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Home My WebLink About0024 ALBERTI WAY - Health 24 Alberti Way Centerville P 248 286 d �llJf J�Vtry Fob m1 ® s �. III 2 i J' PO 12543 110.53LOR HASTINGS, MN t C VII t Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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. General Information SI� 1. Inspector: Iv Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification as; I certify that I have personally inspected the sewage disposal system at this address and that the a CD 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 (310 CMR 15.000).The system: p ®"Passes ❑ Conditionally Passes ❑ Fails r r - ❑ Needs Further Evaluation by the Local Approving Authority 4-26-11 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. It t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage D osal System•Page 1 of 17 All Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M0 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is require or every Centerville MA 02632 4-26-11 d f page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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: System is in good working order with no sign of failure. 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): I � J t5ins-11/10 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 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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): .. f 1. - ... 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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: E The system has a septic tank and soil absorption system (SAS)'and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 page. City/Town 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: ❑ Et. Any portion of the SAS; cesspool of 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 CM 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 Ell °❑ Area-1WPA)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-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts u Tale 5 Official Inspection Form p o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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? ® ❑ 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 CM 15.302(5)] 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 d x #of bedrooms): 330 ( p 9p ) t5ins-11/10 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 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) - Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 years usage (gpd)): Detail: r ail.,v.d FJLi iJJ 3Y •t=f ... , . . Sump pump? ❑ Yes ® No Last date of occupancy: 3-2011 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-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 ' 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Alberti Way Property Address Bank Owned (Contact David Holt @Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 page. City/Town 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: 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: 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-11/10 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 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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: 1990 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Good condition. 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 gal I Sludge depth: 12" t5ins•11/10 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 �M 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 page. City/Town 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 20" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14 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. 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-11/10 Title 6 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 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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.): 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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 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 with water at working level and no sign of back-up. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 page City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal r ❑ leaching chambers j., " 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.): Leach pit is in good condition and empty at inspection with stain line at 24" below inlet 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 24 Alberti Way M Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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-11/10 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 , 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 17800-966-2448) Owner Owner's Name information is Centerville MA 02632 4-26-11 required for 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 0 C_ r T t5ins•11/10 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 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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: 30' 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: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 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 24 Alberti Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448.) Owner Owner's Name information is required for every Centerville MA 02632 4-26-11 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Certified Mail#7006 2150 0002 1042 0446 i+F TOwa. Town of Barnstable Regulatory Services AR HL& MASS. $ Thomas F. Geiler, Director qGp 039. Ay0 Ft?MAC Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 11, 2008 Mariangela Vieira 24 Alberti Way Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION, THE STATE ENVIRONMENTAL CODE, TITLE 5. The property owned by you located at 24 Alberti Way, Hyannis, MA was inspected on August 8, 2008 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.300 and 310 CMR 15.00: There were a total of four (4) bedrooms observed in this dwelling; one (1) was observed on the first floor, two (2) were observed on second floor, and (1) one was observed within the basement. However, the existing septic system (permit # 98-593) was not designed for (4) four bedrooms. It was designed for three (3) bedrooms. 