank.Attach a copy-of the DEP approval. El (describe): Approximate age of all components, date installed (if known) and source of information: 2000 Were sewage odors detected when arriving at the,site? ;. # ,• ; ., «❑ Yes ® No 5. Building Sewer(locate on site plan):., y rh u r ' Depth below 22" grade: _; `:f f+ `feet., =,: Material,ofconstruction:'. 3 ❑ cast iron.:O ® 40'PVC *` `❑ other`'(ezpiain): Distance from private water supply well or-suction line: feet Comments (on condition-of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 cam° Commonwealth of Massachusetts �I Tile 5 Official Inspection Form i�► Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments :. m> 12 Cranberry Ln Property Address Dick Sanford Owner Owner's Name information is required for every Centerville MA 02632 9-23-20 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): . Depth below grade: .16"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: 1500 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" 1„ Scum thickness 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 .15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 P Commonwealth of Massachusetts 3 Title 5 Official Inspection Form i�i Subsurface Sewage-Disposal System Form;Not for Voluntary Assessments 12 Cranberry Ln „. Property Address r Dick Sanford 1 F' Owner Owner's Name - information is required for every Centerville,: MA 02632 9-23-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t, ,a., r ,s,* ; 1 _ 7. Grease Trap (locate on site plan): Depth below grade: feet *° Material of construction: ,Ft ❑ 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:.,,, �„ _.F i3t�e' •:'. ,•� ' ' `Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related'1o`outlet invert, evidence of leakage; etc.):"If. t 8. Tight or Holding Tank (tank must be pumped at time of i nspectio n)(locate on site plan): Depth below grade: Material of construction:. ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official • Inspection Form' i Subsurface Sewage Disposal System Form Not for.Voluntary Assessments 12 Cranberry Ln Property Address Dick Sanford Owner Owner's Name informatior is r required for every Centerville MA 02632 9-23-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) y. 8. Tight or Holding Tank (cont.) fi F Alarm present: ❑ Yes ❑ No , u - 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? -El.Yes ❑ No 9. Distribution Box,(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): Good condition. 9 , 1 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts . r Title 5 Official Inspection . Form p ;► Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments 12 Cranberry Ln + Property Address Dick Sanford Owner Owner's Name information is required for every �Centerville r ,r MA 02632 9-23-20 page. City/Town , ,, State Zip Code Date of Inspection D. System Information (cont.) r , ,t , 10. Pump Chamber(locate on site plan): -•7, r ,,4. Pumps in working order:" i l ° '❑'Yes ❑ No" Alarms in working order: ' , f •t ti : ' . ❑ "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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t , t Type: leaching pits-, , r s ,, number: ` ® leaching chambers number: 2-500's i ❑ leaching galleries number: ❑ leaching trenches - number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official - Inspection, Foam i �'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Cranberry Ln Property Address Dick Sanford Owner Owner's Name - information is required for every Centerville MA 02632 9-23'20 page. City/Town State Zip Code Date of Inspection cont. f D. System Information ( ) 11. Soil Absorption System (SAS) (cont.) ' Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition and empty at inspection with stain line at 6"off bottom of chamber. 12. 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 Comments (note condition of soil, signs of hydraulic failure, levee I of ponding, condition of vegetation, etc.): � r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts -• ; Ell 7 3 Title 5 Official lnspection Forte �.1 C�f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :.w . >" 12 Cranberry Ln Property Address Dick Sanford ,• , - Owner Owner's Name information is required for every Centerville • ., �,_ MA 02632 ' 9-23-20 t page. City/Town , State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): t t`` ' = ;+� .• `Materials of construction: Dimensions _ Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ) r t ' • t • t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 . � .. Commonwealth of Massachusetts - Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 s >' 12 Cranberry Ln 21 Property Address Dick Sanford Owner Owner's Name information is required for every Centerville MA 02632 9-23-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t 1 3J, e # v7v 6 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection .Form �ii, Subsurface Sewage Disposal.System,Form -Not for Voluntary Assessments, • , 12 Cranberry Ln Property Address Dick Sanford ,. Owner Owner's Name ' information is Centerville MA 02632 9-23-20 required for every . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: r► t-, -,; F :'; ,. �, 4 ,., ,, t, ❑ Check Slope _ �,, 'tt +.