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Home My WebLink About0271 AMES WAY - Health 271 AMES WAY, CENTERVILLE A= 170 035 d llil [LPG 12543 € o. 53LOR HASTINGS, MN UK �O scan �� Commonwealth of Massachusetts /�o W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 271 Ames Way Property Address V1 Kent Booraem • Owner Owner's Name information is every Centerville ✓ Ma 02632 4-15-16 required for eve F-►'.. page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered.in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information C'� on the computer, V use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation r� Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-15-16 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 271 Am Wa y a Y Property Address Kent Booraem Owner Owner's Name information is Centerville Ma 02632 4-15-16 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 271 Ames Way M Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 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 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (Actual) 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 334 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2014-60,000gallons 2015-36,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Dec 2015Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 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: Owner- Last pumped 7 years ago. 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-3/13 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 wM 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 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: 5-30-08 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1'6" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6 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: 1000Gallons Sludge depth: 9 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 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 27 Scum thickness 1 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 15" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 271 Ames Way Property Address Kent B r 0o aem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 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): . NA I Depth below grade. Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 271 Ames Way M Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan).- Depth of liquid level above outlet invert 0 11 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.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up or carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is Centerville Ma 02632 4-15-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (3) cultic 3050's ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 page. Cityffown 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 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 REAR A, B DECK., Al,24' B3.34' A2•27* 82-35' 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 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: �No GW 120" 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: 5-30-08 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 271 Ames Way Property Address Kent Booraem Owner Owner's Name information is required for every Centerville Ma 02632 4-15-16 page. CityTTown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i Town of Barnstable Regulatory Services Thomas F. Geiler, Director s;aaIMABCs. 9� AL% Public Health Division 1 3q. �a plfDjN ' Thomas INIcKean, Director 200 Main Street,Hyannis,MA 02601 Office: 503-362-4644 Fax: 503-790-6304 Installer & Designer Certification Form Date: Sewage Permit4z` o� Assessor's ivlap\Parcel 3� Designer: `/F�� L ' ►"'l Installer: Address: A�4 Address: � f¢G ��Vvlw MA , 02�37 On ��`�� as issued a permit to install a dat - (Installer) �� " septic system at _C T WAYCPy►4f"'V 1l�Q based on a design drawn by (address) dated C� (designer) X I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation or thedistribution box and/or septic tank. y I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or anv vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF Mgss (� a D t M. � (Installer's Sivnature) o. 1140 Q TA?,\ (Designer's S natBAI (Affix Designer's Stamp Here) PLEASE RETURN TOABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNST.ABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septie!Designer Certification Form 3-26-adoc ��® r- ® .,. � �q.� �� /� � v `� � � � �J \ �� . . . - � , . No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplicatiou for �Digpotal *pgtem Cottgtruction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑.Complete System ❑Individual Components Location YAdddr-essss or Lot No. 1W F—j t vk4 / Owner's Name,Address,and Tel.No.RAW k Assessor's Map/Parcel /�yA 6 1 �[�Dp ' Installer's Name,Address„and Tel.No. ! _�� Desi ner'se,Addre s and Tel.No/Z/W 1�i!