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Home My WebLink About0302 AMES WAY - Health 3 )2 AMES WAl CENTERVILLE A=170-052 S'.,I O IN UPC 12534 ' No.2�153LLOOFt "&Times,Ur C� r' ti Commonwealth of Massachusetts �- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r G M 302 Ames Way Property Address ^r Jopseph & Danielle Bartlett Owner Owner's Name information is Centerville � MA 02632 5/26/20 required for every r page. City/Town State Zip Code Date of Inspection w.� rs 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 [� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Scott Campbell use the return Name of Inspector key. Cardinal Construction ,y Company Name 32 Ridgetop Rd. Company Address Cotu it MA 02635 City/Town State Zip Code 508-420-1295 S1388 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. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑x Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther Evaluation by the Local Approving Authority 5/26/20 Inspe Ps Signatur 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 4c 302 Ames Way G1M Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. Cityrrown 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: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 M 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑' Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '4M 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ N Backup of sewage.into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ naX❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal g posa System Form Not for Voluntary Assessments M 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ FRI Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑X Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑X Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.] ❑ X❑ The system is a cesspool serving a facility.with a design flow of 2000gpd- 10,000gpd. ❑ ❑X The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. CityTTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, including the SAS, located on site? 0 ❑ 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? 0 ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. 0 ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ❑X No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑X No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2018=138,000 gallons 2019=124,000 gallons Sump pump? ❑ Yes ❑X No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No ` Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water.meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 302 Ames Way M Property Address Jopseph & Danielle Bartlett Owner Owners Name information is required for every Centerville MA 02632 5/26/20 page. Cityrrown 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: Installed 7/29/2016 pumped May 2020 Was system pumped as part of the inspection? ❑ Yes x❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑x 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 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 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: New leaching installed 7/29/2020 Existing tank installed 1980 Were sewage odors detected when arriving at the site? ❑ Yes ❑x No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): J Septic Tank(locate on site plan): 1'3" Depth below grade: feet Material of construction: I 0 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 0 No Dimensions: Sludge.depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 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 4.3 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? Sludge judge tape measure 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 pumped upon septic system inspection completion. May 2020. Both tees in place at time of inspection. Structural integrity of tank is good. Liquid level at proper working height at time of inspection bottom of outlet invert. No evidence of leakage into or out of tank. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 302 Ames Way Property Address JJopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float.switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is Centerville MA 02632 5/26/20 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is set level. Equal distribution out of box with speed levelers. No evidence of solids carryover, no evidence of leakage into or out of box. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: L15ins /13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑x leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure, no ponding or damp soil. Normal vegetation. (grass lawn area) 3" of liquid in leach chamers at time opf inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts 4 . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY °M 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 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: ❑x hand-sketch in the area below ❑ drawing attached separately �y ° 3° t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is required for every Centerville MA 02632 5/26/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water x❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ 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: 2016 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Septic system design plans on record. 