410.450 Means of Egres: Observed room within basement being used as bedroom without second means of egress. You are directed to correct the violations listed above within twenty four(24) hours of your receipt of this notice by removing all beds from basement and ceasing and desisting from using any part of basement as sleeping quarters. Due to the fact this rc>:wn in the basement does not have the proper egress it is not considered a bedroom by Health Division. Although, it may not be used as a bedroom due to septic restrictions. If you choose to install an egress window in said bedroom you must remove a bedroom from the main part of house. This can be done by removing door and enlarging opening to a 5.Oft cased opening. QAOrder letters\Housing violations\Rental ordinance\24 alberti way cent. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Timothy O'Connell, Health Inspector QAOrder letters\Housing violations\Rental ordinance\24 alberti way cent. a FBI Mi41�IGREJA DO EVANGELNO QUADRANGULAR 6® FOURSQUARE GOSPEL CHURCH Em Nantucket Expnassondo 0 onwr de Deus pono vote a suo fo-illa. Fl. o—ce.-I Salva Batiza Cura Vottara Pre.Mario a MarianSda Yeira 508-367-7313 Cultos: i mario—vieiraSS@hotinaA.com S3bados 7:30 pm I a�Neb Request ` Page 1 of 3 v vu In As Route tc i._,_.., t_ R i Request Information t Request ID 22049 Created: 8/4/2008 2:41:05 PM O'Connell, Timothy, Status: Assigned To Staff Assigned To: Health Office i I Anonymous: Yes Request Category: Chapter 170 : Housing Overcrowding edit Estimated 8/7/2008 Change Estimated Jul August 2008 Sep Completion Completion Date: ( Date:` + + -}. Sun Mon Tue Wed Thu Fri Sat 27 28 29 30 31 1 2 + + +I i ( 3 4 5 6 7 8 9 10 11 12 13. 14 15 16 1 17 18 19 20 21 22 23 L 24 25 26 27 28 29 30 `f 31 1 2 3 4 5 6 Created By: Ring, Ernestine Priority: Medium edit Building Dept Citation Numbers: edit Requester Information [Requestor Request DETAILS: LOCATION: 24 ALBERTI WAY Centerville, Ma 02632 Request Parcel Number Map: s248 Block: ,2 6 Lot: 000 3 BASEMENT BEDROOMS WERE ADDED SEVERAL YEARS AGO, BUT j i NOW THEY ARE WORKING ON Parcel Lookup CREATING MORE LIVING SPACE E OVER EXISTING GARAGE. MULTI CARS IN DRIVE WAY AND AT LEAST E 6 ADULTS LIVING THERE AS OF LAST http://issgl2/IntemalWRS/WRequest.aspx?ID=22049 8/5/2008 �` "' t�` �_. +; .. `j eb Request Page 2 of 3 YEAR. NO PERMITS ON FILE FOR RENOVATIONS. .......................... _....... _ __ ..__.._______.__..__,_._____._.__.__ Email: l Edit_Re_questor._Informaton Track Request Progress _........._...................................._......_............. . ._............................._..............--......_____.._._..............__. ......... _.._.. ....._..._. .. . .. _ i Request Work History: Internal Note History: ................................_....................................................................................._........__...._....._............... System entry on 8/4/2008 2:41:05 PM: I Related_Request 22048. System entry on 8/5/2008 8:29:07 AM: Assigned to O'Connell, Timothy Enter work progress: Enter internal note: (dewed by everybody) (Viewed internally only) i l � I Spell Checks Spell Check f E _..............._._.__._....__ ....._.._...__..........._................._........._..._........._..._.._.__....... . _ . .. ._..__._._......._........................._. Add document or image link: ' . .... .. Browse m You can also a folder narne r.; see everything in eh', , ,a `" Current Links: Time worked on request: Response time: 10 Time cent' "_ ari2 in hours. Exam les f time entries:ies t.2 ,5, 035, 1, 3.5, nc:, 1t�r arc r r �€ r >l.�. . '�?`' _,._,� _«. ., ,"v&ti =�,.aC �i�:i.(a. l.�"z C1;". �i�� I:' ,�ac_.�d., o n C � si (,k.;1 ., vz,.:« =b?! 't� si..C32.fs E.Iiii€� fE j rT. )::�t de far Save Changes Check to notify town employee below http://issgl2/IntemalVvRS/WRequest.aspx?ID=22049 8/5/2008 ................................................................................ al Iy b Request Page 3 of 3 ' a Save changes and notify to review this request. citizen* Health Office 1 Close request Cabot, Jaime Close request and notify citizen* Brief message to reviewer: Update, Spell Check Public Use: PrinterFriend.... on_ . ....... Internal Use: Printer Friend l.y._Vers...ion http://issgl2/IntemalWRS/WRequest.aspx?ID=22049 8/5/2008 o4 AIX j w Health blaster Detail Page 1 of 1 .. a 1-...,, ,� `ad>➢,d.,roa,<fr .... - x' :4a�.,.^rza�. {;"4y. Heew aster Detail `3".�..:��i� �. ApsD ir-7t on Center I _oo Selection Marcel Septic IPerc I Well .,..,.. t e1 fan. 1 Parcel: 248-286 Location: 24 ALBERTI WAY, CENTERVILLE Owner: VIEIRA, MARIO D & l ARIANGELA Business name: Business phone F,,----. . Rental property: F7, Deed restricted: F1 Number of bedrooms : 0 Contaminant released: F Fuel storage tank permit: F. Save Parcel Changes Return to Lookup Parcel Info Parcel ID: 248-286 Developer lot:I...OT 4A Location:24 ALBERTI WAY Primary frontage:20 Secondary road: Secondary frontage: Village:CENTERVILLE Fire district:C.0-MM Sewer acct: Road index:0011 lou,,� �.Asbuilt Septic Scan: 248286_1 Interactive map yx Town zone of contribution:WP (Wellhead Protection Overlay District) State zone of contribution:IN C vvner Info Owner: V1EIRA, MARIO D & MAR1ANCELA Co-Owner: Streetl:24 ALBERTI WAY Street2: City:CENT ERVILLE State:MA Zip: 02632 Count Deed date: 10,1/2004 Deed reference: 19092/198 Land Info Acres: 0.33 Use: Single Farn MILL-01 Zoning:RB Neighborhood: (itO, Topography: [ evell Road:Paved Utilities:Public Water,Gas,Septic Location:Rear Location Construction Info B:U ldin olyear Bui;,. `P<<tliff:: ;ri??t (rC t• ;�i 13.'^..t11CCr•!�' 1 1990 1489 3 Bedroom 2 Full Buildings value:15149,500.00 Extra features: $2,800.00 Land value: s-166;500.00 http://Issgl/Intranet/healthMaster/HealthMasterDetail.aspx?ID=248286 8/5/2008 ' �" t �.