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HomeMy WebLinkAbout0064 ANSEL HOWLAND ROAD - Health 64 ANSEL HOWLAND RD., CENTERV. 7/1C'�lQ.© UPC 12534 ' No, 2 � �cs,.co�5°��F HASTIM, MN r Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 64 Ansel Howland Rd, Centerville, MA 02632 Property Address W Eugene T Young Owner Owner's Nam o information is required for every Centervillee _ MA 02632 _ 2/3/2017 page. City/Town State Zip Code Date of Inspection Un Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms /' /-J7 1 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Joseph M Martins use the return Name of Inspector _ key. Accu Sepcheck _ reb Company Name 17 Northside Dr_ Company Address South Dennis MA 02660 CityrFown State Zip Code 508-385-5891 _ S1147 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ ___ ✓_ _ 2/3/2017 spector's Signature _ Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address _ - Eugene T Young Owner Owner's Name --- ---- ..._ _------.. --- -- -- information is Centerville MA 02632 2/3/2017 required for every _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: PUMPING RECOMMENDED OF SEPTIC TANK AND SEPTIC TANK OUTLET COVER WAS REPLACED BY INSPECTOR. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3t13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young Owner Owner's Name information is Centerville MA 02632 2/3/2017 required for every _ page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a.salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form u 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young Owner Owner's Name information is Centerville MA 02632 2/3/2017 required for every .. page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has aseptic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a.private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow t5in5-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts _- --- Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young Owner Owner's Name information is Centerville MA 02632 2/3/2017 required for every — _ page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or El ® tributaryto a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t 15i—•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form " b W a Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 'r 64 Ansel Howland Rd, Centerville, MA 02632 _ Property Address Eu eg ne T Young ___._ Owner Owner's Name _.._ -- ----_- —._ ---- ---...--_--_-- _ information is Centerville MA 02632 2/3/2017 required for every _— _ _ page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): _3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5in5•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address - Eugene T Young _ Owner Owner's Name -- -N information is Centerville MA 02632 2/3/2017 required for every _ _ page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK EXISTING , DISTRIBUTION BOX , 4 SETS OF 4 HI CAP INFILTRATORS 11X25X0.8' GRAVELLESS SYSTEM Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 194 — 9 ( Y 9 (gp ))� Detail: 2015: 80,000 G 2016: 62,000 G Sump pump? ❑ Yes ® No Last date of occupancy: 2/3/2017Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): — — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — 15ins 3l13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young _-- Owner Owner's Name information is required for every Centerville MA 02632 2/3/2017 — _.___..._._-._..._....__.._.— page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: _LAST PUMPED 412014 PER BWWTP _ Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? ------_____._.._....._._._._.._..._Y___-......._......-_......-..--------...---------.---......._-- Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): [Sins•3113 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 ........_..._...._.......------------....................-------'-_.._-._.........-...-...._.._._-.........._... .-- ---._._._._,.-_...._..__._._ _._.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young _ Owner Owner's Name information is Centerville MA 02632 2/3/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: SEPTIC TANK IS 28 YEARS OLD. DISTRIBUTION BOX AND LEACHING 3 YEARS OLD INSTALLED IN 2014. PER BARNSTABLE HEALTH DEPT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: -2 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): - --- - >10 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): OK NO LEAKS Septic Tank(locate on site plan): Depth below grade: 1 ---- feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: &5X6X5 1000 G 8" Sludge depth: --- 15ins•3/13 Title 5 Official.Inspection form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts _ - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments «„ 64 Ansel Howland Rd, Centerville, MA 02632 Property Address -----------------------_—.