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 Commonwealth of Massachusetts . 'Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 302 Ames Way Property Address Jopseph & Danielle Bartlett Owner Owner's Name information is Centerville MA 02632 5/26/20 required for every ' page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑x Inspection Summary: A, B, C, D, or E checked 0 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 Postal CERTIFIED o RECEIPT i. Only For delivery information,visit ourW;�"e-bsite at WWW.USPS.COMO. o � C3 Er cO Certified Mail Fee Coostmarko UT Extra Services&Fees(check box,add fee as appropriate) ❑Return Receipt(hardcopy) $C Return Receipt(electronic) $C ❑Certified Mail Restricted Delivery $t3 ❑Adult Signature Required $❑Adult Signature Restricted Delivery$ 0 Postagerq rq Total Postage and Fees Sent To / C3 ---------�- --- ---P��----------------------------------------- Street andApt.No.,or PO B x N. �;30 _PI4t®�- - -—-- ------------------------------------- ------- - i'l In CO 1P3�- :,, 1 ,, ,,,M. Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail •A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. 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I I � 2JUL • Sender' Please print your name, address, and Z(P in this box I I I ,� II �. c Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 \' I l V I — i i;}i}ilii}:}e :i}�. �;i,;i_" .•� l•;i i� � .}}3ieiF � i;:;� }:•i }�ii J'. £ �E}J ik �S�i}�}��I}ii£iif �. bi' ':!•Ike: /J Town of Barnstable Barnstable . �° Regulatory Services Department AFAme'caC j Z BARNSfABLF- �� Public Health Division m ��FD"AA�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1730 0001 4989 0304 July 20, 2016 Nichole J. Pepi 302 Ames Way Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 302 Ames Way, Centerville, MA was inspected on 07/01/2016 by Mark Polselli, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: 0 Leaching pit or cesspool with high liquid level, <12" below inlet (per Town Code 360-9.1). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE B RD OF HEALTH oma " c eah, R. ., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\302 Ames Way Centerville.doc ' No.OW ( (10 O�. y Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for -MispoSa.Y 6pstrm ConstCUttion VPrmit Application for a Permit to Construct( ) Repair(o�-Upgrade(Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.302% 1461S' Ct1 Owner's Name Address,and Tel.No. Assessor's Map/Parcel `j .,o r7 Installer's N me, ddress,and Tel.NoJ_ g^�°ZO"'"fir 73S Designer's Namp,Address,anti Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4�/,Sr#// CDC r /1'/� ZeD P Date last inspected: Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Signed � �/` Date s s J 1401 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 5 if Date Issued L •� D 0 x� No.ao I �J�� < L/ .. r Fee / THE COMM6AWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS - 4 21ppfication for Misposar *pstrm Construction Permit Application for a Permit to Construct( ) Repair(.'-)—Upgrade(Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.3 02 �=3 �� Owner's Name Address,and Tel.No. Assessor's Map/Parcel/gyp GS7- 01,7 Installer's Named dress and Tel.No.SOg"�2U" y7-5E Designer's Name,Address,and Tel.No.S OQ- G 33/� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) t/V5r#lll Date last inspected: Agreement: '+ f The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental.Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health i Signed � G�i �/� �� Date -7 _Application Appr'oved.by s, Date - Application Disapproved by Date for the following reasons , f Permit No. >'!� ` �J Date Issued 7 --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(c)-- Upgraded( ) Abandoned( )by JC5 e14 /]!�i'�"✓� at 309 %��1'I/_=S Gli 6 / Y T�=`'�//` has been constructed in accordance f - with the provisions of Tittle 5 a`n1 the for Disposal System Construction Permit No. 6 -95G/dated Installer s // Designer 11'1/ 1 t #bedrooms Approved design flow �j G gpd a The issuance of this permit shall no a con ed as a guarantee that the system tlll h 'on aer�designed. Date Inspector `�� C No. �� i(D J Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction �ermit Permission is hereby granted to Construct( ) Repair(�� Upgrade( ) Abandon( ) System located at r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. (e�� C OJ Provided:Construct ' mRV t be completed within three years of the date of this permit. � Date ' , Approved by V `t` (oL — l)-It6_ W4144 -fi "G L4 'f �r� �I-� �� war C�r•L -!.-f (Gp lk�Ld 1^,uot -('0 5t�� Hw`Iv--1- � '. From: 08/02/2016 13:15 4*195 P.001/001 Town of Barnstable Regulatory Services Richard V.Scali,Interim Director • `+.� saaxsrnssZ Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&.Designer Certification Form Date: ` UP Sewage Permit# �Sf Assessor's MaplPareel v �� Designer: ��pp nn J = Install r,)er: ail& fvlt.�I is�✓ � �lll'1� Address: P X_ 1 Address: M rn e , On Z 0/1, p Cc°>/?2 was issued a permit to install a date) fmstaller) f septic system at G^ Vi 1/used on a design drawn by (address) � L� SAIS Intl dated (designer) I certify tYat the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system.referenced above was installed with major changes (i.e. greater than 10 lateral relocation of the SAS or any 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. Strip out(if required)was inspected and the soils were found satisfactory. . I certify that the system referenced above was construct e with the terms - of the PA approval letters(if applicable) i DARN (Installer's Signature) : 1140 I LAA esigner's Signature) (Affix Designer amp Here) PLEASE RETURN TO BARN CABLEPUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:1Septic\Designer Certification Forri Rev 8-14-13.doc Town of Barnstable P#_ice/ q Department of Regulatory Services B ,� t Public Health Division 'Date - MAM � 200 Main Street,Hyannis MA 02601 r rfp lA1K .