�/ 6 c.r Type of Building: Dwelling No.of Bedrooms Lot Size Aa ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 9� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Zoo 0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this and of H th. ^ S' ned Date Application Approved b Date Application Disapproved by: Date for the following reasons Permit No. (� Date Issued �9—. No. � � �L it Fee THE COMMONWEALTH OF MASSACHUSETTS a, Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS V 0(ppYication for atgpont iip.5tem Con5tructton Permit Application for a Permit to Construct O Repair O Upgrade O Abandon O ❑Complete System ❑Individual Components Location Address or Lot No.� 14M F-5 WA- f Owner's Name,Address;and Tel.No. Assessor's Map/Parcel 10 12-0 r Installer's Name,Address,and Tel.No. �/l,`(r�-�f�f/j �� 's ame,Address and Tel.No�P`Et�/ A '.�-/�/ Al;o dor j ' saves C u� a�o t V — 9 Type of Building: Dwelling , No.of Bedrooms Lot Size 5_ •. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.'required) r- 6 "A0 gpd Design flow provided '� ' gpd Plan Date Number of sheets Revision Date i Title r 4" Size of Septic Tank f Type of S.A.S. Description of Soil Nature gfRepairs or Alterations(Answer when applicable) r Dateilast inspected: --- _ Agreement: V _ sThe undersigned agrees to ensure'the construction and maintenance of the afore described on-site sewage disposal system it accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of r Compliance has been issued by this.•oard of Health. ( 1 S'gned Date d" Application Approved b Date rC} Application Disapproved by: > Date for the following reasons Permit No. Date Issued -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CE�RTTIF�rY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by at _� has been constructed in accordance [ with the provisio .o Title and the for Disposal System Construction Permit No. � l dated A)- Installer vy Designer #bedrooms ��. Approved design flow a- gpd The issuance of this permit shell n be tcu d as a guarantee that the systemUrP, tion as desi ned`DateInspector ———No. �� U _ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lwigoal *p!5tem Con5tructton Permit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon 11 ( ) System located at 2 'J`T�/ (" and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special condili Provided: Construction must a co leted within three years of the d to of this p Date - Approve by V '7 TOWN OF BARNSTABLE LOCATION SEWAGE# . 3 ` e 'VILLAGE C ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. . 1 ` � > 6" SEPTIC TANK CAPACITY f Q LEACHING FACILITY:(type) �t�vbs (size) NO.OF BEDROOMS OWNER PERMIT DATE: 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 L,aching Facility(if any wetlands e within 300 feet of leaching:facility). feet FURNISHED BY .. c ,� d- 0_ Al - �7 � A- q- ? I 7 TOWN OF BARNSTABLE %.�4�T'I:3t:• SEWAGE # lvTLLAGE t��A ESSOR'S MAP & LoTM2D 110 INSTALLER'S NAME&PHONE NO. L 35 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Pl°l C4 Olt (size) 1066 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DAJ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r f e_ G� apf 0 44 At 0 B k 2 25` 52 P:o 46 �19 9 1�� a c 6---•0.2---2008 a 0 1 m 3 7 x, NOTICE OF DEED RESTRICTION RESIDENTIAL The Town of Barnstable Board of Health requires, based on 310 CMR 15.214, Title V, Nitrogen Loading Restrictions, the following restriction(s)- Existing Dwelling Restricted to two (2)bedrooms. Be placed on the property located at 271 Ames Way, Centerville, MA 02632; Assessors Map: 170 Parcel: 234, As Deed is recorded at the Barnstable County Registry of Deeds, on the Deed Book 22871 and Page 238. As plan of land is recorded at the Barnstable County Registry of Deeds on a subdivision plan titled "Subdivision Plan of Land in Centerville, Mass, in the Town of Barnstable for JKS Trust" dated March 3, 1978 and record on the Plan Book 324 at Page 73. l' U) r i v 0- I, <<• / 6V-12 LF as owner of the property referenced above acknowledge the deed restriction(s)being placed on the property. I V o V Owner's ignature D to The person named above: , nT I�L to t" e i ley r�m I � -- Acknowledges the foregoing Instrument to be his/her free act and deed, before me. F • �-Notary Public My Commission Expires `� ;- Lo 13 I 1� .Gown of galrnsta.bl e P# Department of Regulatory Services • • 1ViS10DSARNS Date ,ABLM : Public �Iealth D KAM s' 200 Main Street Hyannis MA 02601 J l ` '® Avi �3 Date Scheduled /64',,TjMe 'all b Fee Pd. _ t i . ' • _7 n.. r sposalz j `oil' Suitability Ass_essment fo Sewage Dt 1 �� Witnessed BYI—Q � 4J� ti��r►VcC►J ,7 Performed By: hJ �_ .... ri LOCATION & GENERAL INFORMATIONS `^' Owner's Name G eO we (.(sQt iN►4 I Location Address'.ar7 l Ar�C-,S WAY. , dd Aress 11(0 l ST. 5 *1, ,",�,,,,,,mo�t� ,� Assessor's Map/P4tcel;..•I"7 v 2 3 ' •,Z I Engineer's Name DPc M �,�y/ REPAIR Telephone# NEW CONS1RUlt. ON. 5� OZ'2 Ivy t Land Use ��G st�t� z<IZ� Slopes(9b) L Surface Stones > ! ` >Z ft Drinking Water Well eft ' Distances from: Open Water Body�ft Possible Wet Area� _ , ft Drainage Way S 1 '��D ft. Property Line >�_ft Other SKETCH:(Street name,dimensiods'of lot,exact locations of test holes&Pere tests,locate wetlands in proxitnity to holes) I ` ffrAO &Cw`A6£ ?L-Art) ' . i i • I " "i Parent material(geologic) Depth to Bedrock N 1A Depth to Groundwakdr. Standing Water in Hole:• ) - ' Weeping fro Plt Faee.r.Ay.