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0008 ANSEL HOWLAND ROAD - Health
Ansel Howland Road - Centerville F/R A = 172 225 j �fill n]ellCG 0 UPC 12534 No.2_ 1„3L R HASTINGS.YN No. 4 Fee o d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for ;h5poear *pgtem Cott!truction Permit Application for a Permit to Construct( )Repair Grade(�bandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 8 A�sQ( I�o�vla Assessor's Map/Parcel J / ?a Installer's Name,Address,&&.Bo.CANCO Designer's Name,Address and Tel.No. 350 Main Street W. Yarmout, MA 02673 l 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 J gallons per day. Calculated daily flow 33 o gallons. Plan Date d Number of sheets / Revision Date Title / -� Size of Septic Tank e' o a --------Type of S.A.S. Description of Soil P--c` 'D ks-1 Nature of Repairs or Alterations(Answer when applicable) Ar 1?1"4, 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 E viro ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board f v2w� �- r /&A Signed Date Application Approved by Date Application Disapproved for the following reasog Permit No. vy Date Issued t .,wn. No. / } Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. ] Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS { 01pprication for 3Migpogal *pgtem Construction Permit Application for a Permit to Construct( )Repair( [Tpgrade(Abandon( ) ' ❑Complete System ❑Individual Components Location Address or Lot No.p rrsP ©wlA f Owne'ss Name,Address and Tel.No. ' Assessor's Ma /Parcel 1 )A Me/�t i)/A /. I.. � 7a Installer's Name,Address,and Tel.No. Designer's Name,Address and 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 3 11/U . L(/ gallons per day. Calculated daily flow -?D (0 gallons. 6 d / Revision /V d Plan Date Number of sheets Re Sion Date Title .e<✓.4!�t Size of Septic Tank eXi f;-i /o vU //,w, Type of S.A.S. Description)f))Soil ` G� J Nature of Repairs or Alterations(Answer when applicable) k-P C �)I M 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 ERvirop0ental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board bf It Signed r. Date 5� Application Approved by Z / I` Date Application Disapproved for the following reas Permit No. 9 , -- Date Issued 1. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( ) Repaired ( v)-Upgraded(--7— Abandoned( )by e�(� at R A nle 11f AOcJ/,a ri tom/ /t✓i ha constructed in accordance with the provisions,o itle 5 and the for Disposal System Construction Permit No r.. O dated Installer Designe y The issuance of this perms sha 1 "bt be construed as a guarantee that i he sys em wI ion as designed. Date Inspector Ni. � ����— ------------------------Fee /Vo V t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migaal *pgtem Construction Permit Permission is hereby granted t ConstrucJ( )/Rpair( �g��de(�ba don System located at 17j-e / /�l9G�/1,4 / and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be comp)aetted within three years of the date of thi ;errn t. Date:_. � ! Approved by TOWN OF BARNSTnABLE p LOCATION Q I/AND y. SEWAGE# D J 10 VILLAGE i �ENT�it�IGL�- ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHO�NO. �'d �C,© ��5� SEPTIC TANK CAPACITY' �' (type) .s po (size) o,X LEACHING FACILITY- 2 ) c3 NO.OF BEDROOMS +7 • BUILDER OR OWNER PERMIT DATE: COMPLIANCEDATE: 5'17- 06- Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 J---0 .121 -0 -1- -- I 3 9/16/03 ,a Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I,D A0,edl P• M f%�K(' hereby certify that the engineered plan signed by me dated 2q-0� ,concerning the property located at g A ly Sc—L m—. -li o go" meets all of the. following criteria: • This failed system is connected to a residential dwelling only. There are-no commercial or business.uses associated with the dwelling. • The,soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information). B) G.W.Elevation +adjustment for high G.W. DIFFERENCE BETWEEN A and B /W v SIGNED : V`''' DATE: 7 Z) NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. qAS-eptic\percexemp.doe Town of Barnstable "E rOti Regulatory Services Thomas F.Geiler,Director sntiivsz`itete. HAMPublic Health Division �p t639' �0 TFD a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 21 Ste' Designer: Y • MtUff `J- Installer: '✓ ( �y Address: . P U. F O c ni Address: ?j� l AI Pis - E SANbw" AM 02537 1-44 On �0Ir A+ B b"(, i was issued a permit to install a (date) (installer) septic system at &W14 h01 � D based on a design drawn by (address) I r�'�� " l• Y" ` dated S S� (designer 4-certify that 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. 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 R Ian revision or certified as-built by designer to follow. ���ZH OF Mgss9 DA R o J ER o. 1140 taller's Signature) - o STERN O SqN TARk esi er mltA' i� D s Signature) AffixYDesigner's Stain H( � } ere ( P ) 0— PLEASE RETURN TO BARNSTABLE PUBLIC 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:Health/Septic/Designer Certification Form ' TOWN OF BARNSTABLE LOCATION ��'.��0VX AAJD % SEWAGE# 5-- 7 0f VILLAGE CENTCI i/�LL[_^ ASSESSOR'S MAP&LOT � Z INSTALLER'S NAME&PHONE NO. O SEPTIC TANK CAPACITY CX l6T-I�n /dad!9r LEACHING FACILITY:(type)s� � �U (size) 30 J.X NO.OF BEDROOMS 15 BUILDER OR OWNER ILI&NT9� PERMIT DATE: COMPLIANCE DATE: 6 —/7- 06 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 _� � ' e� � � � �� �� � � M � � �� _ .. � � �� � `� '� �� � N M � � � ', � , � - �� s1 � �� � �� ,� � � � b M � \I Y i i � o i' �` iL_-�, ,THE l 4 Town of Barnstable * BARNSI'ABUI w: Board of Health ArED MA'�a. 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. September 15,2004 Mr. Joseph Pimental 8 Ansel Howland Road Centerville,MA 02632. Dear.Mr..Pimental,. You are granted an extension,.until April 1, 2005, to replace your failed onsite sewage. disposal system component(s).located at 8.Ansel Howland Road, Centerville.- The.septic system originally failed during an inspection conducted by John Graci on': November 28, 1998.. The soil absorption system was in hydraulic failure.according to . Mr. Graci's report...The owner then hired Biosolutions Company and expended`$2,500' for materials and labor including pouring"natures power"bacterial solution into the septic system multiple times.during the period from June 1999.through February 2004. However, an inspection conducted on August 30, 2004 revealed+thatthe system remains. "failed.". The certified septic.system inspector, James Sears,testified that the system was "full".to the.top with wastewater when it was pumped during March 2004. The Board is.of the opinion that the only resolution to this problem is to replace the failed septic component(s). Financial assistance is available through the Town's homeowner septic loan program,administered by Mr. Kendall Ayers. His telephone.number is (508). 375-6610. Sincerely yours,. A/) OayliViller, M.D., Chatan Board of Health Q:WP/Pimental s Page 1 of 4 Town of Barnstable SAYt1V9TA81Ai, � . �,� Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. RESULTS OF THE BOARD OF HEALTH MEETING Held On Tuesday, September 7, 2004, 7:00 PM RESULTS I. New Disposal Works Installer's Permit Application: APPROVED Patrick Sullivan of Marstons Mills. II. Hearings (Continued from Previous Meeting): t CONTINUED A. Nancy Jean- Unit 2WA, 800 Bearses Way, Hyannis- Several complaints received, multiple State Sanitary Code violations observed on June 23, 2004 deemed as conditions which may endanger or impair health, safety:;,., and well-being of persons occupying the premises, Health Agent issued a finding- that the dwelling was unfit for human habitation. A re-inspection will be held on 9/21/04 at 9:45 a.m. CONTINUED B. Irena Zinov - 38 Hawser Bend Road, Centerville, several complaints.F received regarding overcrowding, owner was then ordered by the Health Agent to remove the basement beds, doors and to provide minimum 5' openings to the private rooms discovered in the cellar. Owner stated that she will hire an engineer and will upgrade the system with sufficient capacity to handle two additional bedrooms (five bedrooms total). III. Variance Requests (Continued from Previous Meeting): Extension A. Stephen Callahan representing Joseph Pimental- 8 Ansel Howland Granted Road, Centerville, system failed per-inspection in 1998, owner as ordered to-repair the system--within six.