--. Date Scheduled Time J7� Fee Pd,�D D - \S . � oil Suitability Assessment for Sew e Disposal Performed ew Willessed By: n`/' �S. LOCATION&.GENERAL INFORMATION��Y; )� Location Address Owner's Name� ' C I0 e, Pep I' ✓1�ija�1 i�5 �,-2_ ( Address Assessor's Map/Parcel: u S� 60 Engineer's Nam rff) NBW CONSTRUCTION REPAIR Telephone Land Use n on Slopes O Surface Stones Distances from: Open Water Body tt Possible Wet-Area mil' ft Drinking 1Natcr,Well Dmlhage Way /()D ff Property Line .Lfd ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&Para tests,locate wetlands in proximity to holes) Set° PY-CT , �lq fi,C,'Ra o 7/2S/tom Parent material(geologic) C1.61 Cl Depth to Bedrock Depth to Groundwater. Standing Water In Hole: Weeping from Pit Pnea Estimated Seasonal High Groundwater Pj � DETE ATION FOR SEASONALUIGH WATER TABLE Method Used: _ j Depth Observed standing in obs.hole: In. Depth to still mottles: In., De{lth to weeping from side of obs.hole: b1. Groundwater Adjustment (k. Index Well-# Reading Date: Index Well level „ Adl,•faetor, .. Adj.Oroutldwater•Level. PERCOLATION TEST Witt,.._.._,.,_, "me Observation Hole# t(, Tlma at 4" A Depth of Pero �•`t� Time at 6" o s- Start Pre-soak Time 0 Time(9"-6") End Pro-soak L_ L Rate Min./Inch Site Suitability Assessment: Slto Passed _ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observdtlon Hole Data To Be Completed on Back--- - ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:ISEPTICIPBRCFORKDOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucturc,Stonesf;Boulders. tsistency.%'aravall F1 lj N /0YX s/ `= lo4 s , DEEP OBSERVATION HOLE LOG Hole# '2.-- Depth from Soil Horizon Soil Texture Soil Color Sall Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. 3 A- /,oa ,trtd O V ►� 0„ PJ a blh i C-2, .Z.S DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistonah DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Sol[Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, t , Flood Insurance Rate Man: Above 500 year flood boundary No— Yes Y _ Within 500 year boundary No Yes Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Materlal Does at least four feet of naturally occurring pervious mtitorlal exist in all areas observed thrpughout the area proposed for the soil absorption system? 5 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 Enviro ental Protection and that the above analysis was performed by me consistent with . the requirLfr,j, expertise nd experience described in�10 CUR 15.017. Signature Datb Q:%SflPTIC%PBRCPORM.DOC TOWN OF BARNSTABLE LOCATION �' /i�-►� �SEWAGE# VILLAGE SSESSOR'S &PARCEL 17 �Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPA`CITY"" LEACHING FACILITY.(type) zo- 1-5 (size) NO.OF BEDRO MS - a t . OWNER f e 0 PERMIT DATE: �- ,'�v 16 .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 M p Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N Feet FURNISHED BY v A -ILL' 6 *3 o PwR5,vj*, A3 o f3l L107z� �3- .' Commonwealth of Massachuset 06 _0/ v. Title 5 Official Inspection Form Subsurface Sewage Disposal 5Y.4e€rr Form. NO; for`voluntary Asses;,rnents C_ lof Property Address Ow ner Owner's Name �I CiV10/e"_._ _ ' ` cr' information is / required for every Pvt 4ke4''l-l� page. (ilyfrown ------ 5tate Zip Code Date of fnsp6etion I.& 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. Mpo When out f a General Information Bing out fonts 54 /� a on the computer, ' use ony the tab Inspector. key to move your 1. , cursor- not a use the return // t key.. Name of Inspector 0 Cc y Company Name 00 mpai iy Address /-4 Eity/row n pp //1/1U oj 6 State Zip Code • o� 01�0— ��10 D�� Telephon r j Wense 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 CM 15.000). The system: ❑ Passes ❑ Conditionally Passes Fails ❑ Needs Further Evaluation by the Local Approving Authority Tq a'Yl /�tA 21111,67 lnspect is Signature Daie 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 g, a 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 ttescribes 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. Orr.•V13 'rite 5 orficial impaction Form Subsuiace sewage Disposal Stem•Page 1 of 17 . ti6� Vs Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis"I System Form -Not for Voluntary Assessments 11 5 Property Address OW ner I r information is Qv er's Name required for every /Cei '"'v�` le page. (atylfo rn State Zip Code Date of fhs tion B. Certification (cunt.) Inspection Summar y: 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. Check the box for`yes';."no°or"not determined"(Y, N, ND) for the following statements. If"not determined,°please ex9ain. 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): a tyre•3M3 Title 5 Official lnspectionForm SubsLeaceSswegeDisposal System-Fage2of17 I Commonwealth of Massachusetts Ti 1e 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not ibr Voluntary Assessments Property C2 operty Address , Owner �information is ON Hers nr�� required for every - AU 0�"&T.�- page. C3yfrown State Zip Code Date of ytpekfion B. Certification (coat.) ❑ 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 ❑ NO(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 mannerwhich 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 Sns•3/13 Title 5 Official I spection F orm Subu rface Sewage Disposal System•Page 3 of 17 Commonweafth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °� des l;✓ct Property Address Ow ner information is 'low,nePs Name required for every Ce / v1 vi ` e Oa 6 3a page. City!Town State Zg�Code Date o Ins ection B. certification (corn.) 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 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ p,-� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ rZ7 atic liquid level in the distribution box above outlet invert due to an overloaded clogged SAS or cesspool uid depth in cesspool is less than 6°below invert or available volume is less than%day I ow t9rs•3M 3 Tide 5 Official lrspectionFam:substowesevweDisposal System,Page 4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow net Cw n information is er's Name / 9e edfor every �y�own ri2vt 4Z-1 State Zip Code Date Inspection B. Certification (corn.) Yes No ElRequired pumping more than 4 times in the last year NOT due to clogged or ;11 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. Elny 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. [Phis 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 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. t5ns•3113 Title 50fficial Inspection Form Subsuface Sevwege Disposal S)stem.Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form a Not for Voluntary Assessments Property Address � • P � ON ner QN no's Name information is // l required for every �✓� e�/` Q. page. City/Town State Zip Code Date o(Insoection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes ❑ 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? ❑ as 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 I his inspection? Were as built plans of the system obtained and examined?(If they were not available note as WA) 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 spected 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: t1Y l_I 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)1 D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): ?� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): J tens•W13 Title50ffrciallnspectlonForm SubsulawSewageDispasal System•Page6of17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Roperty Address O� ` � �R Ow ner / information is Owner's Name I/_ / required for every yr JC/i//d e L 3� page. CAA l own State Zip Code-C� Date of InsKectidn D. System Information Description: � IOOO/ G��►!ln�, .�' �C � G h� Number of current residents: / Does residence have a garbage grinder? ❑ Yes o Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes 2 No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes N Last date of occupancy: C tA"-/x Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.R., 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: t5rs-3/13 Title 5 Official Inspection F om[Subsurface Sewage Disposal System-Page 7 of 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address OBI ner ON flees Name / information is �y / required for every 2 0 �! /¢ �o -L page. Oyfrown State Zip Code Date of h6pection D. System Information (coat.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy m: 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(descri be): tyre-3113 Me 5 official Ins pection F arm Subu rface Sevage Disposal Sysmm•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address oar ner Oar ner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: / G N l,,, p xz"/ "7,4L /t f �f Were sewage odors detected when arriving at the site? ❑ Yes o Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: la feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: A feet ;atal construction: ncrete ❑ 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: Sludge depth: 15re•3YI3 Title 5 offreiai inspection F am Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -PS tva Property Address Cw ner Cw ner's Name information is required for every page. Ctty/Town -S-to—te=�- Zip Code Date of ns ction D. System Information (cons.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness eSf Distance from top of scum to top of outlet tee or baffle U / Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): H✓l&1 ✓10 'Lec- L 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 tyre•3H 3 Title 5 Official Insp ection Sutsuiaee Sewage Disposal system,Page 10of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not fur Voluntary Assessments Property Address ON ner ON ne's Name information is /' required for every _ (i e yr ✓yt z 6 3-Z / c, page' Cityrrown state Zip Code Date of'rinspeclion D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng 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 Or 3n3 TiUe50ffiaal InspectionFomc Subsurface SexageDi5pwal Salem•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Oiv ner ON no's Name information is required for every Ile page. City/Town State Zip Code Date of Ins tion D. System Information (cons.) Distribution Box (f 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.): Jl g � >Q Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•M3 TitleSOffiofa!Impectan Form Subudaoe Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments kvi -- Property Address ON ner Cw ner's Name information is / /� required for every Cie,,-het-v' ` 4C fA 00(3ol / 6 page. aty/Town State Zip Code Date of'Ins0ection D. System Info r tion (cont.) Type: leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): p h JI ✓l / Aq 6✓ N Il-e✓ l 4 ' 2� h l �,4�;.— An 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 l5ns•3H 3 Tide 5 0fficid Inspecton F orm Substrrace Sewage Disposal System•Page 13 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lugo c)- Ow ne; Na Property Address , information is ow ner's me required for every page. City/Town State Zip Code Date of I pec' n D. System Information (corn.) 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.): t5is-W3 Title5 Official Impaction Form Subsurface Sewage Disposal System-Page 140f 17 Commonwealth of Massachusetts Tit le 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON ner information is Owner's Name required for every C� e"� v/ /� Q a C page' F/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 leas perm nt reference landmarks or benchmarks. Locate all wells within 100 feet. Locate wher pu ater supply enters the building. Check one of the boxes below. hand-sketch in the area below drawing attached separately 1 Ons-W 3 Title 50fWal Ire pectimForttt SubsufaceSewdgeDisposal System,Page 15d17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 20.) Ory ner Ow ner's Name information is 1 required for every page. Cilylrow° 2Zz State Zo Code Date of pe tion D. System Information (cont.) Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells tea , Estimated depth to high 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 oard of Health-explain: i�lrct '7f t�® ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: AD LA CFO lG�f a�, Before filing this Inspection Report, please see Report Completeness Checklist on next page. t&ns-3n 3 Tito S Official Inspeatim F0rM Substrface Sewage Disposal System•Page 16 cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments AoAeR(Address , Om rier . Ow nees Name ! infomgtion is I_ required for every _ _2OV-I&VL4 OP-6,7c�- / Page• �y/Town State Zip Code Date of E. Report Completeness Checklist a" tnsp�edion Summary:A, B, C, D, or E checked B inspection Summary D(System Failure Criteria Applicable to All Systems)completed D 5y tnforrnation—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 'tu' -8M3 Tmesof icial impecnmForm b ftWaw Sera9e0 V-d Symm•Page 17 of 17 4/0G� No _ TOWN OF BARNSTABLE LOCATION SEWAGE # d VILLAGE ASSESSOR'S MAP a LOT INSTALLER'S NAME & PRONE Np. A & B CANCO SEPTIC TANK CAPACITY % coo LEACHING FACILITY:(t Yl)e)se-� i�UCv (�'�� Pr•;� (size) /;0lip NO. OF BEDROO�IS�_.PRIVATE SELL ORiJBL ��VATER BUILDER OR OWNER i DATE PERMIT ISSUED: C DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes - i �� J� �Try ram, Town of Barnstable + aawvsrnsi.E, + Regulatory Services Department plfD M11�� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) - An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code 360-9.1) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER J Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc TOWN OF BARNSTABLE LOCATION(30c AmS lo 4 v SEWAGE # r � ASSESSOR'S MAP & LOT ) D5A:6R •INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY 4 000 6.41 4- LEACHING FACILITY:(gpe),C" 6r0 C4/ /0"j- (size) OCV NO. OF BEDROOMS .PRIVATE WELL OR B WATER BUILDER OR OWNER DATE PERMIT ISSUED: �I/ DATE COMPLIANCE ISSUED: "' � °� VARIANCE GRANTED: Yes No i i J l� I I 1 J A P P R RAN r._:'......... THE COMMONWEALTH OF MASSACHUSEIMSnstable Conservation Commission BOAR® OF HBALT �, v TOWN OF BARNSTABL Signed Date AVp iration for DiipuiiaI Works Ton,utrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (j,4—an Individual Sewage Disposal System at: • ,3..... ........ ................ . :..._..... .... u r i .'4 ............................................. L ton-Address or Lot No. f�.TT' i-`------------------------------------------- ..........--...................................................................................... W ^ w (Z#q to Owner Address ,.� ----................'--------------------------�------..............------------.....------. ........................................... Installer Address UType of Building Size Lot...........................Sq. feet —t Dwelling—No. of Bedrooms___48.....................................Expansion Attic ( ) Garbage Grinder ( ) aa Other—Type of Building --•------------------------• No. of persons..............�............. Showers--(----)_.— Cafeteria.(... ). Other fixtures ........................................... ------------------------ --`'•---•-------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.....................Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--------..................................................... --••••••---• Date........................................ W Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs. Test Pit No. 2................minutes per inch Depth of.Test Pit---_................ Depth to ground water........................ 9 .••----••----•------••••----••-••-•••-••-••--••--•-•---...--•------••-•.................•------..•-•.......................................................... 0 Description of Soil....................................................................--.................................................................................................. x U ••-••••••••-••••-•--•--•--•----•••-•••---•......--•-••---------•--....•••---•-----••--•----------•-----•-•---••--------•----•-••-------•-••••--•--•--••---•---••-------•-•-------------•---------•----- W x -----------. V Na re of pairs or lteratio —Ans er when a livable_;•_ /_00f3...?. A ............... PP - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State E nmental Code—T e undersigned further agrees not to place the system in operation until a Certificate of Co plian as been issu by the board of health. Signed ...... . ..................... .. ... ......... .............................................. �. ------- Date Application Approved By .......... ' U------- ( -,�....... -- -----7-`- �' Date Application Disapproved for the following reasons- --------- ------------------------------- --- ------- -- -------------- ----------. ...........---------- ------------------------------------------------------------------- --------------- ------------- ---------------------------- -- ------ ------------------------------------------ -------- --------------------------------- Permit No. ............ 1.......3..`�.; *... .... Date Issued -- -------- Date Fx$.o....•.•........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT!- L_ ,-A` ,, is S TOWN OF BARNSTABLE Applirttfiaan for Biaivaalial Workg Tatutrnrtiaan Vatuit Application is hereby made for a Permit to Construct ( ) or Repair (p-)--an Individual Sewage Disposal System at: //Looc ion-Address or Lot No. ....... 1 .....4. �T`d--_- Owner Address �1 -C F' N b '-Ra- U ess Type of Building Installer 4• Size rLOt............................Sq. feet Dwelling—No. of Bedrooms___,S....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures _____________________ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-_______-___-___.