+'- _ ,._; a •�. ,, 4' ❑ Surface water x , ❑ Check cellar ❑ Shallow wells `Estimated depth to high ground water:, 12�+a -feet Please indicate all methods used to determine the high ground water elevation:­ ® Obtained from system design plans on record If checked, date of design plan reviewed:,,,, Date' + ® Observed site(abutting property/observation hole within 150 feet of SAS) _ ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ,. Title 5 Official' lnspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 12 Cranberry Ln �._ rY Property Address Dick Sanford Owner Owner's Name information is required for every Centerville MA 02632 9-23-20 ' ' page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist - Complete all applicable sections of this form inclusive of: J 1, ® A. inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ' ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: ' For 8: Tight/Holding`Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn,on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 12 CRANBERRY LN Property Address N SANTARCANGELO Owner Owner's Name information is BARNSTABLE MA 8-3-16 required for � every page. City/Town State Zip Code Date of Inspection fU Inspection results must be submitted on this form. Inspection forms may not be altered irlfgny way. Please see completeness checklist at the end of the form. p°'`l"t When filling out A. General Information n ,fig W forms on the v computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 026,32 Cityrrown 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _Z� 8-3-16 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 inspectiomdoes,not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is BARNSTABLE MA required for 8-3-16 every page. Citylrown 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: AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. 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-3113 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 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. Cityfrown 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis; performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 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 Assessment's 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is BARNSTABLE MA required for 8-3-16 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms.(design): 3 Number of bedrooms(actual): 2 per assessors DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 M 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: system consists of a 1500 gallon tank d-box and 2 500 gallon chambers with 4 ft of stone Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection El Yes [I 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: Not available through water dept at time of inspection. System not designed for arba a disposal Sump pump? ❑ Yes ❑ No Last date of occupancy: currently occupied Commercial/Industrial flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupied 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? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑. Privy. 0 Shared system (yes or no) (if yes, attach previous inspection records, if any) El 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•3/13 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 11-13-00 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ 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 El 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: 1500 gallon Sludge depth: heavy sludge t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System r Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information(cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness thick scum Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping now or at time of transfer and eve 2-3 yrs there after for maintenance 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM , 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Chambers were opened and had about 10"of liquid at time of inspection with14 inches of usable space and no signs of failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 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 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. Cityrrown 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is BARNSTABLE MA required for 8-3-16 every page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 every page. CitylTown 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: greater than 5 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: 8-2016 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 groundwater elevation: design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 CRANBERRY LN Property Address SANTARCANGELO Owner Owner's Name information is required for BARNSTABLE MA 8-3-16 - every page. CitylTown State Zip Code Date of Inspection E. Report Completeness. Checklist ® inspection Summary: A, B, C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r� TOWN\OF BARNSTABLE �' J LOCATION Z.0 ft 82 SEWAGE #1.`{00 D VILLAGE � r .:r'r � �i.