-months;.systerr -now appears to be 1 f 4operatio4al-after undergoing treatments with "Nature's Power " bacteria. The failed septic system shall be repaired or replaced before April 1, 2005. Denied B. Judith Greenwood - 45 Seth Goodspeed Road, Osterville, four miniature horses, variance requested to maintain stable 35 feet away from owner's home. This request for a variance is denied and the request for a stable license is also denied. However, if the Zoning Board of Appeals(ZBA) approves the applicant's variance request on November 3, 2004,the Board of Health will then grant a variance and a stable license to the applicant-granting permission to keep two horses maximum at this property. If the ZBA denies the variance request on November 3,2004(or if the ZBA votes to continue the matter at the Page 2 of 4 November 3,2004 meeting)then all of the horses shall be removed from this property on or before January 1,2005. IV. New Business- Hearings: ABSENT A. Dana Woodman- 178 Thornton Drive, Hyannis, washing of vehicles without an approved car wash wastewater disposal system or holding tank. ORDERED: A cease and desist notice shall be issued to the violator. If the violator continues to wash vehicles after receiving such notice, he shall be fined $300. Each day's failure to comply with the order shall constitute as a separate violation. SHOW_-CAUSE B. Claudiney DeOliveira and Paul Drake — Rainbow Resort (a/k/a HEARING--Lakeside_inn_and:Suites),-1471 -Route_132;-Hyannis,_failed septic-system; PTO-BE_ ordered-to replace-leaching facility-before.August,1, 2004. -� HELD-ON-OCT : 12,-2004,DUE TO_ -FAILED-SEPTIC SYSTEM- ---� V. New Business —Variance Requests: APPROVAL A. Angelo Petrosino- 9 Southwinds Circle, Centerville, requests building GRANTED permit approval to elevate and fill-in foundation of home due to surface CONTINGENT water run-off problems, existing system consists if cesspools. UPON-RECEIVING.A—"PASSED_SEPTIC.SYSTEM-IN SP.ECTION_REPORT, The owner shall.hire a-DEP�certif'ied"septic'system inspector toAnspect the cesspools to determine ' e-`whether'the-system will pass.an inspection in-accordance with'the"State•Environmental.Code; —Title 5 standards:M the system does'rrot"pass;='-the�owner shall-repair or replace the septic system. (CONT,INUED=B-7Phil=Maker_,8-:Eastwood--Larie7Cotuit,-system failed an inspection:in'_ .'' 1998;owner applied septic-additive'on a'regular basis, system is:reported to5be `—�-The'owner shall"hire a DEP certified-septic system,i nspecto r twinspect the septic system ifi order1 -to determine whether the-system.will.pass_an inspection. If the system does not"pass," the owner shall repair or replace the septic system— 7-7= GRANTED C. Lawrence Benedetto - 359 Santuit Road, Cotuit, 1.6 acre parcel, WITH variances requested in regards to installation of septic components 71 and CONDITIONS 72 feet away from a coastal bank. No more than four(4) bedrooms are authorized. The applicant shall record a properly worded deed restriction, signed by the property owner, at the Registry of Deeds restricting the number of bedrooms at this property to the maximum allowed, before obtaining a disposal works construction permit. GRANTED D. Stephen Wilson, P.E. representing Andris and Dyane Silins- 81 WITH Holway Drive, West Barnstable, 35,732 sq. ft. parcel, variances requested CONDITIONS in regards to more than three feet of soil cover over septic components and to construct a private well on a parcel consisting of less than 40,000 square feet. No more than three (3) bedrooms are authorized. The-applicant:shall record a•properly-worded, deed restriction,signed°by the p p rty owner,of the Registry,of-Diedi7restricting.the.number of bedrooms'at this;property_toAhe-maximum allowed, before obtaining a disposal works construction permit.— —' I Page 3 of 4 GRANTED E. Peter McEntee, P.E. representing Craigville Beach Realty Trust- 1084 WITH Craigville Beach Road, Centerville, 5,079 square feet lot, variances CONDITIONS requested in regards to proposed vertical distance between SAS and maximum groundwater table elevation and variances regarding septic component setbacks to property lines. No more than two (2) bedrooms are authorized. The applicant shall record a properly worded deed restriction, signed by the property owner,at the Registry of Deeds restricting the number of bedrooms at this property to the maximum allowed, before obtaining a disposal works construction permit. CONTINUED F. Peter Sullivan, P.E. representing Kelly Family Realty Trust- 75 Pheasant Way Centerville, 15,678 sq. ft., new construction proposed, variances requested in regards to proposed SAS setback to wetland and vertical distance above the maximum groundwater table elevation. Site visit scheduled to be held On October 12,2004 at 1:00 PM GRANTED G. Terence Chase, P.E. representing Timothy Connolly- 140 Connors CONTINGENT Road, Centerville, repair of a failed system, variances proposed in UPON regards to septic . -,-.components setback to property line and foundation RECEIVING wall. REVISED PLANS SHOWING-REVISED`.PUMP-CHAMBER DESIGN VI. Projects Involving More Than`Siz Bedroom's: DENIED A. Stephen Wilson representing J. Gary'Burkhead- 27 North Bay Road, Oyster Harbors. The applicant must request variance(s) in,regards to setback to a coastal bank. DISCUSSED B. INFORMAL DISCUSSION- Craig Short P.E. —Tradewinds, 780 Craigville Beach Road, Centerville, proposed increase from a 40 bedroom motel with a food service establishment to condominium complex consisting of 42 bedrooms. The applicant must redesign the proposed septic system incorporating innovative/alternative technology. VII. Correspondence Received: DISCUSSED Lee McConnell, Environmental Project Assistant, Barnstable County Department of Health and Environment— Letter and laboratory data relative to less than 1.0 parts per billion of perchlorate discovered in private residential wells. It is recommended that each affect homeowner should retest their well water bi-annually. Vlll. Old Business/ New Business: DISCUSSED A. Joe Capraro, Mom's Apple Pie- Grease recovery device influent and effluent test results. Page 4 of 4 DISCUSSED B. Daniel Ojala, P.E. representing Tim Williams - 30 units at Lot 1 Ost. - West Barnstable Road, proposed connection into Treatment Plant, expansion approved by DEP, 12,100 gallons allocated for housing development. FAILE �INSPECTION , 1�. ._JLOT 2Z� Q COMMONWEALTH OF MASSACHUSETTS 0 Z F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS b Y j d DEPARTMENT OF ENVIRONMENTAL PROTECTION € ECEIVED _ V 350 MAIN STREET S E P 14 2004 WEST YARMOUTH,MA rr 508-775-2800 TOWN OF BARNSTABLE �•r� HEALTH DEPT, TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Map-172 Parc-225 Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner's.Name: PERMENTAL,JOSEPH Owner's Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Date of Inspection AUGUST 24,2004 a c= a Name of Inspector:(please print) JAMES D.SEARS r Company Name: A&B Canco � Mailing Address: 350 Main Street -- West Yarmouth,MA 02673 < Telephone.Number: 508-775-2800 > CERTIFICATION STATEMENT N I certify,that I have personally inspected the sewage disposal system at this address and that the info ation rep�ed co below is true,accurate and complete as of the time of the inspection. The inspection was performed b ed on ntb rn training and experience in the proper function and maintenance of on site sewage disposal systems. I m a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 429,0�4� Date: 8-30-04 The system inspector shall suPitaopy 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 of 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 tot he buyer,if applicable,and the approving authority. Notes and Comments *** This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM — - - -PART A CERTIFICATION(continued) - - Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A 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: N/A _ 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 exfiltradon or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 v Page 3 of 11 _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 8 ANSEL HOWLAND ROAD w CENTERVILLE MA 02632 Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24,2004 C. Further Evaluation is Required by the Board of Health:N/A 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(i)(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 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 public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance ** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 f Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 8 ANSEL HOWLAND ROAD CENT-ERVILLE,MA 02632 — - Owner: PERMENTAL,JAMES - - - Date of Inspection: AUGUST 24,2004 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 pit has been less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped J Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CUR 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il 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 is 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 Title 5 Inspection Form 6/15/2000 4 Y Page 5 of 11 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM__ PART B CHECKLIST Property Address:-- 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 " - Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24,2004 Check if the following have been done. You must indicate`des" 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? J 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)has been determined based on: Yes No J 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(3Xb)] Title 5 Inspection Form 6/15/2000 5 4� Page 6 of 11 OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C - . SYSTEM INFORMATION Property Address: 8 ANSEL HOWLAND=ROAD CENTERVILLE;MA 02632.