°.l V ...�, � 1 I� • .....-w-�-�.� r I Certified Mail#7006 2150 0002 1042 0446 cltE \ Town of Barnstable SO jt Regulatory Services r,BARNSTA t3LE, •} �� a gJJ Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 11, 2008 Mariangela Vieira 24 Alberti Way Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION, THE STATE ENVIRONMENTAL CODE,TITLE 5. The property owned by you located at 24 Alberti Way, Hyannis, MA was inspected on August 8, 2008 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.300 and 310 CMR 15.00: There were a total of four (4) bedrooms observed in this dwelling; one (1) was observed on the first floor, two (2) were observed on second floor, and (1) one was observed within the basement. However, the existing septic system (permit # 98-593) was not designed for (4) four bedrooms. It was designed for three (3)bedrooms. 410.450 Means of Egres: Observed room within basement being used as bedroom without second means of egress. You are directed to correct the violations listed above within twenty four (24) hours of your receipt of this notice by removing all beds from basement and ceasing and desisting from using any part of basement as sleeping quarters. Due to the fact this room in the basement does not have the proper egress it is not considered a bedroom by Health Division. Although, it may not be used as a bedroom due to septic restrictions. If you choose to install an egress window in said bedroom you must remove a bedroom from the main part of house. This can be done by removing door and enlarging opening to a 5.0ft cased opening. Q:\Order letters\Housing viol ations\Rental ordinance\24 alberti way cent. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Timothy O'Connell, Health Inspector Q:\Order letters\Housing violations\Rental ordinance\24 alberti way cent. SENDER: COMPLETE THIS SECTION COMPLETE THIS DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sig11, item'4 if Restricted Delivery is desired. ❑Agent X ■ Print your name and address on the reverse dressee so that we can return the card to you. S. Rec v by(Printed Name) C. Dat of Dp'very ■ Attach this card to the back of the mailpiece, or on the front If space permits. l 1. Article Addressed to: D. Is delivery address different from Item 1? Oyes If YES,enter delivery address below: 925 Aikj� WAY V� OQ 3. Sje�Type / t O'Certlfled Mall ❑ ress Mall ❑Registered 1 Retum Receipt for Merchandise 1�J ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑yes 2. Article Number r i ?r (Transfer from service label 1 70 0'6' "215 0 0 0 0 z 1 4 2 4 4 6' PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES ��T �l • Sender: Please print your name, address, and ZIP+4 In is box • I I I I I i °+Q Town of Banistable I 1 C�J�j Health Division 200 Main Street Hyannis, NIA 02601 I I I I I I I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION idAP Z�g��-� P/�RCEI. ,.___ -%(D A_...�.......:,.s..wM TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 24 Alberti Way Centerville, MA 02632 Owner's Name: Katherine Donahue&James Looney Owner's Address: Date of Inspection: August 2, 2004 - i; Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 �' c Telephone Number: (508) 862-9400 03 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the info ation 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 Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: August 4, 2004 The system inspector shall sub it copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of complet this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 Alberti Way Centerville, MA Owner: Katherine Donahue&James Looney Date of Inspection: August 2, 2004 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 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: 2 3 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 Alberti Way Centerville, MA Owner: Katherine Donahue&James Looney Date of Inspection: August 2, 2004 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 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 Alberti Way Centerville, MA Owner: Katherine Donahue&James Looney Date of Inspection: Augmt 2, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/z 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. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No 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. 4 I Page 5 of i l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 24 Alberti Way Centerville, MA Owner: Katherine Donahue&James Looney Date of Inspection: August 2, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 Alberti Way Centerville, MA Owner: Katherine Donahue&James Looney Date of Inspection: August 2, 2004 FLOW CONDITIONS RESIDENTIAL 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: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 6128190-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Alberti Way Centerville, MA Owner: Katherine Donahue&James Looney Date of Inspection: August 2, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certi ficate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Alberti Way Centerville, MA Owner: Katherine Donahue&James Looney Date of Inspection: August 2, 2004 TIGHT or HOLDING TANK: None (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: izallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): J 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Alberti Way Centerville, MA Owner: Katherine Donahue&James Looney Date of Inspection: August 2, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(IOOOQal.) 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.): The pit had 2'ofliguid on the bottom. The scum line was at the same level. There did not appear to be any signs offailure. The cover was 3'below grade. The bottom to grade was 9'. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURVACEl SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Alberti Way Centerville, MA Owner: Katherine Donahue&James Looney Date of Inspection: August 2, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. Q II a A Q 3 y a 33 3 s 3 10 Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Alberti Way Centerville, M4 Owner: Katherine Donahue&James Looney Date of Inspection: August 2, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 DATE: 1 /21 /02 PROPERTY ADDRESS: 24 Alberti Way ----------------------- Centerville,Mass_-- 02632 ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 1 -Distribution box. 3 . 1 -1000 gallon precast leaching pit. ( 6 'X 9 . 5 ' ) Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code ) 5 . The septic system is in proper working order at the present time. 6 . Waste water is 71 " below the invert pipe of the leaching pit. SIGNATURE:1 J. Name:_j. _ Macomber Jr�______ Company: Josej)h_P. Macomber_& Son , Inc . Address:_ Box-66 RECEIVED --Centerville , Ma . 02632-0066 ----------------- JAN 2 4 2001 Phone: 508-775-3338 --------------------- TOWN OF t3ARNSi-ABLE HEALTH DEPT. THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connectlons P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • a,c✓ COMMONWEALTH OF MASSACHUSET P S EXECUTIVE OFFICE OF ENVIRONMENTAL, AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:24 Alberti Way en ervi e Mass. Owner's Name: Lillian MaTTHEW Owner's Address: Same Date of Inspection: Name of Inspector: (please print) Joseph P.Macomber Jr. Company Name:J.P.Macomber & Son Inc. Mailing Address:Box 66 02632 Telephone Number: — —3�� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /—/Passes Conditionally Passes _ Needs Further Evaluation by the Local Approving Authoriry F �i Inspector's Signatur ailse: Date: The system inspector shall bmit 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 authorir)-. Notes and Comments r ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:24 Alberti Way en ervi e, ass. Owner:Lillian Matthew Date of Inspection: 1 2 02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.. ystem Passes: A4L1 have not found any information hick indicates that any of the failure criteria described in 310 CMR 15.3 03 or 1 ve3;, Z'FfI�TS.3�4 exist ny failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the nrPSPnt- fi i mP'_ B. System Conditionally Passes: ,e� 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: ,4110 Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: �� 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: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 Alberti Way Centerville,Mass. Owner: Lillian Matthew Date of Inspection: 1 /21 /0 2 C. Further Evaluation is Required by the Board of Health: V0 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: 410 Cesspool or privy is within 50 feet of a surface water r' is within 50 feet of a bordering vegetated wetland or a salt marsh � Cesspoolor p privy g g 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: ,C_lL) 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. ,VG The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ,00 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. )—Z) The system has a septic tank and SAS and the SAS is less than,1/00 feet but feet or more from a private water supply well". Method used to determine distance y "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 Alberti Way Centervi e,Mass. Owner: Lillian Matthew Date of Inspection: 1 21 0 2 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no" to each of the following for all inspections: Yes No ackup 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 b x above outlet invert due to an overloaded or clogged SAS or esspool /—+�i�_, 6 (l/ � iquid depth in4esspee4-is less than 6"below invert or available volume is less than '/,day flow — �JRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped O . y 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. _ {� y portion of a cesspool or privy is within a Zone 1 of a public well. ��y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E, Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no/ lJ the system is within 400 feet of a surface drinking water supply — 21 e 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 — — Y g (_ ) PP 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. 4 Page 5 of I ! OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:24 Alberti Way Centerville,Mass. Owner: Lillian Matthew Date of Inspection: 1 / .1 /02 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 2were any of the system components pumped out in the previous two weeks _ Has the system received normal flows in the previous two week period ? 2Have large volumes of water been introduced to the system recently or as part of this inspection ? Y 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.,4*cluding 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 ? ZWas the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes V xisting 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 CM-R 15.302(3)(b)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 Alberti Way en ervi e, ass. Owner: Lillian Matthew Date of Inspection: 1 21 02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system,.(ye or no): '�[if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): 410 Water meter readings, if available(last 2 years usage(gpd)): 2 0 0 0—9, 00.0 gal lons-24 . 66 GPD Sump pump (yes or no): '0 2001 —9, 00.0 gallons-24 . 66 GPD Last date of occupancy: / COMMERCIALIMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 4� Grease trap present(yes or no):,,&i¢ Industrial waste holding tank present(yes or no): .C�/¢ Non-sanitary waste discharged to the Title 5 system(yes or no):�1�/� Water meter readings, if available: 'r/ Last date of occupancy/use: ,ems OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: yam/ Was system pumped as part of the inspection(yes or no): — If yes, volume pumped: _tgallons-- How was quantity pumped determined? �0 Reason for pumping: TYP F SYSTEM eptic tank,distribution box, soil absorption system ,LO Single cesspool Overflow cesspool 45 Privy 9 If/, 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) :�j ight tank Attach a copy of the DEP approval Other(describe): ,,6 Approximate age of all co p Zets t tailed (if known)and source of information:i i Were sewage odors detected when arriving at the site(yes or no):I& 6 * Page 7 of 1 I r OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTA.RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:24 Alberti Way en ervilTe,Mass. Owner:Lillian Matthew Date or Inspection: 1 21 02 BUILDING SEWER (locate on site plan) Depth below grade: .