�.. Estimated Seasonal"igh Groundwater I DtTERMIN TION FOR SEASONAL HIGH WATER TAY3LE Method Used: Depth to sail mottles• ln. Depth dbperved standing in obs.hole: in. it. Depth toiweeping from side of obs.hole: in. OroundWnter Adjustment ' A .factor.,,,._.-�.. AdJ,drnundwaterLevt!I.,,,,e, Index Well# -� Reading Date: Index Well level .--T dl Date..$' '1'Itne• PERCOLATION TEST. , Observation 2 I Time at 911 NA -.---.-- Hole# Time at G" ..... -- Depth of Pere I „„t Time ff'-V) Start Pre-soak Time.C� ic)17 End Pre-soak Rate MinJlnch Site Suitability Ass0sment: Si x Site Failed: Additional Testing Needed(Y/N) te Passed Original .Public Health Division y Observation Hole Data To Be Completed on Back--- -- ***If percolation testis to be conducted within 100' of wetland,you must first notify the Barnstable C4, servation Division at least one(1) wedk prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consis enc %Gravel LOALAVSilo s ,, Q b LOW (G /�Q;SSIMQ metal DEEP OBSERVATION HOLE LOG Hole#_� Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistenc %Gravel) It`t A Lo DEEP OBSERVATION HOLE LOG Hole# 1� Depth from Soil Horizon Soil Texture Soil Color .Soil , Other; Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. - Consistency. o Gravel Y R _A. DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Sop Other =�i Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onistn f`I �. { _jI t Flood Insurance Rate Map: Above 50U year flood boundary No_ Yes _ Within 500 year boundary No X Yes Within 100 year flood boundary No X Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on -.(date)I have passed the soil evaluator examination approved by the Department of Environm ntal Protection and that the above analysis was,performed by me consistent with the requir inin ,expertise and experience described in 3..10 CNR 15.017. Signature Date Q-.\SEPTICIPERCFORM.DOC ti Town of Barnstable Barnstable Regulatory Services Department Wftw'ca cfty namm5-raa�e, "16;9: Public Health Division Plfb MAC a, 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO January 2, 2008 George & Lisa White I PTIfPT'c) tt T R A nn i^f 1 _ c"Xx a z., ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 271 Ames Way, Centerville MA was inspected on September 9, 2007 by Michael DeDecko, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system FAILED under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T E BOARD OF HEALTH —1 C3�S 1\ls� �� a►�I ��-= omas McKean, R.S., CHO # Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\271 Ames Way.doc 7007 0710 0005 5820 7595 '<L\\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is MA 02632 9/9/07 required for CENTERVILLE _�_tatW__ —Zip Code Date of Inspection ------ every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any Important: A. General Information When filling out forms on the computer,use 1 Inspector: LAS only the tab key to move your Michael DeDecko 0 cursor-do not Name of Inspector use the return key. ealty Development Corparation Company Name P.O. Box 2384 4D Company Address _64�r�wn State Zip Code- B. Certification | certify that | have personally inspected the sewagedispona| oysh*nn 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. | mrn o DEP approved myodann inspector pursuant to Section 15.340 of Title 6 (31OCK0R 15.000)' The system: 7 Passes F-1 Conditionally Passes 0 Fl Needs Further Evaluationh Local Approving Authnrity S89/O7______________________________.__ — |napecto/sSignamre— -- `~~ � 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 iOSpeCUOO. If the system is 8 Sh8nBd 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 DER 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 mr different conditions mfuse. zn�o� �� on��.n��w�-�`m n � � \ " � | . | " <L\\ Commonwealth of Massachusetts 913 Title 5 Official Inspection Form - -- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 271 AMES WAY -------._—�.-.-. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH R_D, MA, 02632 Owner Owner's Name information is required for _ _.CENTERVILLE MA 0.2632 9/9/07 -- - --------- every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 271 AMES WAY•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 271 AMES WAY Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: s ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(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. 271 AMES WAY•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts _-- Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a.� 271 AMES WAY Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h 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. 271 AMES WAY•08/06 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 4 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 271 AMES WAY Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for _ --_--.-- every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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 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. 271 AMES WAY•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments air 271 AMES WAY Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for CEN_TERVILLE MA 02632 9/9/07 —.