-,:. _ . Owner: ._ __._... PERMEN -AL,JAMES _ Date of Inspection: AUGUST 24,2004 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2002-65,000 GAL./2003-71,000 GAL./200443,000 GAL. Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: FEBRUARY OF 2004— MARCH OF 2004 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1983 PERMIT #637 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 I . _r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 ANSEL HOWLAND ROAD . . CENTERVELLE,MA 02632 Owner: PERMENTAL,JAMES -' Date of Inspection: AUGUST 24,2004 BUILDING SEWER(locate on site plan): Depth below grade: 12" f Materials of construction: Cast iron J 40 PVC other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): J Depth below grade: 18" Material of construction: concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 GALLON PRE CAST Sludge depth: 1" Distance from top of sludge to the bottom of outlet tee or baffle: 29" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: AS BUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT LEVEL,SHOWS SIGNS OF BEING OVER FULL. SEE ATTATCHED LETTER GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal _ fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 _ Owner: - •PERMENTAL,JAWS - Date of Inspection. AUGUST 24,2004 TIGHT or HOLDING TANK: N/A (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: Igallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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 NOTED ON AS BUILT PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of I 1 -° - - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY`ASSESSMENTS' _ - SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM- PART C. SYSTEM INFORMATION(continued) Property Address: 8 ANSEL HOWLAND ROAD - __. CENTERVILLE,MA 02632 Owner: PERMENTAL;JAMES .- --Date of Inspection:.. AUGUST SOIL ABSORPTION SYSTEM(SAS): J (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 Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1000-GAL PRE CAST PTr.PIT IS 4'BELOW GRADE, /2"COVER AT 1'. AT TIME OF INSPECTION 3'WATER IN PIT.PIT SHOWS SIGNS OF BEING FULL. SEE ATTATCHED LETTER. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SEWAGE DISPOSAL SYSTEM INSPECTIONFOR1VIx PART C _ SYSTEM.INFORMATION(continued)-Property Address: 8.ANSEL HOWLAND ROAD CENTERVILLE.MA 02632 Owner: PERMENTAL.JANIES - Date of Inspection: AUGUST 24. 2004 SKETCH OF SEWAGE-DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benclunarks. Locate all wells within 160 feet. Locate where public water supply enters the building. e_ O O w Title 5 Inspection Fonn 6/1 i/2000 i0 Page,l.l..of.l l - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address - _:�8 ANSEL HOWI:,A1�7-ROAD CENTERVILLE,-MA 02632. Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24,2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 47.3 feet Please indicate(check)all methods used to deternune the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation J Accessed USGS database-explain: You must describe how you established the high ground water elevation: AREA HIGH,NO SIGN OF WATER PROBLEM USGS WELL DATA SDW 252 AT 47.3 Title 5 Inspection Form 6/15/2000 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' DEPARTMENT OF ENVIRONMENTAL PROTECTION -- = ONE WINTER STREET, BOSTON, MA 02108 617-292-5500-- WILLIAM F.WELD _ TRUDY CORE Governor _. . _ Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor _- Commissioner May 7, 1997 SOIL ABSORPTION SYSTEM: It is extremely important that the inspector locate the leaching system, _ . however, excavation of the soil absorption system, once it is located, is typically NOT required. It may be appropriate to expose a portion of the soil absorption system (especially if the leaching system is a pit) to determine its condition if other indications of failure, such as evidence of breakout, ponding, sewage backup, condition of the distribution box, etc. , suggest that a failure of the soil absorption system may have occurred. If the system is a leaching pit, it will generally make sense to open the pit and pump the liquid out of the pit to determine if groundwater infiltrates back into the pit . Approximate layout should be determined by examining topography and noting drain arrangement from access at distribution box. Location of the leaching system can often be done by running a snake down the line (s) - coming from the distribution box. Determine .condition of soil (e .g. clogged, hydrogen sulfide crust, etc . ) Determine level of ponding within disposal area (visual inspection) Determine if. leaching system is below the .high. groundwater elevation. It should be noted that a soil absorption system,. which fails because it is clogged, CAN NOT be made to pass by application to the soil absorption system of physical, chemical or biological agents or treatments. Such failures can, generally, only be corrected by upgrading or replacing the system. The Local Approving Authority should be consulted before any effort is made to .repair or upgrade a failed soil absorption system. HIGH GROUNDWATER DETERMINATION Location .of the bottom of the leaching facility compared to the HIGH groundwater elevation is the most common reason for the failure of systems inspected. It is also the most important reason that sewage is not . adequately treated before it enters the groundwater table . For these reasons it is most important that the HIGH groundwater elevation be properly determined. The phrase HIGH groundwater elevation is used throughout this advice because the groundwater elPvnti nn r•an tTAr Ci e'Mi f; .. + }„r,,,,r.1,,,,.* 4-1— MAIN_STREET-,-.,— ,,,,,. . v.,..._ - WEST YARMOUTH MA 02673 (800)698-3993 FAX:(508)'778=9628 Septic.Service & Mechanical Services Pumping & ,. CO .-Heating & Plumbing n.. a Installation F:ixe Sprinklers Since 1930 August 31,-°2004 Joseph Permental 8 Ansel Howland Road Centerville, MA 02632 Dear Mr. Permantal, The septic system was installed in 1983 and is now over 20 years old. System was inspected in 1998 -by John Graci and at that time had failed. Tank was pumped on- " February of 2004 of 1000 gallons. In March 2004 system was full in to risor, tank and pit were pumped of 2500 gallons. On March 22"d 2004 system was treated by Bio-Solutions Inc., also a terralift probe system with a treatment of nature powder was used. At the time of inspection septic tank was at working level with 6' pit, 3' of water in pit. Walls show pit has been full up into risors. In March of 2004 when system was full and pumped, I opened the covers and pumped system. I saw that the system was full and had failed. See attached letter from Department of Environmental Protection on soil absorption system. Sincerely, James D. Sears Y i 9,g K.Y -� COMMONWEALTH OF MASSACHUSETTS W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION 350 MAIN STREET WEST YARMOUTH,MA �CD 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Map-172 Parc-225 Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner's Name: PERMENTAL,JOSEPH Owner's Address: 8 ANSEL HOWLAND ROAD CENTERVII,LE,MA 02632 Date of hnspeetion AUGUST 24,2004 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco t "" Mailing Address: 350 Main Street m i West Yannouth,MA 02673 N Telephone Number: 508-775-2800 0 C cr, CERTIFICATION