� Materials of consnuction A/Pca ! von Z40 PVC "other(explain): .t4� Distance bom private water supply well or suction line: Comments (on condition ofjoinu, venting, evidence of leakage, etc.): Joints appear tight, No evidence of laakAgp Th., SygtAm is vented through the house vents. SEPTIC TANK: Zlocate on site plan) leeo�PA406ky' d Depth below grade: /�/ Material of consovction: ':c.ncrete /��metal�_CXberglass.d�JPolyethylene '( othcr(explain) (� if tarSk is metal list age:.UO Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of Dimensions: Sludge depth:,—, Distance from top oL.l cge to bottom of outlet tee or bafflew� Scum thickness: Distance �om to p of scum tom of utIet tee orba le: Distance Qom bonom of scum to bonom of outlet tee or baffle: How were dimensions determuned: /�ei9SGJ�i�i Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integ7iry, liquid levels .as related to outlet inven, ev:cenc: of leakage, etc.): Pump the septic tank every 2-3 years. Inlet & outlet tees ` are- in place,The tank �is structurally sound and shows no evidence of leakage. CREASE TRAFY e(!ocatr on site p!an) Depth below grade:.(1 Material of construction,1//tconcreteyiAmetal'/ fiberglass!/�Polyethyleneoe4Vother (explain): � — Dimensions: Scum thickness: �l/A Distance from top of scum to top of outlet tee or baffle: Distance from bonom of s-um io bo^orn of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integriry, liquid levels as related to outlet rover,, ev!,Jence of leakage, etc.): Grease trap is not present- 7 Page 8 of 1 I � � o OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Alberti Way Cen ervi e, ass. Owner: Lillian Matthew Date of Inspection: 1 /21 /02 TIGHT or HOLDING TANKW,(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete�,2metal &A fiiberglass,kY Polyethylene,40 other(explain): . Dimensions: _ 'V14 Capaciry: /I gallons Desisn FIo": gallons/day Alarm present (yes or no): ,!f Alarm level: A,� Alarm in workingder or (yes or no): Date of last pumping: wll Comments (condition of alarm and float switches, etc.): Tight or holding tanks are not presenf. DISTRIBUTION BOX: _jZ(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 4AP 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 has one lateral.No evidence of solids carry over No evidence of -leakage in o or ou DI Aliz: PUMP CHAMBERd/e4{t.(locate on site plan) Pumps in working order(yes or no) ,14 : Alarms in working order(yes or no): # Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is not presen 8 Page 9 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Alberti Way Cen ervi e,Mass. Owner: Lillian Matthew Date of Inspection: 1 21 02 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 1 -1000 gallon precast leaching pit. 6 ' X10 ' If SAS not located explain why: Located; See page 10 Type,. �/leaching pits, number: leaching chambers, number leaching galleries,number: leaching trenches,number, length: leaching fields, number, dimensions: 73 overflow cesspool, number: -0— ,�00 � / innovative/alternative system Type/name of technology:]%r� /11�� C �� 4-/6 Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to medium fine sand.No signs of hydraulic failure or ponding.Waste water is 71 " below the invert pipe Soils are dry.Vegetation is normal. CESSPOOLSQ)Aj1 -(cesspool must be pumped as part of inspect ion)(]ocate on site plan) Number and configuration: D Depth-top of liquid to inlet invert: Depth of solids layer: 4 Depth of scum laver: ► Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): Cesspools are not present PRIVY44 (locate on site plan) Materials of construction: (/rQ Dimensions: I" _ Depth of solid Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is not present. 9 Page 10 or I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Alberti Way Centervi e,Mass. Owner: Lillian Matthew Date or Inspection: 1 /21 /02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch or the sewage disposal system including tics to at least two permanent rcrerence landmarks or benchmarks. Locate all wells within 100 rcet. Locate where public water supply enters the building. 214 % p I AI - 291 ° 2 2: 33, 2, 35rJ 0 3 Z 3�3g , 10 r .i Page 1 1 of 1 1 ► OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Alberti Way Centerville,mass . Owner:Lillian Matthew Date of Inspection: 1 /21 /0 2 SITE EXAM Slope Surface water Check cellar Shallow wells C Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: _ Obtained from system design plans on record - If checked,date of design plan reviewed: _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: Used: Hahrety & Model 12/16/94 Grond water lelevation above sea level USGS; Observation well data ,Tune 1992 USGS; Annljal ,,7�anges of groundwater level 92-000-1 Plate#2 I up Of Qrouno Leaching i6�/ Pit ',eet LLff//�� W Groundwater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Fhmpter Method Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is Al feet. ll ` •nr.+Sr+rT-nrs.-.r�irn�mr•+.nnnrn..,n,•rmnr.�s+trrr++.+�.ennrrnvu +�s+a,w•n .. �^ ' TOWN OF Barnstahl P WARD OF HEALTH � SUIlSURFACR ,SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••T'•t�T••••.' —T.1 t�.TTT.T T"!11'R:1fI1 T`1R lRTT/1RTT,'T—•,'I T11Rn'7�R1.T-'/TITQAf I.P1�I�R'IR7 ltnl A ..J .1Tt/•T'T�•1• .