-_- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -----------•----------------------•-•---.....-•-----------------•--•------------•---•-•......---•--.......................................................... 0 Description of Soil........................................................................................................................................................................ x U ---•----•-•---•--------------------------------•--•-----------------------------•-------------------------------------•-------------------------•-----------------------------........---------------- W - - -- ........................ U Nature of epairs or Alteratio —A ns er when applicable._. w, ,.n s;�� ;43`,F. ..../<XV5--0T'�- -, `r: ! 1 � -? ` �._... .s ,..�_-t----•-------- r ------•--•----- Agreement: 6 6 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—T e undersigned further agrees not to place the system in operation until a Certificate of Compl ai nce has been issu by the board of health. Signed -----. .. . --------------- ------------------------------------- -- -- ------ .¢�v�.�- `� Dare Application Approved By ........ 3J ---``` ---------------------- ram-- Dare Application Disapproved for the following reasons- - -------- ------------------------------------ ----------- --------------------------- --.........------------------ - --------------------------------------- ------------------ ------------------ , Dare PermitNo- ------------C/, ..`.-3)..D-------------------- Issued ....----------------------.............................. Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Terttftra e of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( l� by ...........(- ....... 0 Fk,Q..00------------ Installer at - -?�.........A -�s..$... 1 ."/--------r--------------------C-4--jam--- ZV.-1..L.. .I.J`�.. -------..... --.............................------............ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..... ../.-.. .. ,, ..---- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT Bt CONSTRUE ,AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SAKI FAg.TORY. ��' /J DATE.-.-....... ------------------ --- ------ Inspector ........ '' THE COMMONWEALTH OF MASSACHUSETTS \ BOARD OF HEALTH TOWN OF BARNSTABLE No. 7 FEE...3O, Disposal V orkg Quaanitr Haan umi# Permission is hereby granted...........P--- ........cn-1.j c-a---------------------------------------------------------------------------•.... to Construct ( ) or Repair ( .an Individual Sewage Disposal System at No..--... :kd .. Yam.Cs .._w nY---------t........... N .. ..V.11.>1-C. ..................................................... Street as shown on the application for Disposal `'Forks Construction Permit N ._ �� Dated.......................................... t B oard th of H ea l DATE...............�`/9-- -� -•-----------------------•-------- FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS '. TOWN OF BARNSTABLE 4Iz 5 ATION c'�r i g SEWAGE # VILLAGE (Re,4 -elt l/r'/Le- ASSESSOR'S MAP & LOT `' INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(type)/C,,L--� /000 C-41 1064 (size) NO. OF BEDROOMS ,PRIVATE WELL OR B ATER IBUILDER OR OWNER j eo t " DATE PERMIT ISSUED: -7 DATE COMPLIANCE ISSUED: "' ` VARIANCE GRANTED: Yes No r u 30A 4 CRY , 1 a 3� L0 CAT ION' � E w A C E PERMIT 1110. (14ol-L& I &)cA4z- - ® - 51 YI AC - In � � I ST L�ER'S NAME i ADDRESS • U I D E R ORWW DATt PERMIT ISSUED DATE COMPLIANCE ISSUED ------------------- . o r a No...... ....-y7. Fic$.......10............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....:.........OF........... .................. Appliration for Disposal Works Toustrnrtinn 1hrmit � 0/ 7 6 f Application is hereby made for a Permit to Construct A or Repair ( ) an Individual Sewage Disposal System at oa .. ••-----. -----_ ...... 3 sgaR ... . .. ........ .. .. .. .... L Addres /� or LoWS ... ....._ ^- W �� Owner Address A, Installer Address / � 9� Type of Building � e y Size Lot_._0.....,�...................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic��/}� Garbage Grinder (/ O p, Other—Type of Building ............................ No. of persons............................ Showers- ( ) — Cafeteria ( ) a' Other 'tures Q -••••-•-••----------•----------------------------•-•---------- ---•-----•---- W Design Flo ............ ....... gallons per person ;r day. Total daily flow__..........a�.��--_..---._--gallons. C4 Septic Tank Liquid capacity/.__._...gallons Length. . .... Width---------------- Diameter---------------- Depth.....aa...�._. Disposal Trench— o. .................... Width................... Total Length ... Total leaching area....................sq. ft. Seepage Pit No.__---I...._...__.. Diameter----le------.-_- Dep i below inlet............... Total leaching area.a.#1...sq. ft. Z Other Distribution box (�) Dosin ( Q ~' Percolation Test Results �I�� Performed .�..__ .............. Date..... d. �. ../ .�... '•� minutes per inch Depth of Test Pit.____ � yy/•Test Pit No. 1...._.4�c:.._.. .I�._ Depth to ground water_._._.:_¢?.._..".,_.- . P P P 1�• I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ----------•---- -- ---------------- ----- f_ ' -.... W ---•-•-----------------------------•--•••••-•-••-••-•--------------------••----•----•-------------------------------------------•-••-----------•---•••-••••-•---•••......_....-----...................-- UNature of Repairs or Alterations—Answer when applicable.............................................................................................__. Agreement The and reigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI"U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by th of health. p--� Signe _.. nt:C +�....................... I �_...