STATEMENT N I certify that I have personally inspected the sewage disposal system at this address and that the inforn at'ion repsed no below is tine,accurate and complete as of the time of the inspection. The inspection was performed b sed on ntyD rn training and experience in the proper function and maintenance of on site sewage disposal systems. I m a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 8-30-04 The system inspector shall su mit 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 tot he buyer,if applicable;and the approving authority. Notes and Comments `*This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24.2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A I have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A 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 detennined" 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 extiltration or tank failure is inmannent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24,2004 C. Further Evaluation is Required by the Board of Health:N/A 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 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 public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "* This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24, 2004 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 v/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in pit has been less than 6"below invert or available volume is less than%day flow J 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 1.5,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "Yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed wider Section D shall upgrade the system in accordance with 310 CMR 15.304. The systenm owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 1 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL, JAMES Date of Inspection: AUGUST 24,2004 Check if the following have been done. You must indicate`yes" or"no"as to each of the following Yes No Pumping information was provided by the owner,occupant,or Board of Health J 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? J 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? y/ 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)has been determined based on: Yes No J Existing information. For example,a plan at the Board of Health. J Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24, 2004 FLOW CONDITIONS RESIDENTIAL V Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2002-65,000 GAL./2003-71,000 GAL./200443,000 GAL. Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CNIR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonuation: FEBRUARY OF 2004— MARCH OF 2004 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How,,vas 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) 'right tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1983 PERMIT #637 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contented) Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL, JAMES Date of Inspection: AUGUST 24,2004 BUILDING SEWER(locate on site plan): J Depth below grade: 12" Materials of construction: Cast iron 40 PVC other(explain) _ v _ Distance f-om private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): Depth below grade: 18" Material of construction: concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 GALLON PRE CAST Sludge depth: 1" Distance from top of sludge to the bottom of outlet tee or baffle: 29" Scum thickness: 0" Distance from top of scum to top of outlet tee or battle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: AS BUILT AND TAPE Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage;etc.): MAIN TANK AT LEVEL,SHOWS SIGNS OF BEING OVER FULL. SEE ATTATCHED LETTER GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal _ fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Continents(on pumping recolmnendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24,2004 TIGHT or HOLDING TANK: N/A (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/day Alann present(yes or no) Alann level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: V (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Continents(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 NOTED ON AS BUILT PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarnis in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL,JAMES Date of Inspection: AUGUST 24, 2004 SOIL ABSORPTION SYSTEM(SAS): J (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 Type/name of technology: Conunents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1000-GAL PRE CAST PIT.PI'r IS 4'BELOW GRADE, /2"COVER AT 1'. AT TEVIE OF INSPECTION 3' WATER IN PIT.PIT SHOWS SIGNS OF BEING FULL. SEE ATTATCHED LETTER. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate 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 constriction: Indication of groundwater inflow(yes or no): Conunents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Constriction: Dimensions: Depth of solids: Cormnents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) .Property Address: 8.ANSEL HOWLAND ROAD CENTERVILLE.MA 02632 O�rner: PERMENTAL.JAMES Date of Inspection: AUGUST 24. 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchnnarks. Locate all wells within 100 feet. Locate where public water supply enters the building. C a Title 5 Inspection Form 6/I5/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 ANSEL HOWLAND ROAD CENTERVILLE,MA 02632 Owner: PERMENTAL, JAMES Date of Inspection: AUGUST 24, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 47.3 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: AREA HIGH,NO SIGN OF WATER PROBLEM USGS WELL DATA SDW 252 AT 47.3 Title 5 Inspection Form 6/15/2000 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS C DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 WILLIAM F.WELD TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCI ,► DAVID B.STRUHS Lt.Governor Commissioner May 7, 1997 SOIL ABSORPTION SYSTEM: It is extremely important that the inspector locate the leaching system, however, excavation of the soil absorption system, once it is located, is typically NOT required. It may be appropriate to expose a portion of the soil absorption system (especially if the leaching system is a pit) to determine its condition if other indications of failure, such as evidence of breakout , ponding, sewage backup, condition of the distribution box, etc . , suggest that a failure of the soil absorption system may have occurred. If the system is a leaching pit, it will generally make sense to open the pit and pump the liquid out of the pit to determine if groundwater infiltrates back into the pit . Approximate layout should be determined by examining topography and noting drain arrangement from access at distribution box. Location of the leaching system can often be done by running a snake down the line (s) coming from the distribution box. Determine condition of soil (e .g. clogged, hydrogen sulfide crust, etc . ) Determine level of ponding within disposal area (visual inspection) Determine if. leaching system is below the high groundwater elevation. It should be noted that a soil absorption system, which fails because it is clogged, CAN NOT be made to pass by application to the soil absorption system of physical, chemical or biological agents or treatments. such failures can, generally, only be corrected by upgrading or replacing the system. The Local Approving Authority should be consulted before any effort is made to repair or upgrade a failed soil absorption system. HIGH GROUNDWATER DETERMINATION Location of the bottom of the leaching facility compared to the HIGH groundwater elevation is the most common reason for the failure of systems inspected. It is also the most important reason that sewage is not adequately treated before it enters the groundwater table . For these reasons it is most important that the HIGH groundwater elevation be properly determined. The phrase HIGH groundwater elevation is used throughout this advice because the groundwater elevation can vary significantly throughout the near, from near to vP.ar . and :!i! d f f-rent' tVTJP_� ^f SO_iJ._S . 