— every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 271 AMES WAY•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form im -- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 271 AMES WAY Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for C_ENTERVILLE MA 02632 9/9/07 --- every page. CityfTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 --- 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 ears usage d N/A 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: N/A Date Commercial/Industrial Flow Conditions: Type of Establishment: --- — - -- - Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ---- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - --- --- Last date of occupancy/use: Date — Other(describe): 271 AMES WAY•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form — _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a; 271 AMES WAY Property Address _C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 _ Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 - every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: N/A - ----—Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 271 AMES WAY•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 11 CommonweAlth of Massachusetts ----- Title 5 Official Inspection Form �R = - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 271 AMES WAY —-- — --- Property Address C_/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is CENTERVILLE MA _ 02632 9/9/07 required for — - State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Building Sewer(locate on site plan): 2' -- -- Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): JOINTS TIGHT,YES VENTED,NO LEAKAGE. _ -- Septic Tank (locate on site plan): Depth below grade: 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 -------------------------------------- --------------------------------- 1000 G_AL. Dimensions: 2„ ------------ Sludge depth: 32" ---.----- Distance from top of sludge to bottom of outlet tee or baffle ----- — Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle -- MEASURED How were dimensions determined? — 271 AMES WAY•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form — - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 271 AMES WAY __ ---_--._ Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 ------- - - -------------- Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for — — -- -- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NO NEED TO PUMP, TEE'S INTACT,STRUCTALLY SOUND, LIQUID LEVEL EQUAL WITH OUTLET INVERT, NO 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 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). 271 AMES WAY•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 271 AMES WAY Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is LLE MA 02632 9/9/07 CENTERVI required for - - --- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: --- -- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 271 AMES WAY•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .' 271 AMES WAY -----____-- Property Address C_/O DAVID HO_LT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 0_2_6.32 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for — ------ — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number. --------- ❑ leaching chambers number: ---------- ❑ leaching galleries number: --- - --- ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ------------- ❑ innovative/alternative system f Type/name of technology: ---- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOIL-GRAVEL/SAND, YES SIGNS OF HYDRAULIC FAILURE, PONDING FULL,NO DAMP SOIL, VEGETATION - NORMAL. 271 AMES WAY•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments — ---- �r 271 AMES WAY -- Prop Y ert Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 _ required for ----- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — ----------- Depth-top of liquid to inlet invert ---- Depth of solids layer — --_- Depth of scum layer -- Dimensions of cesspool ---- -- Materials of construction -------- Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: -- Dimensions Depth of solids --- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I 271 AMES WAY-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts --_ � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 AMES WAY — -- Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 -- -- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. 271 AMES WAY•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts -- —_-W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 AMES WAY — -------- Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 40.00' ------ — Estimated depth to ground water: 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: -BARN-STABLE GISYou must describe how you established the high ground water elevation: BARNSTABLE GIS --- -------- 271 AMES WAY-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts Executive Office of Environmental Affairs kip Dept. of Environmental Protection One winter Street Boston Ma. 02108 Jolui G;t Ad ' D.E.P. Title V Septic Inspector P.O. Box 2119 Jeaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI �� f�E,VEQ Lt.Governor iJ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR 01 4 1998 PART A CERTIFICATION kr.