�..-�_._._----------- Eugene T Young Owner Owner's Name information is required for every Centerville MA 02632 2/3/2017 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26 Scum thickness — Distance from top of scum to top.of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? CORETAKER _— Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PUMPING IS RECOMMENDED AS SOLIDS ARE 20%OF TANK VOLUME. HAS PVC INLET PIPE AND PVC OUTLET TEE. LIQUID LEVEL IS 48"AT OUTLET INVERT. NO EVIDENCE OF LEAKAGE. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain). Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 6 Official Inspection Form!Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young _ Owner Owner's Name information is Centerville MA 02632 2/3/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A- Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ---- — Capacity: gallons - Design Flow: - ------- gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date — Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts --= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young Owner Owner's Name information is required for every Centerville _ _ MA 0263_2 2/3/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert AT OUTLET INVERTS 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.): HAS ONE PIPE IN AND 4 PIPES OUT . HAS SPEED LEVELLERS AND FLOW DISTRIBUTION IS EVEN -----------------— ---- — Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5in5•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young Owner Owner's Name — information is Centerville MA 02632 2/3/2017 required for every _ _ page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number.- ® leaching chambers number: 16 ❑ 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.): OBSERVED INSPECTION PORT: DRY AND SOIL IS CLEAN. GRADE TO SAS BOTTOM IS 5'. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration N/A Depth-top of liquid to inlet invert Depth of solids layer ---- ---- Depth of scum layer -- Dimensions of cesspool ------ - Materials of construction - Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts -� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young Owner Owner's Name — -- — __ --- ----_.--_----__-- information is Centerville MA _02632 _ 2/3/2017 required for every _ page. Cityrrown —� _ State Zip Code Date of Inspect- ion-D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: N/A — — Dimensions - -- --- — ---- Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•M3 _ Title 5 Official Inspection Form:Subsurface Se vage Disposal System•Page 14 of 17 Commonwealth of Massachusetts — -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address Eugene T Young _ Owner Owner's Name information is Centerville MA 02632 2/3/2017 required for every C page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately LA) O Z D is r � f 3 � 2�j131 ��1 7a-; P°R1' � = g i /UTS -- 1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 R Commonwealth of Massachusetts 4;l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 ?roperty Address Eugene T Young Owner Owners Name information is Centerville MA 02632 2/3/2017 required for every - — page. City/Town State Zip Code Date of Inspection `J. System Information (cont.) Site Exam: ® Check Slope ® Surface water Check cellar ® Shallow wells >11.9 Estimated depth to high groundwater: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) t� Accessed USGS database -explain: CCC groundwater contour map You must describe how you established the high ground water elevation: DESIGN TEST HOLE ON 216/2014: NO GROUNDWATER AT 12'.AT ELEVATION 55.9'. GRADE TO SAS BOTTOM IS 5'. NO ADJUSTMENT USED IN DESIGN. CAPE COD COMMISSION GROUNDWATER CONTOUR IS 36'WITH A MAX RISE OF 8'. SEPARATION MATH : 55.9- (36+8+5)=6.9 Before filing this Inspection Report, please see Report Completeness Checklist on next page. ISM 3113 Title.5 Official lnspecdon Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Ansel Howland Rd, Centerville, MA 02632 Property Address — Eugene T Young Owner Owner's Name information is Centerville MA 02632 2/3/2017 required for every _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection.Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Lb CATION E W A G E PE RMIT NO. Y•ILLAGE n hl--,e -7— aU, �-- INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED 6 DATE COMPLIANCE ISSUED-,, © T ' 3c0 .42 1� 1 TOWN OFF LOCATION: S " �1> VILLAGE:Q=L JI f LOT#: .P RMIT#: Z oI eA,4z&a� o C�,(V INSTALLER'S NAME: INSTALLER'S PHONE#: � LEACHING FACILITY: (type)& �J CA -7"AfY (size) !l• � k'Z,:�' NO.OF BEDROOMS: BUILDER OIlj�: PERMIT DATE: COMPLIANCE DATE: DRAW DIAGRAM ON BACK fl O gg �� COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION �/� Property Address: 64 ANSEL HOWLAND RD CENTERVILLE, MA 01632 M172 P230 L01 Name of Owner RITA MCLEAN Address of Owner: 64 ANSEL HOWLAND RD CENTERVILLE,MA 02632 Date of Inspection: 11/6/00 O� Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15,340 of Title 5(310 CMR 15.000) "? �6 � Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 OOP Telephone Number: 508-564-6813 FAX 508-564-7270 ` CERTIFICATION STATEMENT 4 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails '#zs Inspector's Signature: Date:11/7/00 The System Inspector shaliesystem copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.RECOMMEND MOVING THE BUSHES THAT IS GROWING NEAR DISTRIBUTION BOX TO PREVENT POSSIBLE ROOT DAMAGE revised 9/2/98 Pape 1 of 11 1 \� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P230 L010 Name of Owner RITA MCLEAN Date of Inspection: 1116/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion o the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances. If"not determined",explain why not. n/a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n& Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced n/a 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 k1 �t Kilrf , y revised 9/2/98 Paqe 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 ANSEL'HOWLAND RD CENTERVILLE, MA 02632 M172 P230 1-010 Name of Owner RITA MCLEAW Date of Inspection: 1116100 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I: NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within.50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. t . _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, F, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n/a (approximation not valid). 3) OTHER nla i SI SkI e�, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P230 L010 Name of Owner RITA MCLEAN Date of Inspection: 11/6/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each Pf the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No - X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. - X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. - 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).Number of times pumped n/a. 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 I of a public well. i(� _ 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. ,t 0 E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: It 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. Ile ll.;, revised 9/2198 Paoe 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 64 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P230 L010 Name of Owner: RITA MCLEAN Date of Inspection: 1116/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X - Pumping information was provided by the owner,occupant,or Board of Health. X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. 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. X - 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.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. ittt , ifi'SW it} tl =t revised 9/2/98 Paoe 5 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 64 ANSEL,HOWLAND RD CENTERVILLE, MA 02632 M172 P230 L010 Name of Owner RITA MCLEAN Date of Inspection: 1116100 FLOW CONDITIONS RFSIDFNTIAI Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):PM Is Total DESIGN flow: 330 gpd Number of current residents:1 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAIJINDLISTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:nla !.:. 1�) OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1982 g`A Sewage odors detected when arriving at the site:(yes or no): NO �f 'I revised 9/2/98 Paoe 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P230 L010 Name of Owner RITA MCLEAN Date of Inspection: 11/6/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 12" Material of construction: _ cast iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 6" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10 Sludge depth: 2" Distance from top of sludge to bottom of odtlettee or baffle: 32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.) . 1, THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: ; i, (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) n/a i revised 9/2/98 Paoe 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P230 1-010 Name of Owner RITA MCLEAN Date of Inspection: 11/6/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_.metal_Fiberglass _Polyethylene _other Explain: n/a t .l Dimensions: n/a Capacity: n/a gallons iu;r Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.RECOMMEND MOVING TREE NEAR D-BOX TO PREVENT POSSIBLE ROOT DAMAGE. PUMP CHAMBER: _ (locate on site plan) Vu;a Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: t! (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a ` fit i •.ty revised 912/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P230 L010 Name of Owner RITA MCLEAN Date of Inspection: 1116/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND,AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD V OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN I'OF WATER IN IT. CESSPOOLS: — (locate on site plan) 1 . Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a f Depth of scum layer. n/a I Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a t f; Comments: 1`'I (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 ANSEL HOWLAND RD CENTERVILLE, MA 02532 M172 P230 1-010 Name of Owner RITA MCLEAN Date of Inspection: 11/6/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) L5[,qb Lo.l� D 0 C O, /k 3` Ab 41) i 43 All revised 912.198 n ,,., � Town ©f Barnstable �t�THE ram, Regulatory Services 4y 9• h �'P Richard V. Scali, Interim Director + BARNSMBLE, ' 9 MASS. Public Health Division i639' �� AjF%6,59 ' Thomas McKean, Director 200 Main Street,Hyannis, TVIA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Desiener Certification Form ' q p X Z 5� Date; �` ®I Sewabe Permi#4 s Assessor s 14Ia �Parce Designer: Installer: ZOD 6_"4p_� Address: �i,l —,� IU Address: V � v On �b �60� was issued a permit to install a ( ate) (installer septic system at Cj � ��>���® ��� based on a design drawn by ( ddress) dated /l (designer) _Z1 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in com fiance with the terms of the a rov 1 tters (if applicable) `�^ ' DAVID s' le ' 'mature) r idc.1066 A. si 's Signature) (Affix Desib dip Here) PLEASE RETURN TO BARNSTABLE PUBLIC D UNTIL Bfl TH IS TES PORN1 AND AS- OF COMPLIANCE WILL NOT BE IS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc r Town-of Barnstable °FINE r Regulatory Services ti Richard V. Scali,Interim Director BASZAs Public Health Division 9 MASS. g �'ArE0 3+ADO Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Systems Property Address: # 4Kk�_ ` Assessor's Map\Parcel: -`� 1 72 1#2W Property Owners Name: OLWYzk r In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an "x" in the applicable box next to each line certifying the information. Yes ❑ I have been provided a copy of the Title 5 UA technology Approval letters. �, 1 page Standard Conditions letter and the specific technology letter) Z ave been rovided with the Owner's Manual pave been provided with the Operation and Maintenance Manual IJ For Systems installed under a Remedial Use A fill my Ely Approval, I agree to fulfill responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) �nd the Approval El5 For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) ❑ If the design does not provide for the use of garbage grinders, the restriction is understood and accepted /El Whether or not covered by a warranty, I understand the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303 I , 'PA u L F. -0 A L L 0 2 A N agree to comply with all terms and conditions above. Property Owners printed name Property Owners Signature Date Note: This form must be submitted along with the septic s stem disposal works permit application for all I\A systems including new construction, repairs\upgrades, with and without aggregate (stone) and with conventional design criteria or credited design criteria. Q:\Septic\IA homeowner certification.doc No l `_ V Fee 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for Misposal *pstrm Coustrurtion Permit Application for a Permit to Construct(4-' Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No e• Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ?� ZV �j7 �It�/�G/ 4VI4 J�p- Installer's Name,Address,and Tel.No. 444,yAG ,4 Designer's Name,Address,and Tel.N o-3?4Y.,0 AF0177 marital� C���� �'�j�g ��BOG`� �� �"iV�l i,�P��V I'�eN't►?�Q— ��j— �17 7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3�'O gpd Design flow provided gpd Plan Date zo—Y Number of sheets Revision Date Title Size of Septic Tank /Oa® 96 C-, Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -d e t�"le D. ^ i 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 Envi nment ode and not to place the system in operation until a Certificate of Compliance has been issued by this Board eal Si d 9 Date Application Approved by - Date��/o�Za I y Application Disapproved b L_VDate for the following reasons Permit No. 2DI L( 0 IG — Date Issued -71 j°tom C q ` l No. C.�®l� — O - :'` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for loisposa! 6pstem Construction Permit Application for a Permit to Construct(L-y Repair(�j'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 9 W6• Owner's Name,Address,and Tel. Assessor's Map/ParcelW,/ �Z l�y(/,SC/ I&V10110 Av- Installer's Name,Address,and Tel.No ah/ 4M74.i/ Designer's Name,Address,and Tel.No. 1.2,fy, ��f bJ�-A, ���Di�Ce1� �o�Si � �!