350 MAIN STREET TEL: (508) 775-2800 WEST YARMOUTH MA 02673 (800) 698-3993 FAX:(508) 778-9628 Septic Service sa Mechanical Services Pumping 8 G� Heating & Plumbing Installation Fire Sprinklers Since 1930 August 31, 2004 Joseph Permental 8 Ansel Howland Road Centerville, MA 02632 Dear Mr. Permantal, The septic system was installed in 1983 and is now over 20 years old. System was inspected in 1998 by John Graci and at that time had failed. Tank was pumped on February of 2004 of 1000 gallons. In March 2004 system was full in to risor, tank and pit were pumped of 2500 gallons. On March 22"d 2004 system was treated by Bio-Solutions Inc., also a terralift probe system with a treatment of nature powder was used. At the time of inspection septic tank was at working level with 6' pit, 3' of water in pit. Walls show pit has been full up into risors. In March of 2004 when system was full and pumped, I opened the covers and pumped system. I saw that the system was full and had failed. See attached letter from Department of Environmental Protection on soil absorption system. Sincerely, James D. Sears BY STREET 6/1/2004 ID Permit# Date, Hauler Prop Owner H'seE# 622 989618.1 3/25/1998 Robinson Mara 116 1014 989887.1 4/20/1998 Bortolotti Meyer 84 1015 989887.2 4/20/1998 Bortolotti Cullotta 195 1025 989919.2 4/21/1998 Bortolotti Varney 140 1026 989916.1 4/21/1998 Bortolotti Brunelle 152 �- - 2054 9807.T1.2 6/25/1998 Bortolotti---'- - Pamental -8 2591 981090.2 7/28/1998 A& B Canco Hilf 54 2944 981432.1 8/20/1998 Bortolotti Mara 116 3377 981731.2 9/16/1998 Bortolotti Callatta 195 3911 982087.1 10/23/1998 Macomber Quinn 104 4404 982428.1 11/30/1998 Abco Dever, Chip 22 5050 992905.1 2/1/1999 Macomber Rogers 167 6358 993904.2 5/12/1999 Bortolotti Spidle 133 6500 993981.1 5/19/1999 Bortolotti Donat 204 6949 994201.1 6/15/1999 Ace Long 176 7727 994701.1 7/29/1999 Macomber Mara 116 8372 995251.2 9/2/1999 Bortolotti Creighton 181 8446 995320.3 9/8/1999 Bortolotti Cullota 195 8907 995615.1 10/7/1999 Ace Haley 142 9184 995803.1 10/25/1999 Robinson Cullotta 195 9384 995906.2 11/4/1999 Bortolotti Butler 113 10817 20000024.5 2/8/2000 Bousfield Brunelle 152 10881 20007033.3 3/9/2000 A& B Canco Hilf 54 11814 20007750.1 5/4/2000 Macomber Levine 61 11817 20007509.2 5/4/2000 Abco Shea 707 12592 20008295.1 6/20/2000 Macomber Quinn 104 12715 20008386.1 6/27/2000 A& B Canco Borini 71 13235 20008734.1 7/24/2000 Robinson Donat 204 13386 20008817.1 8/1/2000 A& B Canco McLean 64 15506 20000205.3 11/22/2000 Bortolotti Creighton 181 16600 20010989.1 3/2/2001 Bortolotti Brunelle 152 16798 20011109.1 3/20/2001 Macomber Dever 22 17143 20011298.1 4/12/2001 Macomber Hogan 94 18479 20012129.1 6/20/2001 Robinson Donat 207 20015 20013064.4 9/12/2001 A& B Canco Jordan 34 20042 20013054.1 9/14/2001 A& B Canco Lannquist 44 20915 20013575.1 11/1/2001 Robinson Huber 164 21850 20024160.1 1/14/2002 Bortolotti Brunelle 152 22850 20024637.4 3/18/2002 A& B Canco Milliken 217 23386 20025012.1 4/18/2002 Bortolotti Spidle 133 23917 20025355.1 5/14/2002 Robinson Mara 116 24497 20025640.2 6/11/2002 Macomber Quinn 104 25640 20026288.1 8/8/2002 Bortolotti Masteralexis 84 25865 20026424.1 8/20/2002 Robinson Halloran 64 27513 20027311.3 11/14/2002 A& B Canco IHilf 54 27688 20027401.1 11/26/2002 Macomber IMcGill 81 Pagel .z BY STREET 6/1/2004 --1a IQ: Permit# C?ate, W Hauled Prop Owner se# 27949 20027594.2 12/18/2002 A& B Canco Spidle 133 28740 20038122.4 3/6/2003 Bortolotti Donat 204 28744 20038173.1 3/6/2003 Bortolotti Brunelle 152 30279 20039028.2 5/28/2003 Macomber Freeman 61 30381 20039125.2 6/2/2003 Macomber McGill 31 30425 20039146.1 6/3/2003 Bortolotti Butler 113 32667 20031377.2 9/15/2003 Macomber Haley 143 33857 20032154.1 11/12/2003 Macomber McGill 81 34154 20032320.1 12/1/2003 Macomber Dever 22 34817 20042659.1 2/4/2004 A&.B Canco Pemental 8 34985 20042823.2 2/25/2004 Bortolotti Burnelle 152 35092 20042908.3 3/5/2004 Bortolotti Donat 204 35432 20043107.2 4/1/2004 A& B Canco Pimental ' -8 35565 20043172.1 4/9/2004 Macomber McGill 81 357791 20043273.1 4/21/2004 Macomber Lake 71 Page 3 BY STREET 8/24/2004 ID Permit# Date... `, H auler W,Pro,p,Owne� ',y Hse# Streets;, 622 989618.1 3/25/1998 Robinson Mara 116 Ansel Howland Centerville Septic 1014 989887.1 4/20/1998 Bortolotti Meyer 84 Ansel Howland Centerville Septic 1015 989887.2 4/20/1998 Bortolotti Cullotta 195 Ansel Howland Centerville Septic 1025 989919.2 4/21/1998 Bortolotti Varney 140 Ansel Howland Centerville Septic 1026 989916.1 4/21/1998 Bortolotti Brunelle 152 Ansel Howland Centerville Septic_ 2054 980771.2 , 6/25/1998 Bortolotti Pamental 8 Ansel Howland Centerville Septic - 2591 981090.2 7/28/1998 A& B Canco Hilf 54 Ansel Howland Centerville Septic 2944 981432.1 8/20/1998 Bortolotti Mara 116 Ansel Howland Centerville Septic 3377 981731.2 9/16/1998 Bortolotti Callatta 195 Ansel Howland Centerville Septic 3911 982087.1 10/23/1998 Macomber Quinn 104 Ansel Howland Centerville Septic 4404 982428.1 11/30/1998 Abco Dever, Chip 22 Ansel Howland Centerville Septic 5050 992905.1 2/1/1999 Macomber Rogers 167 Ansel Howland Centerville Septic 6358 993904.2 5/12/1999 Bortolotti Spidle 133 Ansel Howland Centerville Septic 6500 993981.1 5/19/1999 Bortolotti Donat 204 Ansel Howland Centerville Septic 6949 994201.1 6/15/1999 Ace Long 176 Ansel Howland Centerville Septic 7727 994701.1 7/29/1999 Macomber Mara 116 Ansel Howland Centerville Septic 8372 995251.2 9/2/1999 Bortolotti Creighton 181 Ansel Howland Centerville Septic 8446 995320.3 9/8/1999 Bortolotti Cullota 195 Ansel Howland Centerville Septic 8907 995615.1 10/7/1999 Ace Haley 142 Ansel Howland Centerville Septic 9184 995803.1 10/25/1999 Robinson Cullotta 195 Ansel Howland Centerville Septic 9384 995906.2 11/4/1999 Bortolotti Butler 113 Ansel Howland Centerville Septic 10817 20000024.5 2/8/2000 Bousfield Brunelle 152 Ansel Howland Centerville Septic Yes 10881 20007033.3 3/9/2000 A& B Canco Hilf 54 Ansel Howland Centerville Septic 11814 20007750.1 5/4/2000 Macomber Levine 61 Ansel Howland Centerville Septic 11817 20007509.2 5/4/2000 Abco Shea 707 Ansel Howland Hyannis 12592 20008295.1 6/20/2000 Macomber Quinn 104 Ansel Howland Centerville Septic 12715 20008386.1 6/27/2000 A& B Canco Borini 71 Ansel Howland Centerville Septic 13235 20008734.1 7/24/2000 Robinson Donat 204 Ansel Howland Centerville Septic 13386 20008817.1 8/1/2000 A& B Canco McLean 64 Ansel.Howland Centerville Septic 15506 20000205.3 11/22/2000 Bortolotti Creighton 181 Ansel Howland Centerville Septic 16600 20010989.1 3/2/2001 Bortolotti Brunelle 152 Ansel Howland Centerville Septic 16798 20011109.1 3/20/2001 IMacomber Dever 22 Ansel Howland Centerville Septic 17143 20011298.1 4/12/2001 IMacomber IHogan 94 Ansel Howland Centerville Septic Pagel BY STREET 8/24/2004 JD Perrn_it# ''. . W., Date ,- Hauler . Prop:Qw6, Hse ; Street,,, __. ', Villa a W, Source ,Dis,_osed'nat B< 18479 20012129.1 6/20/2001 Robinson Donat 207 Ansel Howland Centerville Septic 20015 20013064.4 9/12/2001 A& B Canco Jordan 34 Ansel Howland Centerville Septic 20042 20013054.1 9/14/2001 A& B Canco Lannquist 44 Ansel Howland Centerville Septic 209151 20013575.1 11/1/2001 Robinson Huber 164Ansel Howland Centerville Septic 21850 20024160.1 1/14/2002 Bortolotti Brunelle 152 Ansel Howland Centerville Septic 22850 20024637.4 3/18/2002 A& B Canco Milliken 217 Ansel Howland Centerville Septic 23386 20025012.1 4/18/2002 Bortolotti Spidle 133 Ansel Howland Centerville Septic 23917 20025355.1 5/14/2002 Robinson Mara 116 Ansel Howland Centerville Septic 24497 20025640.2 6/11/2002 Macomber Quinn 104 Ansel Howland Centerville Septic 25640 20026288.1 8/8/2002 Bortolotti Masteralexis 84 Ansel Howland Centerville Septic 25865 20026424.1 8/20/2002 Robinson Halloran 64 Ansel Howland Centerville Septic 27513 20027311.3 11/14/2002 A& B Canco Hilf 54 Ansel Howland Centerville Septic 27688 20027401.1 11/26/2002 Macomber McGill 81 Ansel Howland Centerville Septic 27949 20027594.2 12/18/2002 A& B Canco Spidle 133 Ansel Howland Centerville Septic 28740 20038122.4 3/6/2003 Bortolotti Donat 204 Ansel Howland Centerville Septic 28744 20038173.1 3/6/2003 Bortolotti Brunelle 152 Ansel Howland Centerville Septic 30279 20039028.2 5/28/2003 Macomber Freeman 61 Ansel Howland Centerville Septic 30381 20039125.2 6/2/2003 Macomber McGill 31 Ansel Howland Centerville Septic 30425 20039146.1 6/3/2003 Bortolotti Butler 113 Ansel Howland Centerville Septic 32667 20031377.2 9/15/2003 Macomber Haley 143 Ansel Howland Centerville Septic 33857 20032154.1 11/12/2003 Macomber McGill 81 Ansel Howland Centerville Septic 34154 20032320.1 12/1/2003 Macomber Dever 22 Ansel Howland Centerville Cesspool/septi 34817 _20042659.1 2/4/2004 A&.B.Canco Pemental 8 Ansel.Howland Centerville— Septic--� 34985 20042823.2 2/25/2004 Bortolotti Burnelle 152 Ansel Howland Centerville Septic _ 35092 20042908.3 3/5/2004 Bortolotti Donat 204 Ansel Howland Centerville Septic - .35432 -20043107.2 4/1/2004 A& B Canco Pimental 8 Ansel Howland Centerville Septic — -- 355651 20043172.1 4/9/2004 Macomber McGill 81 Ansel Howland Centerville Septic 35779 20043273.1 4/21/2004 Macomber Lake 71 Ansel Howland Centerville ISeptic 36477 20043731.1 5/24/2004 Robinson ILamb I 49 Ansel.Howland Centerville ISeptic 36538 20043735.1 5/27/2004 Roberts Septic ILamb, Mike 49 Ansel Howland Centerville ISeptic Page 2 i R rO Town of Barnstable Regulatory Services * BARNSTASLE, * Thomas F. Geiler,Director — y MASS. `b 1639. .