�. �n�s ---�—�—�. --•� SESSOR'S MAP&LOT ; ® INSTALLER'S NAME&PHONE NO. C . , r so,v SEPTIC TANK CAPACITY i LEACHING FACILITY: (type);k•/te—/&,& e/�,g,dj/�ef'S _(size) LSD NO.OF BEDROOMS_ BUILDER OR OWNER G 16W6 PERMITDATE: OMPLIANCE DATE: (� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet j 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 i j Furnished by I I i i J ? Q Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 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:When filling out A. General Information When forms the S� computer, r,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name tQ P.O.Box 763 Company Address Centerville Ma. 02632 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 Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority t 5/5/2009 Insp ctor's i e Date �='s Va U?' at The system inspector shall submit a copy of this inspection report to the Appro"v g Auth15 ty(Board of Health or DEP)within 30 days of completing this inspection. If the system is a hared system Fri has a design flow of 10,000 gpd or greater, the inspector and the system owner s all subrpit the , report to the appropriate regional office of the DEP. The original should be sent to he 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. n � -510q t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 { i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is wired for required Centerville Ma. 02632 5/5/2009 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: The septic system is in proper working order at the present time. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 4 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for , Centerville Ma. 02632 5/5/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 '/2 day flow l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts H v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. CityFrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name_ information is required for Centerville Ma. 02632 5/5/2009 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 ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09108 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 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1500 gallon septic tank,distribution box and two drywells. Number of current residents: unknown 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 2007:4,000 g ( y g (gp )) 2008:1,000 Detail: 2007:11gpd 2008:3gpd 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): ITV 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from rivate water supplywell or suction line. 10+ P feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.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: 1500 Sludge depth: 2" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 4 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How.were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of leakage.Tank appears 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 t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): p *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information cont. Y (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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 is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Drywells were dry at time of inspection.Stain line is 19" below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 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 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 'Map Page 1 of 2 Town of Barnstable Geographic Information System p Parcel Viewer. Custom Map Abutters Ma size _ �,r.0 zoom Out QIn . AK Kv In U O�' Ob C, b E 5V A. b I 2O Feet ,. ... Set Scale 1" 20 I Aerial Photos I MAP DISCLAIMER Pnnvrinhf)nng-,)nnA Tnuin of ROmefehlo KAA All rinhfc rnccns, ht.trr//www.town.ha.rncta.hle.ma.-»s/arcims/anngeoann/man.acnx?nronertvTD=2_1404R&.mann--- 5/5/2009 I' Commonwealth of Massachusetts Title Official t e 5 ® cal Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required_for Centerville Ma. 02632 5/5/2009 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 leaching 55' 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 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Cranberry Lane Property Address Helga Seifart Owner Owner's Name information is required for Centerville Ma. 02632 5/5/2009 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file F l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 .... � is ARNSTABLE RS SBF`IZC`TA K�FAL"�"X'. P P R IT; I ...._..._..._ DAB �t+p�r�imi D�tancc$e�ihrcdn':E�1o• � ,'Maxu umAd�us Gf4ondwat+ 'F010 t"xaBottomofL hto�Fa l�ty Feefi Pmratta'tbr�tlpply` eu a�c� gaoyaist= onsst or 20� v ea ng ) Tee# Mob . { Edge o€Wet�attd and.I.eae�i+g�'�f�Y��tlands e�dst . I Fw�Iisbed BY' � l o � a L14 : y - as -3 -as- -3- 3q TOWN OF BARNSTABLE LOCATION 1A C 9 A Al ge 99 S/ SEWAGE 4000` i VILLAGE •' - d ;9"A'S�R'S MAP & LOT INSTALLER'S NAME&PHONE NO. 1- 11'�7.Nl AC 0 dd ff eA t SOAJ SEPTIC TANK CAPACITY. .4 S-G o LEACHING FACILITY: (type)2•%'1fjWC1,4,6//Sef- S (size) S'0 0, G.rL NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: d 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 . . � �� � �` ` ;t \ �b � � � • 3q � �a i °� � � Fe CAW }' Enie`red in cornputer': 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSAC.HUSES . s4 Application for Migomf *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( AXl�Complete System ❑Individual Components l Location Address or Lot No.12 Cranberry Lane Owner's Name,Address and Tel.No Theodora Wegener } f. gaalle,Mass. 02632 12 Cranberry Lane Centerville,Mass ti 02632 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 775-3338 775-3338 J?PPMacomber & Son Ins. J.P.Macomber & Son Inc Bo 6 e 2 Type of Building: drooms Lot Size sq.ft. Garbage Grinder DwellingXXYNo.of Be ( ) Other -'Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures r: Design Flow OSS 4 A 220 gallons per day. Calculated daily flow �.,� n_ n gallons. l ®�+ �rr1 O-220 3 Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 3 F, Description of Soil r` oamy sand o medium tine sand. r Nature of Repairs or Alterations(Answer when applicable) OLutttilly cesspouls. 111s tai hkil%j ti - 1 -JVV 9cft,tuli tank r box and two SbO gai i e cn g } cnam ers packea in 41 o s one. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system ' in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B and of Health. lj Signed A Date 10 31 r � z Application Approved by &9 P!— Date Application Disapproved f th lowi4g r1as ns v Permit No. Date Issued ita —————— ———————————————————————————————— f ' Ll THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS , fi certificate of Compliance r , ' THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )UpgradedAXX) Abandoned( )by "I at .1 a 1 i" of i has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer =F _ Designer The issuance of ttus permit a 1 not •e construe as a guarantee that the system wi function as designe Date 1 -2 .�.^e Inspector ) *;l 'l% v/ /j.� / �'�;' ', ilk, ---------------------- ———— -- .� No. 10 Fee t THE COMMONWEALTH OF MASSACHUSETTS "k PUBLIC HEALTH DIVISION - BARNSTABLE MASSACHUSETTS s S ligo$ar *pgtem Construction Permit Permission is hereby ranted to Construct Repair Upgrade y g ( ) p ( )Upg XX)Abandon( ) t System located at C and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must be completed within three years of the date of this�permit.i-, . `! w� Date: "'7 1 �. � Approved by P� �/ 1. No. Fe,; 5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for 0iopotal 6potern Con.5truction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( Mf�Complete System ❑Individual Components Location Addressor Lot No. 2 Cranberry Lane Owner's Name,Address and Tel.NoT eodora Wegener Centerville,Mass. 02632 12 Cranberry Lane Centerville,Mass Assessor's Map/Parcel P 3 7 02632 Installer's Name,Address,and Tel.No. 7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 7 7 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc, Box 66 Centerville,MASS. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XXXNo.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow -''3 gallons per day. Calculated daily flow 2 X 1 1 0=2 2 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Loamy sand to maditrm fine wand Nature of Repairs or Alterations(Answer when applicable) Om i t t i n q cesspools. I n s t a l l i nq 1 -1500 gallon tank lDistribution box and two 500 gallon leaching chambers packed in 4 ' of stone- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Co a and not to place the system in operation until a Certifi- cate of Compliance has been iss d by t ' azd f Health. Signed + a Date 1 0/31 Application Approved by Date Application Disapproved for the following reasons - Permit No. Date Issued NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) L Joseph P.Macomber Jr. hereby certify that the application for disposal works construction permit signed by me dated 1-0/31 /0 0 concerning the property located at 12 Cranberry Lane Centerville,Mass. meets all of the following criteria: �- • The failed stem is connected to a residentialdw elling�' _ only. There are no commercial or business uses associated with the dwelling. , • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of-the-proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested.or needed. • The bottom of the proposed leaching facility will D2Lbc located less than five feet above the maximum adjusted groundwaici table elevation.'(Adjust the groundwater table using the Frimptor method when applicable) • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14.) feet above the maximum adjusted groundwater table elevation, , Please complete the following: A) Top of Ground Surface E! anon(using GIS information) B) G, ' Elevation + the MAX. High G.W. Adjustment . DIFFERENCE BETWEEN A and B �' l SIGNED : DAB: 1 0/31 /00 .40 (Sket oposed plan of system on back). Q:heilth folder.cent ,. , l i t � �®�O�/ V ���� D � . . � TOWN OF BARNSTABLE j LOCATION �'� C�` — ;� SEWAGE #1000 VILLAGE C ���� 11) V/ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO._ .�/� 0 r S f? SEPTIC TANK CAPACITY i LEACHING FACILITY: (type) 5 (size) S© O, G.4L NO. OF BEDROOMS if R OWNER •� / BUILDER O �y PERMIT DATE: 7� COMPLIANCE DATE: Separation Distance Between the: Feet + Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply.Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge.of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by I 41 6/4c i I _