� -TYPO OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRES$ 24 Alberti Way Centervilleff,,Mass. ' ASSESSORS MAP , BLOCK AND PARCEL # Of3 OWNER' s NAME Lillian Matthew PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & $.vn Inc COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Street Town or City State r1P COMPANY TELEPHONE (508 ) 775 - 3338 FAX (508 ) 790 -1578 - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal. system nt this address and that the inrortnation reported is true , accurate , and omplete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : '//System PASSED ti : The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or- Lhe. environment as defined in 310 CMR 15 - 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have con acted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date copy of this certification must be provided to the OWNER, the BUYER One where applicable ) and the BOARD OF H$AL71H. * If the inspection FAILED, the owner or"'*operator shall u within one year of the date of the inspection, unless allowed dortrequiredm otherwise as provided in 3.10 ChIR 16 . 305 partd .doc I = -SETTS OF � SACHI-COyVONW EXECUTIVE OFFICE OF ENVIRONMENTAL AIRS 1� DEPARTMENT OF ENVIRONMENTAL PRO CTION�f r tI ONE WINTER STREET, BOSTON MA 02108 (617) 292- 5(J0 JU r N 10 1999 fAOP ftiver T COXE 9Uy '1�E cretary ARGEO PAUL CELLUCCI D STRUHS rnor ommissioner Gove SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E ti 1�/7 PART A A p r CERTIFICATION /t Property Address: SE 1 WYP Name of Owner kf, S C/6 Address of Owner: S/A/r G Date of Inspection: 5"6-tqcllq Name of Inspector:(Please Print) EUWN(2 D Cr &-xisF/ELQ 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: _aWARD C LGOuS F111CW Mailing Address: D2 tv000 / Vic A OaS-63 Telephone Number: SO 8 f08 S CERTIFICATION STATEMENT j I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes — Conditionally Passes Needs Furthe'r Evaluation By the Local Approving Authority Fails i Inspector's Signature: Data: 5-/5' The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is'a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS 1000 6.4tC0/V fJ-13�X /poo GA.LCOIZJ (,E/�;N Pi7' �g 1N�HS of �-JZ�VI� �,vyDc, GODO CarU Di7101'U . I revised 9/2/98 Pagel of11 i 'i w Printed on Recycled Paper i i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: `A j , S/ )L/C,R Date of Inspection: S- INSPECTION SUMMARY: Check O B, C, O/ A A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 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. Indicate yes, no, or not determined(Y, N, or NO). Describe basis of determination in all instances. If "not determined",explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection;or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). i broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed I t revised 9/2/98 Page 2of11 ( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 At 6�2Ti L�% Owner: L'L) • S'9 UC(e2 Date of Inspection: J_ -0[�1 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. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. i i 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well;unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER r i revised 9/2/98 I Page 3of11 ' f w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) y C (�.� Property Address:y� P 6ERTI Owner: (J'VI S/i V C/L:� Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necbssary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. I Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or — — i cesspool. j Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. I ! — — 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). Number of times pumped,—. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no. acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) { The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised .9/2/98 Page 4of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property pAddress:11- _p&86-RTI a,"I"! Owner: Date of Inspection: J J r Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. r None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. i As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling ways inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. y _ The site was inspected for signs of breakout. _ All system components, , have been located on the site. X _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)) _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintenance of Subsurface Disposal Systems. L i S i t l � r J I I revised 9/2/98 Page 5of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n� SYSTEM INFORMATION Property Address: 2 AL66RTI L(•1 11) Owner: W,SAUc162 Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design):_ Number of bedrooms(actual): Total DESIGN flow 330 Number of current residents: ' Garbage grinder(yes or®1:_W Laundry(separate system) (yes or(&):IW, If yes,separate inspection required Laundry system inspected s or no) n Seasonal use(yes or )_ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or&:kv Last date of occupancy: . 7-ILL OCCUPIES COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ $ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) 4 Last date of occupancy: i GENERAL INFORMATION PUMPING RECORDS and source of information: wrvl pc D 3 YR,5 /�Go System pumped as part of inspection: (yes or®A-V If yes, volume pumped: gallons Reason for pumping: TYF 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other t1 J APPROXIMATE AGE of all components,date installed(if known)and source of information: �V vo �d Sewage odors detected when arriving at the site:(yes or n�c) revised 9/2/98 Page 6of11 i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) I Property Address: OL6077 1� Owner: Date of Inspection: I S I4GQ BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) I Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK- (locate on site plan) Depth below grade: in'��(S Material of construction: Aconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,/list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 11�,1LX Y�/0'LJX Sludge depth: • Iti'CHS �ItiCNS Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:111U0 fNCNS Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: J How dimensions were determined:'t-/+��!