�� Public Health Division ivision Fa Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 C Fax: 508-790-6304 e2T-� `7 ®oa. �Qoo �� Cl( a� h E. Pemental Date: A riI 29 2004 Joseph P , 8 Ansel Howland Road Centerville, Ma. 02632 NON-COMPLIANCE WITH.STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 8 Ansel Howland Rd., Centerville was inspected on, 11/28/98 by John Graci a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: SAS was in hydraulic failure. Our records show that the system has been in a failed state for more than two years. You are ordered to hire a professional engineer or registered sanitarian to prepare a plan of proposed replacement septic system component(s). This plan is to be submitted to the Town of Barnstable Public Health Division Office (Regulatory Services, 200 Main Street, Hyannis),within (90) days receipt of this letter. The plan will bring the septic system into compliance with 310 CMR 15.00,The State Environmental Code, Title V. You are also ordered to upgrade or replace the septic system within six months (180) days of your receipt of this letter. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. You have the option of requesting an adjudicatory hearing pursuant to 310 CMR 15.422 Failure to comply . h this order will automatically result in a public hearing scheduled before the Board of Health. E O T BOARD OF HEALTH omas A. Mc ean, R.S., C.H.O. Agent of the Board of Health , CC: Board of Health / J AWled_septic_letters 350 MAIN STREET. ' «' }�tars a r - :•_ 1 � EL WEST YARMOUTH'MA 02673 '� , ' R - r -t (8 00)698W 3993 _ t u Fax(508)778`9628 Septic Service = t` r.t;.a , Mechanical Services ".Pumping& Installation ", }' Heating&Plumbing } t - : z _ Fire Sprinklers L Duct-Work Cleaning . = x "? =x —777 Since 1930 , fi•� SPA' SEPTIC PUMPING N. F 35250 SERVICE INFORMATION: . `BILLING- AGCT # +:14895 , COD_ PEMENTAL . JOSEPH JOS � � EPH PEMENTAL 8 ANSEL HOWLAND, ROADHOWLANDx:ROADe CENTERVI.LLE, MA 0 A 3 2 CENTERVILLE, -MA' 02632; - CONTACT. SITE PHONE: 508, 428- C2Q5 :P. O:#.JQSEPH Y = ' 64 ' SP . W O R K R E Q U E S T . MAINTENANG PUMPING .DATE 2/02/04 2_�,04/04 AM.. JH/AB N RESPONSIBLE FOR DAMAGE TO UNDERGROUND SPRINKLERS OR UTILITIES WHEN 'DIGGING ' K i WORK PERFORMED AND EQUIPMENT NEEDED/USED' �rljri PUMPING/SEPTIC SVC LABOR PUMPING CHG c GALLONS, PUMPED SEPTIC GREASE DISPOSAL .CHG: � ✓ DL TNK/PIT:TANK SLZE/TYPE/LOCATION0 /� � IL SIZE/TYPE LEACHING: FIELD-- GALLEY PITS, S : HOSE/LOCATE: DRAIN1''CLNG^ EQU� , ��r .' �.� ;, �> _ MATL USED: �� V Y3RTY TECH .DATE TRVL ( START END L�HRGb TIME MATERYALS. y 0Sr- 9. SLS TAX: ,^ y Y P/2 X. x SUBTOTAL A6 I I ( ( (.. �` ,�LESPYMT -: iXsU. � p e t , AMOUNT—DUE I hereby accepT.- a - services performed as satisfa_ct6ry�and in working order.WUu d t ar +mot clj s wy r " x= 4' iL s r4N�h _ Interestwi l 1 bey„charged gat 1 1/2 o Aper month urr aidb l;a esBuybeagrees _ yr fii tx " i .y tr '� t '�Onry +`vj,�.^'• '' ''... 3. e .;," .:� ''3r,^?,':'.'`-r* +� x' '•^'t ;,+.`r.. --.S p sk` .r ..a'. pay 5 •C. .'}, acm d<`a J...'i "� x ,c -t ^-.,.".a $ y , t ^Y,'!*`'Y - -"` :'k. W. 7�'�. to- :al l),collectioncosts.,.. redit-:Ca COMPLETE IAICOMPL 'SIGNATURE = DATE r ` 350 MAIN STREET TEL: (508) 775-2800 WEST YARMOUTH, MA 02673 (800) 698-3993 FAX: (508) 778-9628 Septic Service Mechanical Services Pumping & Installation O Heating & Plumbing Duct-Work Cleaning Fire Sprinklers Since 1930 SERVICE INFORMATION: LOC: PRIORITY: BILL INFORMATION: GPI tiS£j- I{r' 4 ti;) ` o TERMS: COD CHG CR CRD C �N SERVICE LOC PHONE #'s � Z AUTH. BY: _ OPEN DATE: DSPTCH: WORK REQUESTED REASON: REMARK: pU - t, ._�a.r -Z4 /!7 ——————————————————————————————————————————— DESCRIPTION TOTAL AMOUNT WORK PERFORMED Oa j<,4.L- PUMPING CHG: x ADDL TANK/PIT: l�v�' ADDL HOSE: LOCATING CHG: �j CLEAR DRAIN: WATER BLAST: TECH DATE TRVL START END CHGED TIME EVALUATION: PRIORITY CHG- V DISPOSAL CH : LABOR CHG: COVERS/FRAMES: 5% SLS TAX: I hereby accept the services performed as satisfactory and 7�! SUBTOTAL: acknowledge equipment was left in good condition. LESS PYMT: / U Interest at 1 1/2% per month after 30 days unpaid. ' AMOUNT DUE: Buyer agrees to all collection costs. ' CHECK#: COMPLETE INCOMPL. SIGNATURE: SOC..SEC.#: 3propossal ns BioSolut io Inc. Westboro, MA 01581 a Grapevine, Texas 76051 Tel: (508) 836-3123 a (800) 240-2400 a Fax: (508) 366-6568 E-mail: BioSolutions@MSN.COM PROPOSAL SUBMITTED T PHONE DATE 3 CT STREET JOB NAME CITY, TATE,AND ZIP CODE JOB LOCATION SALESPERSON 1 DEPOSIT ONE We hereby tubmit specifications and estimates for: ............................................................................................................................................................................................................................... ..................... ...................................................................................................................................................... ......................,/.. JE..�:srCL...........1.......�..f... .11�r.... .....c..Q_ji).............6.........}(...�.....f.y......... ....p..:.'. .. ..,f ..... ... _,.................................................................... CU J ............................................................................................................. .�� ....a. ..._ .......... ..................1.. .. ......�?.... .......... ...... .e ........... ........ 7 �J .. . ................................................................................................................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................ ................ ......................A .................................................................. ....................................... C .. ...j..........:.........::.._ ...:. .... .............. . .. ..................................~............................................................................................................................ 1 ...................................................................................................................................................................................... �:............................................................................................................................................................................................................ .............................._......................................................................................................................................................................................................................................................................................................................................................................... . .� cs. -.�} ,q , ,r ..................................................................... ... ...P...... .. Q�c.... ....... ,..... ........... 1?': '....:.9 ,............... . .!�:................................ ........................................................................ 