�, Date Application Approved By------ ....... .......... . • -------------••------- Date Application Disapproved for the following reasons:-----•--------------------------•--------------...--•----------------------------------------------••••••..•--- ---------------------------------------------------------------------------------------------•---••-----.._..........----------------------------------------------------------------••......------------ Date PermitNo......................................................._ Issued-..... .. .......................... Date . L No....... ..._....... Fimic .....-...a............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH/ D. r7...:. oF.......... 4.Y.�7...5.Z" .-h../. ................... Appfiration for DiopooFal Works Tonotrnr#ion 1hrmit Application is hereby made for a Permit to Construct Y X or Repair ( ) an Individual Sewage Disposal System at• '/� 7" t ....... ....... .- oL. Addres ..... -------------------- -•---• .....---------•......._....... Owner Address w � •----------=--•-••-•--•-•---...._....._..........----- .... ._.a.0.:d.................. Installer Address• J 9�U Type of Building �. Size Lot/......f..................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic��•j Garbage Grinder X10 Other—Type of Building ............................ No. of persons.........:........_......... Showers ( ) — Cafeteria ( ) dOther turesf- -------------•---_-----••--------•----•--•--------------•-------------_...__..... w gn gallons P P P ly. •,y .. ga Ions. Desi Flow.._..._.... � .�_.._.. lions per person per da Total da>1 flow................ ��:._........_. WSeptic Tank—Liquid capacity/OOPgallons Length.L r..... Width---6_.......... Diameter................ Depth..... x Disposal Trench—No..................... Width...._............. Total Length.............I...... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.__ ._......... Depti below inlet....d(&........... Total leaching area. . ...sq. ft. Z Other Distribution box (/ ) Dosin�ant,(Mo '-' Percolation Test Results Performed by..l'_j. Y?fit!j... :.. .-.._ ... Date..._. �., .� Test Pit No. 1...... ..___minutes per inch "Depth of Test Pit._.-��y.►-.1 . De th to ound water....--- .�?1:.._.1• P P .. P gT G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil............ ... rh S 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 has be issued by th of health. igne ....... ................... Date Application Approved By----- ... ..... :-------- s/J. ------------------ ...... `.� "'r3" ---•--•----- 1 Date Application Disapproved for the following reasons:...................---------•--------------------------------•----------------...-----------------.........._... .........................:............................................................................................................................................................................... Date PermitNo............... ::...................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ,-►y'� BOARD OFF,'HHEALTcH/,� :...J..... . �...........OF...............!s��r�'Tr•6�.................................. CInr#ifiratr of Tompfianrr THIS IS TO CER IFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by...............ram.......--• ................................... -•.........................•--•----- ---------------•--•---....._._...._-------•--=......-•-•----...._..--•---.........._.....-•----•-•••-. ,y Installer at.................. 11, ..............................................�' ................. ^ ? 1 has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...892-..>3............... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL-FUNCTION SATISFACTORY. DATE.:.........................--------•-••-....._......---•--•--------•----•...._. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t'� f-!6!y^.F........... .........;............................ ..3_4 FEE ............ Disposal Work Tonotrudiatt pamit Permissin hereby granted..---- ...........: ....... ...•-•---...------••-------....--------.........-•---------.......----.......................-- to Constructp �or Repair ( ) an Individual Sewage Disposal System atNo------------- ........ ..... 1 ..----.-•--• ------........-----------------•-•---------..................... Street as shown on the application for Disposal Works Construction it No..................... Dated...._._______..__......_................. ----........ --------------•----•---••--. G Board of He DATE...... :��.d__�............................•-----...------ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 1 , t-�- j 30Z LOCATION' [WAGE PERMIT NO. INSTALLER'S NAME a ADDRESS • U1 0ER OR DATt PERMIT ISSUED ' HHowie DATE COMPLIANCE ISSUED V� u �� t 1 `. s�� I�! � �� '„ ,.y... �� E-1 a ..*� �a� ___,.._.c�..o - 5 { � i 1 i .. } i f � v 0 "a i 00 lot 1 D� 1A.t ^. �aD c �wtvurtavul. •— iom.+M.wwnu�..rf.e.rntWsrwf+nw+m9 # 'I f pcsc - � _ k-e 771 -r7 , �`� CEN_TERVILLE ___ 46 LEGEND 100 45 123.20' _ ----- I PROPOSED CONTOUR i LOT LI ® PROPOSED SPOT GRADE t I AREA = 15956 sf+— I --- 98 -- EXISTING CONTOUR i i N PLAN BOOK 324 PAGE 72 �� + 96.52 EXISTING SPOT GRADE AAMf wAY o ' I ASSR MAP1 70 PCL 57-17 —�— EXISTING WATER SERVICE '� SHED / tUM z TEST PIT BfRT Ml� RO_ ,2 44 1 EXIST. 1,000G 1 / ^ \ LEACH IT TH . Q 0 20.39 LOCUS MAP Z \ I LOCUS INFORMATION ( � 0 11 �O =----- TITLE REF: BK 28755 PG 189 EXIST. 