��M4 �/ZG—/Z9Sf �C CNVi�PG✓L/°�PA7/ILS��- �',�� �177 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building - No.of Persons Showers( ) Cafeteria'( ) Other Fixtures _ Design Flow(min.required) 3�3 O gpd Design flow provided �j�� gpd Plan Date A Number of sheets � Revision Date Title � / Size of Septic Tank /Oav 9t C ' Type of S.A.S.lb i Q/( rQ,i7�i s' -i, �„' ,'/,T�'Al- I%S Description of Soil 't '4 - r Nature of Repairs or Alterations(Answer when applicable) 4,d, T 4. 4jr i,n���TC A Date last inspected: Agreement: I The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in q accordance with the provisions of Title 5 of the Envi nment ode and not to place the system in operation until a Certificate of Compliance has been issued by this Board eal Si d -. Date��/u f/ Application Approved by Date!60/Z" y Application Disapproved b Date for the following reasons Permit No.201 L( _ D 67 Date Issued J41°rzo f q THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed ) Repaired(✓) Upgraded(✓) Abandoned( by L14,e$Ql 4c ,U t,< C Q f I1 at h�/ A, �eA,1A a!O �h. has been constructed in accordance with the provisions of Title 5 and the re, sposallSSystem Construction Permit No.3 I y- d� dated 3I t/ Installeq iN/O( 6,?f1 '(_q�D�r2r/ Designer / / #bedrooms 3 Approved design ow ?j Sc> X Jin gpdo� The issuance of this permit ha not beI;Izk nst ed as a guarantee that the system wil nct•• fs to. IC Date Inspector V -------------------------------,------------------------ ---------------- -----=--=-- =--------------- -------------------------------- No.20I (' — Qb-?_ Fe4 /00 THE COMMONWEALTH OF MASSACHUSETTS / PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction J)ermit Permission is hereby granted to Construct( ) Repair(✓) Upgrade Abandon( ) System located at(1 )A-_/ LAA1-f MCA ed and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions oispecial conditions. Provided:Construction must be completed within three years of the date of this permit. :j Date 110 I ZO I t-� Approved by ycff,tt�rkj,� Town.of Barnstable �y Department of Regulatory Services Public Health Division Date M.A93 .639• ��� 200 Main Street,Hyannis MA 02601 rya nnt.�A Date Scheduled, d f Tune Fee Pd. Soil Suitability Assessment for Se e Dis o y n Performed By: Witnessed By: r. / I,®Cr�7CION�i (i]E+NEA�LS.I,IlVI��JI�1V$.E TION Location Address 6 V ,4�el,_14,/411� A*m Owner's Name /1Q11GQ'./ij �'V WT U w Address �� '.QTi��� Assessor's Map/Parcel: 30 Engineer's Name-peyi o NEW CONSTRUMION REPAIR Land Use Slopes(96) Surface Stones Distances from: Open Walser Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SJUJUM:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands fu proximity to holes) da.a Gv.. f A Nc LL_ V k Ll © N I ' Parent material(geologic). Depth to Bedrock, Depth to Groundwater. Standing Water in Hole: Weeping from Pit PIICe Estimated Seasonal High Groundwater A :AVAVaWA JOT 0R SEAS O.t V A AA.11GHY W V NA 1 ER 1d,.t B LAE Method Used: Dephl nbscrved sG nd,ng I. ub5.' e: In, Depth to soll mottles: Depth to weeping from side of obs_hole: In, Groundwater Adjustment ft. Index Well# Reading Date: Index Well]raver _ Act,flactor�mae•, Adj.C)rtlundwater Levol R s y� PEI R,COI.,ATI.O 1 TEST bate Thum Observation- _%i" � / Hole# Time at 9" Depth of Pere a� Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./luch � Site Suitability Assessn,eht: Site Passed Site Palled: Additional Testing Needed(Y/N) 'b'Sl•- Original: Public Health Division Observation Hole Data To:13c Completed on Back----------- ***lf percolation test is to be conducted within 100' of Wetland,you ni>ust first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\.SEPTIC ERCPORM.DOC DEEP.OBSERVATION DOLE LOG -Hole# Depth from Sall Horizon Soil Texture .Soil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. onsi§tency,%orayel) l/ ► �, — loo— DEEP 013SERVATION HOLE LOG Dole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% r el 17 h '11/77 DEEP OBSERVATION MOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in-) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cut,Ststo cy,%OraVOD I DEEP OBSERVATION HOLE LOG bole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Ca n s' ten o v.96.Q r�g� ri Flood Insurance hate Map: Above 500 year flood boundary No es Within 500 year boundary No_,�es Within 100 year flood boundary No� Yes ]depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious at rial exist in all areas observed throughout the area proposed for the soil absorption system? If.not,what is the depth of natur lly occurring perv' us material? Certifiication I certify that on (date)I have passed the soil evaluator examination approved by the Department ofEnviro mental Protection and at the above analysis was performed y me consistent with the required training,expertise an c d cribed in 10 CMR 15.017. 