0.......................................................................... ........................................................................................................................................................................................................................................................................................................................ Ve i3ropo6e hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: dollars($ ). Payment to be made as follows: All material Is guaranteed to be as specified. All work to be completed In a workmanlike manner Authorized according to standard practices. Anyalteratlon or deviation from above specifications Involving Signature extra costs will be executed only upon written orders,and will become an extra charge over and g above the estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Owner to carry fire,tomado,and other necessary Insurance. Customer responsible for reasonable anomey s fees and costs if collection Is required.Interest of 1.5%monthly on unpaid Note: This proposal may be balance will be assessed. withdrawn by us if not accepted within days. ttE�ltAttLE OfrOO�aY-The above prices,specifications,and conditions are satisfactory and are hereby accepted. You are authorized to do the Signature . work as specified. Payment will be made as outlined above. Date of Acceptance: Signature, t t Commonwealth of Massachusetts Executive Office of Envirolunental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 Jolui Gf-ad D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLI (508)564-6813 Governor overn F.wELD FAILED INSPECTICiA ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION oF� z O Property Address: 8 ANSEL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25idress of Owner: _1998 Date of Inspection: 11/12/98 (If different) Name of Inspector: JOHN GRACI MR.PEMENTAL 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: _ Passes This Inspection Is based on criteria defined In Title V Conditio ally Passes code 310 CMR 16303.My findings are of how the system is performing at the time of the inspection.My Inspection does _ Needs flur er Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the X Fails septic system and any of its components useful life. Inspector's Signature: Date: 1V28/9s The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: 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 CoMpilance(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 lank 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 04127417) One Winter Street is Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 ANSEL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25 Owner: MR.PEMENTAL Date of Inspection:11r12198 _ Sewage backup or.breakout or high.static water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or 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: x 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 _x Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. . x_ Discharge or ponding of Effluent to th@ @urf@c@ of ih@ ground or @urf@c@ w@t@r@ du@ to @n ov@flo@d@d or elodgEd cesspool. x SAS is in hydraulic failure. (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 ANSEL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25 Owner: MR.PEMENTAL Date of Inspection:11f12198 D]SYSTEM FAILS(continued) Yes No x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — x Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. — —x- Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No x the system is within 400 feet of a surface drinking water supply x the system is within 200 feet of a tributary to a surface drinking water supply _ x the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. C (rovlsed 01I17)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 8 ANSEL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25 Owner: MR.PEMENTAL Date of Inspection:11112/98 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _X_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x — As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. 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 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 8ANSEL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25 Owner: MR.PEMENTAL Date of Inspection:11r112198 FLOW CONDITIONS RESIDENTIAL: Design flow: 3W g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): Yea 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): nfa Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:U gallons/day Grease trap present: (yes or no) ye Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no)-to Water meter readings, if available: nra Last date of occupancy: nra OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS LAST PUMPED IN JUNE BY BORTOLOTTI System pumped as part of inspection: (yes or no)No If yes,volume pumped:U gallons Reason for pumping: Na TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no).( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(if known)and source Information: SYSTEM WAS INSTALLED 15 YEARS AGO,PER 83-MT Sewage odors detected when arriving at the site:(yes or no) No (revlsed 04I27M7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 ANSEL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25 Owner: MR.PEMENTAL Date of Inspection:11r1219s SEPTIC TANK:x (locate on site plan) Depth below grade: 2' Material of construction:x concreate_metal_FRP_Polyethylene—other(explain) If tank is metal, list age rda . Is age confirmed by Certificate of Compliance Nc (Yes/No) Dimensions: Le'6"H6'7"W4'+0" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness:+" Distance from top of scum to top of outlet tee or baffle:OVER Distance form bottom of scum to bottom of outlet tee or baffle:rda 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 SYSTEM EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: rda 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.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 2'6" Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction Iine:7OWN Diameter: rga_ Qmments: (conditions of joints,venting,evidence of leakage,etc.) (revlaed 0412797) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 ANSEL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25 Owner: MR.PEMENTAL Date of Inspection:/1112198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Capacity: nla gallons Design flow: Na gallons/day Alarm level:_nia Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) roe DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ve: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) rda (revised 04l2M) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S ANSEL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25 Owner: MR.PEMENTAL Date of Inspection:11112199 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: rda Type: leaching pits,number: 1000 GALLON LEACH PITS leaching chambers, number:rda leaching galleries, number: rda leaching trenches,number,length: nla leaching fields, number,dimensions:n1a overflow cesspool,number:nla Alternate system: rda Name of Technology:_rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING,THE LIQUID WAS OVER THE INVERT INLET,PIT IS IN HYDRAULIC FAILURE. CESSPOOLS: (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: Tva Depth of solids layer: rda Depth of scum layer: rda Dimensions of cesspool: Na Materials of construction: rda Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda PRIVY: (locate on site plan) Materials of construction: We Dimensions: rda Depth of solids: rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda (reylead 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 8 AN8EL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25 MR.PEMENTAL 11112198 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) its S�f•Q rsYiM �'a 6 O C O Ag lit A( C7 8�ay (revmed04127197) Page 9 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 8 ANSEL HOWLAND RD.CENTERVILLE MAP 172 PAR 225 L 25 MR.PEMENTAL 11112199 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 your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revised0027197) page I0 of 10 p....gJ................ ©......t...... �l THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALjH ...........OF................ ............................ ..... ........................... Appliration for Uiiipoottl Works Tonstrnr#inn jJrrmit Application is hereby made for a Permit to Construct ( ) Repair ( ) an Individual Sewage Disposal System at: I�" ; 2 4f��" ............... .... ................ � V' ........_.. . ...... ..... .. . ocatio - ddress �� or�LotLNo. .................�. ... .............................................. ='!-�=�......'!� �!... ........._......... wner °.. Address W •-------------•-- �� ..............------•-----. ----------- Installer Address �^ dType of Building Size Lot.......... .f..v.G-` O.Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .. , ........ ................. ..... . W Design Flow............... ..._...gallons per person per day. Total daily flow.._...."Zjh..v................gallons. WSeptic Tank—Liquid capacity.._ gallons Length................ Width................ Diameter................ Depth................ 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........