1,goo -- � PARCEL ID: MAP 170 PAR. 057/017 Y SEPTIC ANK pp SEPTIC SYSTEM EXISTING REPAIR PLAN ' DWELLING 46 LOCATED AT: PAVED 302 AMES WAY (\ /1 DRIVEWAY EOP OF FNDN CEN TER VI LLE, MA 4 6.9 4+ -- � � PREPARED FOR NICHOLE PER JULY 25, 2016 \ 45 OF 9S \ o' DA R M. y N 11411> \ 77.52' S4N E� ITAR\p� \ PARKING A tltl - - EDGE OF PAVEMENT MEYER & SONS INC. AMEN WAY P. O. Box 981 E. SANDWICH, MA 02537 PH. (508)360-3311 BENCHOMARK fax (774)413-9468 PAINT SPOT ON meyerandsonstitle5@gmaiLcom coN 45 95 CORNER www.meyerandsons.com USGS DATUM ASSUMED SCALE 1"=20' SHEET 1 OF 2 J 1491 -ELEV. TOP FOUNDATION NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (46.0) 46.94 F.G.EL: 46.50 F.G.EL: 46.30 F.G. EL: 46.20 1 n MAINTAIN 2% MIN SLOPE OVER LEACHING AREA aW. F.G.EL: 44.57 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2" STONE OR FILTER FABRIC DOUBLE WASHED STONE -A 6" «rr a 4" SCH 40 PVC 1o"t ©11N 1 MIN. ®®®® ®®®® t4 6 ®®®®®E3®®®®® TEE'S ARE TO BE ( , ) ®®®®®®®®®®® -� 4" SCH 40 PVC INV.42.85 2 EFF. DEPTH ®®®®®®oll �'`'•�A'��` INV. 43.30 V.42.65 4' 2 X 8.5' 4' EXISTING OUTLET / BAFFLE EPROPOSED DB-3 EFFECTIVE LENGTH = 25' •• DISTRIBUTION BOX (H20) INV. ELEV.= 42.0 INV. 43.55 EXISTING 1 ,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON �tN �F '�A,rs OUTLET TEE AS MANUFACTURED BY 9�y / BREAKOUT TUF-TITE, ZABEL, OR EQUAL D MRRLM/`' ✓ TOP CONC. ELEV.= 43.0 ELEV.= 43.0 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING 0. 1 INV. ELEV.= 42.0W3.75' ®® ®® PIPE INVERTS PRIOR TO CONSTRUCTION ®®®®®® . 2) D-BOX SHALL BE SET LEVEL AND TRUE TO �J �P�6jSjEQ�� ®®®®®®® GRADE ON A MECHANICALLY COMPACTED SIX S4NiITAVRL BOTTOM EL.= 40.0 ®®5 FT.®® 3.75' INCH CRUSHED STONE BASE, AS SPECIFIED IN l 310 CMR 15.221(2) I� 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK SEPARATION 5.35 FT. EFFECTIVE WIDTH = 12.5' WITH GALLON SEPTIC TANK IF FAILED, SEPTIC SYSTEM PROFILE DAMAGEDED,, NOT H2O LOADING, OR UNDERSIZED. 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 34.65 SOIL ABSORPTION SYSTEM (SECTION) GAS BAFFLE AS REQUIRED (500 GALLON H2O LEACH CHAMBER) GENERAL NOTES: SOIL LOGS DESIGN CRITERIA 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL P#: 15109 NUMBER OF BEDROOMS: 3 BEDROOOM BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: JULY 13, 2016 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS. SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFlLLED PRIOR WITNESS: DAVID STANTON, BARNSTABLE B.O.H. DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE GARBAGE GRINDER: NO (not designed for garbage grinder) DESIGN ENGINEER. l 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING Elev. TP-1 Depth I Elev. TP2 DepthSEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXISTING 1,000 GAL. SEPTIC TANK - FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 45.90 0" 45.90 0" ( )330 = 445.94 S.F. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. FILL FILL LEACHING AREA REQUIRED: 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 45.15 9" 45.15 9" .74 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF A A HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. LOAMY SAND LOAMY SAND 1OYR 3/2 1OYR 3/2 USE TWO (2) 500 GALLON (H20) PRECAST LEACH CHAMBERS W/ 4' 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 44.82 13" 44.82 13" STONE ON SIDES & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED B TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 10YR 5/8 LOAMY SAND LOAMY SAND lOYR 5/8 BOTTOM AREA: 25 x 12.5= 312.5 SF 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE 43.30 30" 43.30 30" SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF C THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING C CONSTRUCTION. LOAMY SAND LOAMY SAND TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D /� 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 10YR 6/6 10YR 6/6 D/ 42.23 44" 42.23 44" DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P. vs. 330 G.P.O. yeq'd 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION ✓ PERC O EL. 40.90 C2 MEDIUM SAND C2 MEDIUM SAND 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY 2.5Y 6/4 2.5Y 6/4 PROPOSED SEPTIC SYSTEM U P G E P LAN AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 34.65 135" 4 34.65 135" 302 AMES WAY, CENTERVILLE, MA 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. 15. ALL PIPING TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPECIFIED) PERC RATE <2 MIN/IN. ("C2" HORIZON) Prepared for: Pepi NO GROUNDWATER OBSERVED Engineering and Survey by: SCALE DRAWN I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 MEYER&SONS,INC. N.T.S. DMM to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO BOX 981 requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October, 1999. EAST SANDWICH,M.4 02537 DATE CHECKED- SHEET N0. 508-3622922 07/25/16 DMM 2 of 2 IEy s y a � s � o , 74 �nt ,rc I .r TC Lr-- 9 G 77 1 � M , d S o t a Scfh A10 , .dot 4-f- - /, At, ,k _ 3 `� S 1 C.S/�N p�V.-I TR VC 7- ON 6� ♦ C p ►" v I 1-n c-/ tS r T Q t "C' \140 „-. D O 04 .: � c 70 77 t �e/�-� b.s ?'�a•r $oJc • ' W'iAi WNil a 4 - - - — _ _ ` r- r C. --P _ l : _f3 I is i.. °G t:.'• :.,rc is _ t W r40 17gk Vic OA. b. i �o —. /44 ;z io�s.... ..y �� ass Z[ /isr T7 1 ,. lot- �J� 01 ` r Z ,.77 44 . -. E ' t b-. ' '' t•" . Qom: -.. i J - •.. , , % vJ Q Q{.` -� --- �1 -a Q": (V FRANK �4 CQNERY' vs FRANK Na.6232 CONERY ': No. 6573 at T AL- /9» s A/& PLAN aF LAND 1 Cf;`NT,=— /e v/k k AE. MASSOWNED BV NJ ° FRANK CONERY S TRENTON ST. HYANNIS, MASS. 0ZWl • }_O h .. � _ R�vis-rareefl sNrnKQtie � uwo suwvevor+ �V y C . p SCALE 1 IN --, 0 FT. 8/I9/a70 �./V ........,...r. ,.. . »,.... .. .. pp -:5 .5,4 ray ra I n n. �.�cr.�-, / l e _ wi i,fix 9.�f. d. V)' 7Z I � , � .�c��r6po,r" gaih 0 �.5/(5i N 944 41. �( `01- �"i e L /?7 a}^ . �G/ ,19e,, . . 10 *-c VZei m/-rr Pet- 1rf� 4. ��s � clr7 r/1.ZafT9' 4o� ._ v/ c. fir, bra '" •ay ° C El.qj , Qk O�F Al FRAM( � -z CONERY �' 1 Z FRANK • - I `� `:' 'P No. 6232 ci CONERY 41�GISTSit cep No. 6573�p Q/ 1 1 J "�D $ i PLANOF LAND 1 IN W -r R V/k k 0- MASS. Vr �, OWNED 13Y FRANK Y �?QNERY � T �?N St � n ANNfS. MASS. 0260 FmciisTanm ENGINCRA a "tvo supveroa C� ` . A SCALE 1 IN �,ZD FT. 81l 9/�?o