��4Rlysj, 3S fir. Property Address: 271 AMES WAY CENTERVILLE �C Address of Owner: A. Date of Inspection: 11/17/98 (If different) Name of Inspector: JOHN ORACI RON TIVEY;87 ACRE HILL RD.BARNSTABLE I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on criteria defined In Title V Condition P sses code 310 CMR 16.303.My findings are of how the system is - performing at the time of the inspection.My inspection does _ Needs F h Evaluation By the Local Approving Authority not Impyany warranty or guarantee of the longevity ofthe Falls septic system and any of Its components useful tire. Inspector's Signature: �. Date: ttr17r98 The System Inspector shall s bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. k., INSPECTION SUMMARY: Check A, B, C,or D: A]"SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of — CdThpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection-, or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised OQ7197) One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 271 AMES WAY CENTERVILLE Owner: RON TIVEY;87 ACRE HILL RD.BARNSTABLE MA.02630 Date of Inspection:11117/98 _ Sew.aQe backup or.breakout or hiah.static water level observed.in.the distri.bution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or Clogged cesspool. SAS is in hydraulic failure. (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 271 AMES WAY CENTERVILLE Owner: RON TIVEY;87 ACRE HILL RD.BARNSTABLE MA.02630 Date of Inspectlon:11r17ig8 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: ,c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with NIA. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revlsed 0411719T) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 271 AMES WAY CENTERVILLE Owner: RON TIVEY;87 ACRE HILL RD.BARNSTABLE MA.02630 Date of Inspection:11f17198 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 g•p•d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 4 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: Na COMMERCIAL/INDUSTRIAL: Type of establishment: Na Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nfe Last date of occupancy: nfa OTHER:(Describe) We Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: nfa System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: We TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source information: 1979 Sewage odors detected when arriving at the site:(yes or no) No (revised 04R7)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 271 AMES WAY CENTERVILLE Owner: RON TIVEY;87 ACRE HILL RD.BARNSTABLE MA.02630 Date of Inspection:11117199 SEPTIC TANK: x (locate on site plan) Depth below grade: e" Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age nos . Is age confirmed by Certificate of Compliance No (Yes/No). Dimensions: Le•e^H5'7^W4'10" Sludge depth:2' Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: Distance from top of scum to top of outlet tee or baffle:S" Distance form bottom of scum to bottom of outlet tee or baffle: 17" How dimensions were determined: MEASURED Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY ONE TO TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: nfa Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nla Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:Ma Distance from bottom of scum to bottom of outlet tee or baffle: Na Date of last pumping* Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) nfa BUILDING SEWER: (Locate on site plan) Depth below grade: v Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line TOWN Diameter: nla Qmments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04Q7)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 271 AMES WAY CENTERVILLE Owner: RON TIVEY;87 ACRE HILL RD.BARNSTABLE MA.02630 Date of Inspection:11117198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: n/a Capacity: rda gallons Design flow: rda gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ves Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) rda (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 271 AMES WAY CENTERVILLE Owner: RON TIVEY;87 ACRE HILL RD.BARNSTABLE MA.02630 Date of Inspection:11117199 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: 10DO GALLON LEACH PIT leaching chambers, number:Na leaching galleries, number: Na leaching trenches,number,length: rda leaching fields,number,dimensions:rda overflow cesspool,number:nla Alternate system: Na Name of Technology:_Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE PIT HAD 6"OF LEACHING LEFT AT THE TIME OF THE INSPECTION,RECOMMEND PUMPING SYSTEM NOW. CESSPOOLS: (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: rda Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: rda Materials of construction: Na Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY: (locate on site plan) Materials of construction: We Dimensions: rue Depth of solids: rda Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na (revised 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 271 AMES WAY CENTERVILLE RON TIVEY;87 ACRE HILL RD.BARNSTABLE MA.02630 11117198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) IN f ,4A /-C y)t C� )Y &5 ?7 DC 33 (reAnd"W19T Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 271 AMES WAY CENTERVILLE RON TIVEY;87 ACRE HILL RD.BARNSTABLE MA.02630 11117199 Depth of groundwater 12• Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in our own words how you established the High Groundwater Elevation.