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•----------------------------------------------------------------------------••-•-......••-••--•.......................................................... 0 Description of Soil........................................................................................................................................................................ x U ----••••-•--•---------•------•......•................•------•------._...-----......------._...--•••.....-------•-•-•-••--...---•------•---•--•-•-------------------------------...........-------•---•-- 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 TITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is by the e�,ard of health Application Approve -:: .. - -------- Date Application Disappro d for e following reasons:....................................•-------------------------•----------------•----------=-------•--.....•----- .....................•-----....--•-•-----•--•------....._..........------------.................--..........................---......•-•---••--------•••-•••-----••• --------.... ----•---•--- Date PermitNo......................................................... Issued-........................................................ Date �. �,.— ----------- Fss....... THE COMMONWEALTH OF MASSACHUSETTS I ' iBOARD O !-IEA TH a' .............OF...........((,j,.G ' g `......: ......................... Appliratiou for Uiipniittl Works Tonitrnrtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ............... .. ._=:-:-:-. ............... '....... .............n• .------•--•-----•-•---................. Address or Iotiodi%.;io ........................................... !� ............................... �Dwner — � -Address ...................... ......... .......................... ............... ...........................................Installer Address Type of Building �2 Size Lot.... ...�..+ . ` Sq. feet Dwelling—No. of Bedrooms.._...V....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures --.. _ W Design Flow...............4- --------- gallons per person per day. Total daily flow...... ...............gallons. WSeptic Tank—Liquid capacity- .-gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ...y............... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....4_...-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) PercolationTest Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------------------------------------------------------•-............._......................................................... 0 Description of Soil......................................................................................................................................................................... x U ----------------------------------------------------•---------------.........----.....-----•------......---•-------------...----•--------- w P.f' UNature ofWRepairs or Alterations—Answer when applicable............................................................................................... ----------------------------•-------------------•--------------•------------•---------------.._.....------......•-----------------...----.............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE; 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is Grp by the b rdfof health. r�^"` i r gned.. ��f ,t y'� r Application Approve i M .` .D�� Date Application Disappro d f or,,, a following reasons-----------------------------•-••----•-------•----.......----------------•------•---------- --..._.......-•---- ._----------•....................................... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of Tamplittnrr T IS...... O CERTIFY, That the Individual Sew...age Disposal System constructed ) or Repaired ( ) -� y� w...........................� ................................... Ins ller at.....-- --��'---••-----. .`-•------ --------------- .......------.....------.........---•----------•---..... ---- -------- has been installed in accordance with the provisions o I F 5 f he State Sanitary Code desc 'wed in the application for Disposal Works Construction Permit N o.-__ ._. _.'...& . ......... dated---.. .,�! `�,,�......_..... THE ISSUANqX OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL / N ION SATISFACTORY. DATE.... �� ..I! . ----------------------------------------------- Inspector..... THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH N ...........................................OF..................................................................................... FEE: U........... Roposal Morb Tontrnrtion Permit Permission is ereby grante ----.• S'e......--�--•--.---P---------- --------------------------------------------------------------------------- to Construc or pair an Indivlrtl al- wa e Disposal System at N Street as sho/onappli ion for Disposal Works Co �Efuction Permit No....._.... ::___.... Dated.. � .. �............ Boa dof Health DAT .�-� \\H FORM 1255 A. M..SULKIN,-INC.. B05TON j �,1►.1 G LG- F A M L Y - ;S G o R o M 7:S• iI 1,1�'� GAR�AGE (�Q�1.1DEQ. ! �• II Dn�;LY FLovv z Ito X 3 = 73oG•PP jEPT1G TA►.1K = 330x15D% = /-�9 %G.F? R �^ �j21Z � �q : i� U$t= l000 GAL. o1,5Po5AL PIT v5E 1000 6AL. .j m (�j 150 5.F x 2 5 - 375 G.Fc 7r4 50TTOM � -T oT A L_ D E S 1 G N = .4-2�7 6.R D. P��N� li -TOTAL. RAIL-Y F�ov! jj PE2coLATio�1 RATE c I''iN ZMIN o�LE55 i Q IQ M) Cp !i o 20o� �a,A.tadi � �P Ur 6/'js 1( �N Of Mks RICHARD �l. o ALAN � b +f A. W. I I�1 vC.� fJ�IS BAXTER v o ONES " 24048 o Q U o. 25 ~— suWO F� I AL I� To P FWD -- ' NoLI -Iogl eo0 !' �S G, r.. N'i` ' ^ Imo• SCo•D � yr LOAM 10 o0 IN\J• INS. G 55.$ SEPTIC 2 I 000 INS• r 5>'•L TANK � L.EAGu PIT ANY. iNY. �� w�Tu _S�.Z. 5�•�- I� �p vJAS�160 v 670 N E C LOT Pi-A" i PRar-IL G- o 4A- I o N C'�' �145 I.L 1.10 SCAT E SCALD AT "T N� t-Oc.V �:1T1 OIL 511a 4YN I �{E.REO► 1 GOMPI.`(5 YJITN`THE Slo6llt1 � I �� A►.1D 5>=TE�GK 2.6QUIQ-1=MENT� q� -C1-�� `�T (a W N p t~ R-►�1zTA3t.�3 a N 1 S IIo7" l'� 3 �6 � LOGp.TED WITNI�I T E FLooD -PLAIN �L • D AT E- LL — j, REG 15�626•-D'LAW D S u ev EYoeS "TUIS PLL�t�1 I �j NClT an5r_r� Old AN OSTE2VILLZ- UtAaW7F Sv2vey -TN4 oI=F`SET5 5uouLD DTd C7ETERI^IN. _L.o� LINE APPLICP.►-1T i I I w ASSESSORS MAP • 11�.- NOTES: TEST . HOLE LOGS r+�tertii�� PARCEL : 1 THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH a t �p sr ► FLOOD ZONE : 00tl �{��'..*1�� SOIL EVALUATOR : D. Me�'-�' R.S., C.��. - -THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF ,qQ � W N .I- itl—�-�--�� Al2Njt.,�, BOARD OF HEALTH REGULATIONS. WITNESS : ii, (? - i REFERENCE a. BI ' l� DATE : LT =�- qo—q 2) THEINSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLATION RATE 2,MlrJ SEWER ` INVERTS AND SEPTIC COMPONENTS PRIOR TO INSTALLATION. CL <, Sate.. 0.7 y / Y" o`� $fit SUILVIf (� FE Nl, FL—" or TH- I TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION t ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE Nyel A G, S&W,{ DETERMINATION. i �. J i _-----�,_.----._w � � 4) ALL PIPING TO BE 4 SCHEDULE 40 @ 1/8 l FOOT.. (UNLESS t - - LOAM SPECIFIED OTHERWISE) _ i MAP / 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A LOCATION C N �� (0� Sf GARBAGE DISPOSAL. M t U 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON S C A BASE OF 6"OF CRUSHED STONE. Z.Sy 7 - tTM c� 5r lJ Mo f� fi _ 5r1 , �/ -P by No W 0 e�5cP vco 1 o P t+�lO ISO' pp-op, l.�Rlw-ttiN _ -_.. _ _.. _ . .__._.. ____ ._... f 99 v W �r i s - �--o P E1TL> t or S PTI C SYSTEM DESIG E E N FLOW ESI 1 MATE �T a I k Utz 4g if Nance 2 BEDROOMS AT I ID .GAL/DAY/BEDROOM - �3� GAL/DAY �t A NSEL HO WL A1�1D ROAD SEPTIC LANK EDGE OF PAVEMENT !� -4M— — ) C) GAL/DAY x 2 DAYS GAL USE / OLDSGALLON SEPTI C TANK — =k/d7nJ � ' t � 1 124.73 ft \ $ �,-1Ni tr Fttsh SOIL ABSORPTION SYSTEM �4 - o , J T 2 1 ! A RFA 15006 Sr �- s l DE .AREA:�f C � � IK i BOTTOM AREA: O x (0 k _ D.1�l " \ 3 62 .�. SEPTIC ; SYSTEM SECTION � . EXISTING ' fT- 4/8-DWELLINGFNDN __N TOP OF } i co �.m ,. EL 63.55 / p w/,�, A �, .�--; Iq i t h MAK iD LE/ .! o / ( '`j GAL D-BOX 5 , .to1 _ I t_ t1 S tza ---- SEPTIC TANK ! 1 x� n SO _ Df3- as�Qo sHEfl 301 BENCH MARK 30Lx16 2 f t TOP OF DRAIN GRATE ELEVATION - 59.86 or- S o.7d 62 USGS DATUM ASSUMED r � OF Mq s-9 �3 PLAN �— o D N SITE AND SEWAGE PLAN i SCALE: n MEYER LOCATION : Ns �. rur� f N aTE '� No. 1140 (: A4 PREPARED FOR t� �.. 0 3 DARREN SCALE : M. MEYER, R.S. 43 VINE STREET DATE : !v zylp�f a w o DUXBURY, MA 02332 w DATE HEALTH AGENT (781) 585-0293 Z i i