+i EASURE Comments: (recommendation for pumpin condition of inlet and outlet tees or baffles, depth of liquid le el in relationtout�tinv��, structural integrity, evidence of leakage,etc.) K STj PUC �� &/06'10 c 61�7t AT 1307 n E Wr cfi k GREASE TRAP: (locate on site plan) i Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other explain) I 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: t R Comments: I (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.) F i revised 9/2/98 Page 7of11 i I I ' i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C SYSTEM INFORMATION(continued) ' n I Property Address: aq /�C QE2�� W y Owner: Date of Inspection: Ill i TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:4 (locate on site plan) Depth of liquid level above outlet invert rM(Lj O F 00tbST f f PC Comments: (note if level and distribution is equal, evidence f solids carryover, evidence of leakage into or out of box, etc.) A)() SocI AS OIyF; p/PE /N -- OtVe- P/PE ©c.t'7, k PUMP CHAMBER:_ (locate on site plan) I j Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition:of pumps and appurtenances,etc.) i I revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirmed) Property Address:`) W l Owner: o-),S/4UC 1ck pp Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): 1-14 (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: �N�c 6177-COJU LCAGN PfT leaching pits, number:_ leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydra I'c it're, level of po din d soil, c ition of ve elation, etc.) i /Lrb S/GNS o�. 1� r'f0�AUUL �+ru '� y ' ►t)cl of GIQUtp i�usinr✓ I 0 CESSPOOLS:_ (locate on site plan) i 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 (cesspool must be pumped as part of inspection) 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.) I i j i • I i t revisedL 9/2/98 Page 9orn . 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address y a BERT 1 w y' Owrw: C(), SAUCIEg Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 31 38 ' i p I P I 7 1 I revise / /d 9 2 9 8 . Page 10 of 11 I t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PART C SYSTEM INFORMATION(continued) Property Address: Owner: (0 , S4001EK Date of InsPecti -on- r NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater)' Feet Please indicate all the methods used to determine High Groundwater Elevation: i 9 i Obtained from Design Plans on record i Observed Site(Abutting property, observation hole, basement sump etc.) i Determined from local conditions i Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) mmR 6R6uNJD w19TE'1Q off+P 7)P0 P k . i i revised 9/2/98 i page it or it k Flca.....I... ©.._ THE COMMONWEALTH OF MASSACHUSETTS 1_��OARD OF HEALT .. ... ....................O F......Lt/�!!r�'y '. n!................... Appliration for Uiipn,sal Works Toustrudinn rrrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at' �... ..1'�_l_�ty Oaq - --.� �_.I1``'. .. - - ----� ------ ----•-- ._ .. _ ...._..... oca i or U No. - - - - • - - - --- ►Wa �..Sl.. ...I�J.�S1Llwne� ln` .---•.................•• . -1_!�!.:�......... g......._._................................. Installer !k Address Type ng Size Lot... 3.Z7.....Sq. feet U Dwellin —No. of Bedrooms............... ...•...............Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures WW fix tures .................................... ..pe.r. Jay. Total t. . w �1. ........__.__..... Ion s.Design Flow----------------I.jD gallons per _ � Septic Tank—Li uidca_ aci't .Ce.�._ballons Length... Width:.�,1.3�_... Diameter................ De th._....�---..x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..........f.......... Diameter.......J.,C?....... Depth below inlet.....4t............ Total leaching area_Z(v1.2Q.sq. ft. Z Other Distribution box ()Q Dosing tank ( ) Percolation Test Results Performed by......�..�� ,Q ....................... Date___.�j�2 _..`(�........... Test Pit No. I---'— ---•minutes per inch Depth of Test Pit....LAW!._ Depth to ground water... f=, Test Pit No. 2....LZ...minutes per inch Depth of Test Pit....l:5.'�>...... Depth to ground water.. Description of Soil.... _l ...... ........u A4g 6a"t -wiv ...._..Q-�_(��`.......-• ........ ?`.-.4 w:_ :5 .51 !� .- .".•"ql; -- -t�:.S!�# 5�n UW ••-•-•---------- ...................................... 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 AITLZ 5 of the State Sanitary Code— The undersigned further agr es not to place the system in operation until a Certificate of Compliance h een issued the a d of healt Signed.._. Lf Date Application Approved By............. '"'`-}............. ........ _ 41l0 Q Date Application Disapproved for the following reasons-----------------------••--•--•-....-•-------•--------------......-------------......•••-•-••••••-=----......-- ....................•------•--•••------•......--••-•--•-..........•-•-•-•---------------•••••••--........................._...............-•-•••-•-•--•.....-----•----•-......._•--•----............... C� •-Date Permit No..-----,� =.�._Lq........................ Issued................................ z�--......... Date n ; . -._• �- :_ _ - _'t. :iFEB THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH R` J :.. Appliration for Di-oposal Works Tontitrnrtion Permit Application is hereby made for a Permit' to Construct (-y)f or Repair ( ) an Individual Sewage Disposal System at: [�(� ( ( . ......_...• ««...«_ ..................... ----------• -------•-• = .................... (,'��/�/ ! rLocatlani/-Address p� '''j(n t//� (// or Lot No.�/ 1... �•.A'V t�C A-- 1_1'Vl I I .i aY �V i «V`� �i _- , / �� 1___ �,!'� _�_t/_l,l�Q ................. .._ _..... ... ........ ._. .....Owner Address •--•-•---------- _. � rG......................................� ------------------ .............._..... Installer Address Type of-Building, — -- Size Lot...LLL33 7-....Sq. feet D Owl welling>E No. of Bedrooms________________5._..