1 Signature Date G 1 QAS LPTIC�PRRCPORM.DOC s THE COMMONWEALTH OF MASSACHUSETTS BOARDX�� HEALTH ..A- 6.................OF...... ............................. ApplirFatiun for UiipuuFal Morks Tunitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........ ocation-Addre s o No. -_. wnez Address ----------� =e --------------------------------------- --------------- ------- -------- Installer Address d Type of Building Size Lot... _._Sq. feet U Dwelling—No. of Bedrooms..............3............................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria Q' Other fixtures ___________________________________ ______ W Design Flow....... _.2�_.,....................gallons per person per day. Total daily flow............. C1_................gallons. WSeptic Tank—Liquid capacit/�4 ----gallons Length................ Width................ Diameter----------------- Depth................. x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._ , '' '--__ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest 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........................ a ------------------------------------- •-•---------- •------------------------- ------------ ---------- --------------------- •---------- __------------------------- Descriptionof Soil..................................................................................... -------------------------------------------------------------..._......-----•••--- x W UNature of Repairs.or Alterations—Answer when applicable................................................................................................ ----------------------------•------••-----------------------------------------------.................-••--•--•-•---•-----••-•••---•-•-•---•••••-----•-••••••........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTTY-E 5 of the State Sanitary Code—The undersigne,0 further agrees not to place the system in operation until a Certificate of Compliance has beeAie by the,boardO health. Sign � D Application Approve/.. -•--• -••-••------••••-•__---• ---/-'.-=.3 �-------- Date ApplicationDisapp owing reasons----------------------------------------------------------------------------------------------------------•------ --------------•------------------------------------------------------------------------ Date PermitNo......................................................... Issued_....................................................... Date � 4 No.4 -�;5 r a-- Fims.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .....O F........................................•---------------------------.-.._.-..-..._......_. Appliratiun for Biupusttl Workii Tomitrurtion firrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................---......_..................................................................... -......_....--------------..........---------------•-•---...................-..................__. Location-Address or Lot No. •--•^-•..............-----•---..-........-•-•----....--------•••---------......--•••••--------.. ..-•-....----..............._..._....--•-•--•-------•--•-•--•---•----^-----...................--- Owner Address ------------------•-----------•---•--•--.....-•---••----•----....._....-•--•--------•--••--------- ......_..--•----•--..._.._....-------•-------.............------...--•---------•--•--------------- Installer Address � Type of Building Size Lot............................S q. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria 04 Other fixtures -----•-••--••------------------•----•---------------------•---------•-•------------------•-•-------------•--------...._......----------.._.......---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter-------------___ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..........:.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water______________________.. G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•---------------------------•-----------•------••-------•------------•---------------------------......................................................... ODescription of Soil..............................................................................................................._....................................................... x U -----------------•-•---•-----••----._........---•---•-----•----•---•-----•-----...._.._.......-•••--.._..-------•-------•--•---------------•----•-------••-------------•-•--....-----...---------••----- W ----------------••-------------------------•----------•-------...-•--------•----------------------------•---------•--•------------------------------------------•-•-•---•--..._.._..-------------------- VNature of Repairs or Alterations—Answer when applicable................................................................................................ .................................................