(MUST be completed) Y Y 9 USGS MAPS AND CHARTS (revised002T197) page 10 of 10 o LOf, A ,TJON SEW PERMIT N0. VILLAGE INSTA LLER'S NAME i ADDRESS W, -Gbh BUILDER OR OWNER I �eluh.r DATE PERMIT ISSUED _�f.-� 7y DATE COMPLIANCE ISSUED • f R G Q- Fus....Z� THE COMMONWEALTH OF-MASSACHUSETTS BOARD OF HEALTH N................OF...:.. /Q l ..LV. ..%f�. _ ------.........---....----- Appliration for Bhgpoii al Workii Tonstrurtinn Prrutit Application is hereby made for a Permit to Cons . ctr(�or Repair ( ) an Individual Sewage Disposal System at: — 7- V 0,0�;a ri — I.�,[' kc.2R... .... Y ------•---- .... a ........................ Locatn drZ411f/{ o t Nq(, `�__..........�.._... ............ ........................... •' t.....................................`------------------................. ---- Ow er f Address a ..._i. ...... -� -x_ ?..... ...... -------•--------------------------------------------------------------------------------- Installer Address Type of Building Size Lot.r-5. ...... a........Sq. feet V Dwelling—No. of Bedrooms.........**x2_.—..........................Expansion Attic ( ) Garbage Grinder QV4 Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures ------------------------------•- W Design Flow......../,/V........................gallons per j%Q�nper day. Total daily flow........... ...............gallons. WSeptic Tank—Liquid capacity/.iAno..gallons Length-8..rz_.._. Width. A.--.. Diameter________________ Depth.•S•-R.-... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--____-----_------sq. ft. Seepage Pit N ........ Diameter-----8_ Depth below inlet..6_......... Total Total leaching area.c�.�..sq. ft. z Other Distribution box (_.__.� Dosing tank ( ) °� ` /VC /),;z, • ~' Percolation Test Results Performed by_j�)Z-l.evk..... D.N.W.G'!_0....................... Date_._// r Q _....___.. aTest Pit No. L./_2..minutes per inch Depth of Test Pit../� ....... Depth to ground water./_V-Q/Ve..... G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .................................................-............................................................................................................ O Description of Soil.......0-n-M ----��/Y.m........Alv.>.........�V-65-©/L v �' � l�C,�tla.t i9�rn � t � ............ ................. x ---------------------------------------------------------------------------------------------------------------------------------------------••--------•----......--•-•---•-•-•---------•-...._..._..... 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 LI'= 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. S'gned ........................ ................... Date Application Approved B .................... ...i ' ,1.. 7.`?'f-••••••••. PP Y ,! Date Application Disapproved for the following reasons:............................................... -•-•--....-•••••.......................... ----•---._.... .......--•--.......•..•....-•---------------•---------------••----------------------.........-------------••••••-•••---••••-•--•-••----... . ---....-----------------•. -----------------.......... Date , � Permit No......................................................... Issued... 2--------!`'--c �=-•---7 ..----•------------ Date 7'No 1 � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...1.2ow..A)...............OF.......� .ttit. . 't ""--------••--------...----- Aptiratiott f nr Dispnsia1 Works Tot' strnrtinn Urrmit Application is hereby made for a Permit to Consstri ct (141f or Repair ( ) an Individual Sewage Disposal System at: _ G /" ' 4 aa . Am. .--+ ----------- ........ f .....". .' .......................... r_ f Locaf ntill dres - �j�+f (� ��...+o��t W Ower r ...................._Address tt t . ...................... r ....---..-.-.......--------------------:....... ------................_ Installer Address Type of Building Size Lot.i ...Sq. feet Dwelling—No. of Bedrooms_-_.....°�•-:.........................Expansion Attic ( ,.) Garbage Grinder Other—Type e of Building Pa YP g ............................ No. of persons------------................ Showers (` ) — Cafeteria ( ) Q' Other fixtures ..........:............................ W Design Flow........//. '.........................gallons per l<son per day. Total daily flow........... . -_ _.. gallons. WSeptic Tank—Liquid capacity/tvA..gallons LengthA..P..'.'. Width.!?!.�"`. Diameter.............:.. Depth..�+r"._AV...«. x Disposal Trench—No..................:.. Width.............. .... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....__../______.,Diameter ... .......... Depth.below inlet--,. ......... Total leaching area.'9t ..sq. ft. Other Distribution box ( Dosing tank (. ) h ' / y�" ' a Percolation Test Results Performed by_,/,./Z f- ,)A....4_Ct ........... ......... Date... i ......... a Test Pit No. 1__4Z--._.minutes per inch Depth of Test Pit./..2.. +_.._.._ Depth to ground water./VA? ..... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•-------------------------------------------------------•----•---..............._..............-- ........................................................ O Description of Soil....... .`.t III .........e!Alt/ .........14t,-T114....----- J+� /Ay��,�•� /�/ ,�t� y+� yr, �/J ,/ ...._.......�,+.�-+-•---- . U .. f»_........d_.G.0 y- 6.N ......--. AvJ' A&5.�..•...-�{=1!,`_�S'....•.......S.".,eYY.o- ................... W UNature of Repairs or Alterations—Answer when applicable......................................:::...................................................... ............................................. •-••---------•------------•------------------------------•---.....---------...---------------------------•- ......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE: 5 of the State Sanitary Code,The undersigned further•agrees not to place the system in operation until a Certificate of Compliance hasp een issued by the board of health. s; gned .............-•--•......:...............••-•-•--••-•-------•••----••......•-------• .......................... Date Application Approved B .................... ....... '= r Date Application Disapproved for the following reasons:..........................-•---••-•........................................•---------•--... .__...._.._... ............................................................-............................................._ Date Permit No...................................................-.... Issued-....................................................... '-•---•-------•----. Date THE COMMONWEALTH,'O.R MASSACHUSETTS BOARD HEA TH r .....................OF... ....... ... . ...... ..... .. ........................... Tntif iratr of T antlrliatta THIS IS TO CERTIF ,�Tthe Indiv' >al S Disposal System constructed (11 ) or Repairedby ---- --- • ••---• ..-•-- .......................................................... •. - 00 Instal r z�. -------- has been installed in accordance with the pr�ovisioof T 5 of The State Sanitary Code,.as described in the T ' 3 ----•---• dated--- --- application for Disposal Works Construction Permit �o.._ t THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.---•••.ff ,1 � Z. 7 , Inspector.. E COMMONWEALTH OF MASSACHUSETTS /f- BOARD HEALTH :..;....t�... .............OF....... . .. ...................................... No._ :. {....'�L�r ? FEE...7 ...�.. Disposal kil � dilan rrntit Permission is h y granted---------•- •_.. ......•----•-•••-••••-... r to Construct ( or epa• dividual Sewage D's�-t System '� et as shown on the application for Disposal Works Construction Permit-No o.................... Dated...... ...'.�s'.¢_ ....... ---------••- . Board of 7th DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.: PUBLISHERS rP A �ma`.�� _ PA0L: -M,6aRl4AY IN5FEC701K l 4, 7 3.5, N p V , ., 1178. LbT 34 w as L G T 3 6 v , 'l:.I NELfv, 0, LOAM AND < ' SuQSoic. EXIST1•N` a F.O U N DAVON S MA G4 � ,��18+` �o r ---•-, eon x ' . . . - E_LE•V. 4. S r - -• a ®. �ESTO . ` SEPTIC' HOLE. Q TA N K L D. . /� / t. .f �r�+}./8.+0 5, ➢ F oz 1 a C1 �A 6 GrJ\ �AicotljlV ! e; 6a () • D I ST ��t t 5 c3ox 0 RESERVE, 70G.1/Y i�/t9 `' AVA/LA8Le G EACN • PIT j5 cu z-o/NG s ETc-�;n c e zs uu �M�vTs S CA.L E = 30 F . F20N T %Q Si DE 'j 0. 7Z�4 Tc'.' P20F7lOSEI D SE P T/C 5 y5 TAM COn/S.T2 UC TlON SHA L� C'ONF02M .TO MA SS.. DE 5 i G/V F—L O W - � GAL/,D.A Y E'•N lS T//VG ENV/20N/AIL-iVT�kL GOOD T/TLE' r L G Q CA/ 2,4 TE � r v°i5 '7, 77� L3 �14/1f 57'A.CiL � NEA'47-H' 7ULA 7-/0IVS .�'EQU//ZGD LEACH 1. . •` TOP of �20,oOSL" U LEACH/ A2t1 _ GAO MA�v1/oLEcoVE,p TO �XTEATD Tp tM�E2✓/OZ/S COt/E�2 1 - TO. p2G V,fn./T .�iA/C-S kV • � / - .�20i�• /�/FLLT2;4T/ith ao.x I Z/"WIPE o p.e M/NiMun> - �`ru.r� ✓ 3 �i.v. 4' D/A• ATF•2' Zi51A t 4,. /DM/N MiN of TCf/ -2- Al/At P/T 3 0 Fr ` i FOOT ' ./4 . �4*/-FOOT �ircfl - ✓ �¢ _ /2 D/A. ' -Y- MiN / 5 /4,./moor o2C�Oa_ WAS<f�U 1000 { Get L L O N/ /N tYE 2T s��T/c Ta.v,e .• ". G, 34 /5 • �`"� 80 .Ev � - • . e . �•Z� rINA 7 Iz T/G N T), /N V"Z7" /n/vE zr ND GA�BACE G,2/niDE2 L O C,17-/0/l/ , %w r - \' SEAT/C TA.N 17/5TQ/F3UTi6W BQX r , _�• 5 QUTL-.z--- AAJL> L�.4CA//A-1 —17- �U� ORD co` TOiNFO�GE� c�O.VGT'ETIE 3000 �/ All- T.4. ':Gam ' '• .'y�/a ' t9 i • .i /,, (,r/ r",r = :°pY' �F Dl<I r b"v=1; /V'�T / � A ' I CERTIFY THE EXISTING GOCAT/01�/ l5 C0RRE'CT AS SN 'N AND IT. `;'-�� • �t OGv /a4E 5 CO PLy tc.)/ TH THC OUILDINrx :567 3/a CA - �, ce�w, iZE6�Uf RL'1IVTS T11 ?' N ,�; JR RN 5 TA OLD LEGEND Stoney{! Al PROPOSED CONTOUR ¢ - 'g) ® PROPOSED SPOT GRADE -- 98 -- EXISTING CONTOUR . ems r7, �ash. + 96.52 EXISTING SPOT GRADE ,x; A.