__._.________._____Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures .....................................= ,��-__..•_.--••-•-•---------------- •----•-----•-•----•--•••--.._..•••••-•••••.._...................-•--_ W Design Flow.................__�_ ..._.__._____. gallons per pwersen per day. Total daily flow WSeptic Tank—Liquid capacity_Q ._gallons Length___ _f2___. Width:_�;_L�2__._ Diameter................ Depth._'Z�1( x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..........I.......... Diameter........!_!...... Depth below inlet.....f............ Total leaching area_'ZG2._2.sq. ft. Z Other Distribution box (I ) Dosing tank ( ) f Percolation Test Results Performed by....... l• 1.? A . .....-E_._..�___ __________________ Date___. ?t 2'?.�.`�0___.___._... 1 Test Pit No. I._..__-_7:___.minutes per inch Depth of cTest Pit..... Depth to ground water.... 1_ f= Test Pit No. 2..__L...:_._minutes per inch Depth of Test Pit.....L`z ..... Depth to ground O Description of Soil � " ...ldtu x "." 1' f)-3 .................. '�? �- �,�, r A ti E_-�ittJh-t SC�v✓r`� 'b� in` (�. (.d+f 1 i Y �F(Jh Uu..fir ^•r,_.. U Nature of Repairs or Alterations—Answer when applicable.-................................................................................:. ...--...---•-•-•-----•------•---------------------•---------....-•-•-------•---------••--•----.._..---._........----------------------------•--•----.--.....---.._._.._..-•---•-•---•••---•-•••••--_.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha°'s,, een issued by�the board of health Signed .......__. .. U � -�-"'r -Date Application Approved By_____________� �.'1 �.-.. Dte (..�.c Application Disapproved for the following reasons:-------•------•--•----••-•-•--••--------------------•--•------------------------------••-------...--•........._ ......--•--------•-••----.•.......--•-------•-----•-•-------•--------•..................•------------.............--•---•------------------------•-----••--------•------------------...................« te Permit No........ d..=.. x` �-------------•••••_._.. Issued...... �'�. au.----- Date THE COMMONWEALTH OF MASSACHUSETTS �� *�/ BOARD OF HEALTH01 ` Tntif iratr of Tompliatta THIS IS TO CERTIFY, That theAI dividual Sewage Disposal System constructed (IV) or Repaired ( ) by.......... - ..... r .. a ' •• .. ...........••------•...._....--••---•-••.....-••---•--•-•--•••--••---•..................................._..... � x Installer has been installed in accordance with the provisions of-TIT P 5 of The State Sanitary Code as described in the ruc application for Disposal Works Consttion*Permit No....... _"�3_ ____________ dated...............__......_....-__........._.._:._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �'a `' ._. Inspectorc�:.... DATE................ ..! ...._..... ...... * _?_h.+:g,;.r-« -»X-#'6.1'w+r�tsllrsi+u r.air.•ra:.r.r...-.w...«.+Ka.....•..nr.rw e,...s.w Yli'.•-r iw i�*I#VyF7rMM 1FHY•ry wb r�l•-+tur.+ra r._.r.r+..« +.+;.s V*#*_R 01***1W*'W0Qn THE COMMONWEALTH OF MASSACHUSETTS BOARD OF �,v I HEALTH ff�r . .........OF......I .................................................................................................. No.. FEE.... ........ '1• r Disposal orki on --jJtrurtion Permit Permission is hereby granted.---------- / rcY- to Construct (Xy or Repair ( ) 'an �Ifidividual Sewage Disposal System at No................ �a y�9 ' . �_��'� �.... . .......... k•t .¢wtX•�C�-------•................................... Street as shown on the application for Disposal Works Construction Permit No.�/_._:��.4K..._-_--Dated.......................................... ....................................... ._. ................................... ....... ._.._ Qbard of Health DATE.......................// 6' � �[ TOWN OF BARNSTABLE LOCATION / �I e/�' I SEWAGE # VILLAGE—' Cep �rl��`Gl Q ASSESSOR'S MAP&1LOT INSTA?LER;S NAME&PHONE NO. SEPTIC 'TANK CAPACITY LEACFUNG l~ACILITl': (tyke) t-f (size) NO,OF'EEDROOMS,_ 3 . BU LDElt OR OWNER PERMIT®AaTLI:- -,_...,—_.— _....:_.-f-OtbI L.IANCM DATE,:,,,_ Separation Distance Betweea the: Maximum AdjusU- ,Groundwater Table to the Snttorh of beaching Facility -Fee Private,Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of Pachins facility) / CIS Furitlshed by_ r"ir' .�� L 1 a G►� t 0o a D— 33e' D- 3� ' 5 1. �J OWN OF BARNSTABLE LOCATION / G" W� SEWAGE # 'YILLAGE 1LrV� ASSESSOR'S MAP & LOTa�� $6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY a LEACHING FACILITY: (type) PST 6X 6_ (size) NO.OF BEDROOMS 3 BUILDER OR OWNER bOtNot%t . 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 leachi g facility) Feet Furnished by i a � a a°I 3 y a 33 3 3 3to 3g. ' TOWN OF BARNSTABLE LOCATION Lc4 '(A At�eS4.' WfV SEWAGE # ^ l3y VILLAGE Cep -i-e;JA4 ASSESSOR'S MAP St LOTJ)/F 4 F 6% INSTALLER'S NAME Sk PHONE NO. SEPTIC TANK CAPACITY I, 666) LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER °` Si 6 V' l d•'^S DATE PERMIT ISSUED: 6z ��q6 DATE COUPLIANCE ISSUED: Ze-1'74? VARIANCE GRANTED: Yes No y h ' "4P -� Ll TOWN OF BAMSTABLE LOrA.TIONs'��/��i �i ,/ SEWAGE # VILLA,GE � �yil, � /�9 • ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 Leac 'ng Facility(If any etl exist within 300 fee o !c. n f " 'ty) ! Feet Furnished / 24 f-I6,4 way Ceuj4uu,'llQ wad Iwo ' 33 2-35 3 - M cep - i �v i { . .' 1 •}ate. • ...+. :. _ .-.- __ - ..- - • � if �l ts~ 1 O r� i 4 1 O Iy T � C I I ��V S � NI �1 '� IY3�0 3 x -71 r � )t»-ru MSL 61*4D 7AY-Er1 �eoM .�4� yf?,, '• _ . evai i..s 3, Ptoe PiTo4. I/4'/P-T uaLZr--Fl OT46elr4tSE tJOT6P' y ;.-A; — ,% � � 4, D�ifst�.l LLysc7t*1G bl.L�r.,Q.ST t,tt►.11TS �`�� -i'-= � Y44-. Ca• CZ z i lot-4 V E T64 L-s ro r3E e 64 60T To Sc F 1 t. ,• it 44 t _ i I — ,.ire .# �% ? + Q r*11'S.t, � f�'{"�•- ��.ti i _"�_�.._ „ l�f,. .__.. 4..,, ._._. , + U �. /' { r''^ ---------_ ✓_ f3Efle�r_».�S ,,^L. 1 t � C>�, �P,e �'' GPD •W � -:a _i � dam, � � _ �'/ ,+ . __ - i -r F' T.. 6 E _ OuWtk1 down Gape CnQ�n�r(rny � i�G `• ,; � c 4 � CIu L i � A"e R.L.G. P.E. DATA' ep