-------------••---------------------..._.._.......---•--------------•-------------------•------------•-•--------•-••-•----------------•----•--------•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign ---- --•-•.............. Da Application Approved B Z':.e_:-==-=-=--------•-----------------------------...--••---------•---..._......- ?-3 � Date Application Disappr6 d�fd,•'the following reasons----------------------------------------------------........................................................... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... ,//�J Tatifiratr of Toutpliunrr T"I�YIS 0 C RTIFY, That the Individual Sewage Disposal System constructed �r Repaired ( ) -•--^ _-------- •; -.�_----•- -----••_____________•-•------•------------ at f `� l%lr/ _lit � G 7✓/ ....... ! °_._.-. has been installed in accordance with the provisions of TIe'lZ 5 of The State Sanitary Code s/dcribed in the application for Disposal Works Construction Permit No..____r- 75��________________ dated_-_ j ______.__....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �J� DATE...................................V..4/ _..----•-•-•--...------- Inspector...--' --•-----------------------•-------•--•-------... t THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HE "L/ �� �� ...............OF....... ,3J No._.... ..�...-_------ FEE_______________•........ iu o 1 ku onu#rudiott rruti# Permission is ereby granted.. =L --------------------•-- = ------- to Construc or Repair ( ) Individ 1 $t� e D' osal stem _ r at No. - t -- ------•-- j/ .. ._ . Street �1— -7�Y /�/` as shown on the application for Disposal Works Construction Permit No..................... Dated_._.__.___...__.___....................... •----•--•--------------'.......;, ------............................................................ L/L -J Board of Health DATE.................................... ---...----// ................ FORM 1255 HOBBS & WARREN. 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TEST LOGS _ Huard ot PARCEL: 'rhe ilislalladoll Shall C0111i'.., Willi'l'itle V and 'Fown of I lealth Regulations. FLOOD ZONE: SO I L EVALUATOR: 7W9 Vk�uja ation ul'titilities, sewer inverts and septic 2) 'llic installer shall verify the loc, W I TNES 3 , HErElIENCE: !- components prior to installation and setting imme elevations. Z)Ee-0 rl� f�b7 DATE: ?2 -avity septic pipilig to be 4 inch Sch,10 PVC at 1/8" per libut. 'I'lie first -------- 3) All gi PERCOLAT 1014 RATE: /I two lbet out of the d-box to [lie leaching shall be level. 1 �fJ4) 1-his plan is not to be utilized tior property line determination nor any other Impose o 4!S+jX,7-7— [her than the proposed system installation. F 1 111-2 5) All septic collipollents must ineet'Fitle V specifications. Loll/ 6) Parking shall clot be constructed over I I 10 septic components. 7) 'rhe property is bounded by property cornets and property lines. 8) 'the property owner shall review design considerations to approve or total IF X, LOCH i ON MAP design flow arid number of bedrooms to be considered for design. Receipt of payment I'm the plan and installation based on the plan shall be deemed approval of the design flow by the owner. A- 9) 'I'lie existing teaching or cesspools shall be pumped and tilled with material per Title V abandonment procedures. 'those within (lie proposed SAS shall be removed along with contaminated soil and replaced with clean sand per C) Title V specs. 10)systell, components to be 10 feet firom water line. Sewer lines crossing the - - -- - -- / --- ✓ l� water line shall be sleeved with 4 such SCI 140 -PVC with ends grouted if -7 applicable. 'I'lie proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place.' 11) If a garbage grinder exists it is to be removed and is the responsibility or the /06, C)C> SEPT I C SYSTEM f DES I GN owner to ensure such. 12)'Fhe installer is to take caution in excavation around the gas lime if such FLOW ESTIMATE exists. Y" ( — of the sewer -ielevation�13)'Fheiristallcrsliallvei y.thelocation, quantityand elevation BEDROOMS AT g1 GAL/DAY/BEDROOM 7;:_k�GAL/DAY lilies exiting (lie dwelling prior to the ins(allation. 14)'I'Iiis plati is relnesentative only that a systern call fit oil a property meeting c;EPTIC TA14K 'fitle V tecluitenients. J r_-__/_A_.-'GAL/DAY x 2 DA IS GAL USE 10MGALLON SEPTIC TANK �XJtTP44 4�0�ABWWTJ 401T_WV9_Rl— .� - ��N OF M��,, 1-ILM ,�I40 17 J, DAVID, B. M Sol 'nji N 6 T ' �2 0 1 14-2 �5 CK El r I C SYSTEM SECT I ON &J014tr "D DF 0 �2. hro Ifl (f 417 f) 10, GAL 0 SEPTIC TANK ?c4)?F OF W?uKt -�-� l , Fol Vol Wit y21 _ 12 �_ 7 siTE AND SEWAGE PLAN LOCAT I ON A NOWLA Vq D PREPARED FOR : E)Iwqt CCU, RW SCALE: o , DAV I D B , NIASONF5 DAZE: DBC ENVIRONMENTAL UlEsIGHS -1 . MA EAST SANDWICI UATE HEALTI-I AGENT ( 508 ) B33- 2177