^res iwmy ay Je;Farr,(� W— EXISTING WATER SERVICE —\ --- TEST PIT U 4� . j — — — —----- T ;` ' - - -• 59.E � �- ------------- — — R N�c q c N T�\\� ``` \ -— — — t-y .. n AREA = 15422 sf +'��_�� q4� ------ Q 1 a�otn LOCUS MAP N.T.S. GENERAL NOTES: i PAVED 1 DRIVEWAY i 1 \\\ -`9 j 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL CA BOARD OF HEALTH AND THE DESIGN ENGINEER. I 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS j water service OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE — — �— • — -opproxl o C 2_——— LOCAL RULES AND REGULATIONS. Z aqo� c,Z 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE Z DESIGN ENGINEER. _J 7qo 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN lLJ / u coNNECT To Ex 'In,c Rvc PIPING. ' ENGINEER BEFORE CONSTRUCTION CONTINUES. �'� I / W o j I v II EL. 40.23 1 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. EXtSTihLQ TANK IS UNDER __——_ / w 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF I W O J COf1CRETE R-A WITH — —'j THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF ! I LLJ OPEN A.CCEss TO�CS=✓�R._ —— HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. W TANK IS STRUCTURALLY ------ �— . O Lo I i SOUND WITH ra0 LOAD ON TOP, 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED w Ln 1 j TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. p 1 \ p 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE w j 1 \ 4q �� j THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING Existing Leach Pit cx ;� i O CONSTRUCTION. (Note lO) co n/ 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED I N 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION I i 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY v /! O AN IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY - - D D 41.03 ft I 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. O �u � �Q 14. NO WETLANDS WITHIN 150' OF PROPOSED LEACHING. �� cn 15. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED) LR CO J Q v OF Mgssq� i DART M 11140 PROPOSED SEPTIC SYSTEM UPGRADE PLAN STEM 271 AMES WAY, CENTERVILLE, MA SANI TAR\�`� Prepared for: Mike Dedecko l� I MAP:/,7o Engineering by: Surveying by: SCALE DRAWN JOB. NO. f SURVEY REFERENCE: "�� LOT. DARRENM.MEYER,R.S. Eco-Tech Environmental 1"=20' DMM PLAN OF LAND BY GEORGE LOW, JR., PLS �3Y PO Box981 DATED: MARCH 3, 1978 t DEED BOOK.-ZZ871 EASTSANDWICH,MA02537 (508) 364-0894 DATE CHECKED SHEET N0. DEED PAGE.-I230 50a362-2922 05/30/08 DMM 1 of 2 i r ELEV. TOP FOUNDATION NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS (Existing) FINISH GRADE=41.40 - 40.50 = 44.34�.• -F.G .EL: 43.0 F.G.EL• 41.68 F.G. EL: 41.93 � I A MAINTAIN 2% MIN SLOPE OVER LEACHING AREA MAX. COVER OVER LEACHING = 3.0 FT. w COVERS TO WITHIN 6 OF GRADE 6" INSPECTION PORT W/IN 6" OF FINISH GRADE e" . 4" SCH 40 .PVC 4" SCH 40 PVC O ° ° ° O O O ° ° °RIM �S=)% 1o"I 14" \:INV.40.52 S= 1% (MIN.) 6 S= 1% (MIN.) (MIN' TEE'S ARE TO BE 4" SCH 40 PVC INV.39.0 ° ° ° ° ° ° ° ° ° °f . INV.38.8 f EXIST. OUT GAS J PROPOSED DB-3 BAFFLE H=.10 DISTRIBUTION BOX 250 INV. 40.77 EXISTING 1,000 GALLON SEPTIC TANK INV. ELEV.= 37.90 Fl17ERFABRI 9" MIN. GAS BAFFLE TO B E INSTALLED O N NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING OR 2' ��°�DOS IASRM Srw sal PER TI TLE 5 OUTLET TEE AS MANUFACTURED BY PIPE INVERTS PRIOR TO CONSTRUCTION TUF-TITE, ZABEL, OR EQUAL 2) D-BOX SHALL BE SET LEVEL AND TRUE To BREAKOUT EL. = 38.40 GRADE ON A MECHANICALL COMPACTED SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN INV. ELEV.= 37.90 310 CMR 15.221(2) J/4- I-1/8• 24" 30.5" DOUBLE WASI-D SMW 3) REPLACE EXISTING 1,000 GALLON SEPTIC lNI/ERT TANK WITH 1500 GALLON SEPTIC TANK 1 BOTTOM EL.= 35.90 IF FAILED, DAMAGED, OR UNDERSIZED. 4) INSTALL INLET & OUTLET TEES AS REQUIRED SEPARATION 6.10 FT. I' 146" P#: 1221011, SOIL LOGS SEPTIC SYSTEM PROFILE BOTTOM of TH-1 EL: 29.80 SOIL ABSORPTION SYSTEM (SECTION) N.T.S. DESIGN CRITERIA DATE: MAY 30, 2008 " SOIL EVALUATOR: DARREN MEYER, R.S., CSE NUMBER OF BEDROOMS: 2 BR ACTUAL/3 BR DESIGN (2 BR DEED RESTRICTION REQ'D) WITNESS: DONALD DESMARAIS SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) HEALTH AGENT DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 110 G.P.D. Elev. TH-1 Depth Elev. TH-2 Depth DESIGN FLOW: 330 G.P.D. 39.80 0" 40.90 p" KI T Bfh BR GARBAGE GRINDER: NO (not designed for garbage grinder) A LOAMY SAND 10YR 3/2 FILL GAR i SEPTIC TANK: 330 gpd x 2 = 660 gpd USE EXISTING 1,000 GALLON SEPTIC TANK 39.30 6' 40.23 8" i B A LOAAYMRY SAD LI V. RM BR LEACHING AREA REQUIRED: (3 3/2 ��) = 445.94 S.F. LOAMY SAND 10YR s/a 39.98 B 11 USE THREE (3) INFILTRATOR 3050 UNITS WITH 4 FT. STONE 3s.8o C1 3s" LOAMY SAND ON THE SIDES & 1.3 FT. STONE ON ENDS: 25' L'x 12.16' W x 2'D a 10YR 6/8 FIRST FLOOR BOTTOM AREA: 25 x 12.16 = 304 SF _ `i PERC 0 35.3 37.90 C1 36" SIDE AREA: (25 + 12.16) X 2 X 2 = 148.64 SF TOTAL SQUARE FEET PROVIDED = 452.6 vs. 445.94 REQ'D MEDIUM MEDIUM DESIGN FLOW PROVIDED: 0.74(452.6 S.F.) = 334.95 G.P.D. vs. 330 G.P.D. req'd SAND SAND OF Mqs 2.5Y 6/4 2.5Y 6/4 �� s9�. PROPOSED SEPTIC SYSTEM UPGRADE PLAN n2 Ci D M M 271 AMES WAY, CENTERVILLE, MA 29.80 120" 30.90 120" " No. 1140 "' Prepared for: Mike Dedecko PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) p Engineering by: Surveying by: SCALE DRAWN JOB. NO. NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED 'PFC�SIFRE DARRENM.MEYER,R.S. DMM SANITAR�p� PO BOX981 Pico-Tech Environmental N.T.S. EASTSANDWICN,MA 02537 (508) 364-0894 DATE CHECKED SHEET NO. 508-3622922 05/30/08 DMM 2 of 2 1