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HomeMy WebLinkAbout0101 ANSEL HOWLAND ROAD - Health 101 Ansel Howland Road Centerville P A = 172 224 OmMb au y UPC 10259 No.Ham_ NAGTINQ•, MN Commonwealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Ansel Howland Road Property Address Frances Bigda Owner Owner's Name information is Centerville MA 02632. 5-6-15 required for every _... _.._..._..._._........._._.___ _ ,_._....__ �.... __.....__ __. page. Cityt'rown State Zip Code Date of Inspec_.tion linspection 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 —__._. 1n filling out forms A. Geti iral ormatfon yr 4;,�,�„t�uirirrrrj�,, on the computer, Yr v� V ��y�t GFhFq Sri�ir� use only the tabJ�- _ y Vey to move your 1 Inspector: _ '• G ; cursor-do not James USears JAML.S ;= usethe return ---.-____._ _.................._..............- _._. .._..... ._ .__� - r.^__...... key. Name of Inspector u L.. Co _ :C Capewide Enterprises LLC . NSg�'r"�������. _ 153 Commercial Street �,rr t Company Address ......__� tViashpee —_ __._... ._ ._ MA _._............_..: _ Q2649 _..... _.__...._.___.._. .:. City/Town State Zip Code 508-477-8877 51623 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 r-vmplete 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. #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 _ d'.. 5-8-15 __..._....._......._....._....._............________ ...._— _ _ .................. _.. ..._. pector's signature Dale 61 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority- ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system wiU perform in the future under the same or different conditions of use. ?�g t;R<es 3rf3 71iH 5 ctfaai l:?&peakm faint:Subsurf ar Sewage alspasat";)Start•Pogo i ut tI G'cl » d _i:;fj q 1 i �e® � Commonwealth of Massachusetts TM µ- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Ansel Howland Road roperty Cdress Frances Biqda owner n.. _r _.— _ �._.... _, �..._.. wne's Name information is required for every Centerville MA." __ 02632 5-6-15 page_ Crtyl[own State Zip Cody - Date of Irmperaion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E J 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 GMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The s sty em is a 1000 GaL Tank D Box and Pit. 8) System Conditionally Passes: 0 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 exfltration 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 El N Q NO(Explain below): I t6drs 3113Tile S of; al lnspevicon Farm;Sub5u^taca Sewage Disposal SyS;em-Faae 2 of 17 d dogl';,,0 9 l 0l Ae4J Commonwealth of Massachusetts Title 5 Official Inspection Fora =s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,m 101 Ansel Howland Road _. .._.........._.._.__........._._.— Property Address __—._....__.�v.......... ____.-- Frances Bigda Owner .......__ .__.... wrler's Name information is required for everCentervilley --... .. __. _.......... ___.._................._....�..x_.._ MA 02632 5-6-15 . ............... _ _. _ ._.�.. ..,. ..............__ page. Cityrrown State Zip Code Date of Inspection B. Certification (font.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ 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 Beard 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)(6)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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•3133 O!fi"'"SPectiOr"l OM:Subsur€soa SeWage❑i&M-M Sys€em•Psg®3 of"7 f d d£9•c�0 c 6 0 l� I a , Commonwealth of Massachusetts _- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 101 Ansel Howland Road _....._....__�_ —._.._ -__._ _..__.............____...._.___.__.__..._.. _..._._.v__............ Property Adtlress f rances ai da CCtwner -- ..........-... 9_ — ........_�._...... _� ..... _ Ovmer's Name information is Centerville required for every _. MA 02632 5-6 75 page. Cityfrown — - — Slate Zip Code late of Inspection B. Certification (cons.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 0 The system has a septic tank and SAS and the SAS is less than 100 fit 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 bEP 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 is less than 6" below invert or available volume is less than Y2 day flow 1°i 7- 4bins°2M T019 S OffkW 115pac60n FOM SUt1-%TlaCe Svxage WSP01,61 SySlwn•Page 4 of 17 d b dEG°l~Q q L O 1. Ar=Ki Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` ry 101 Ansel . —_ ....___ .._......_._._..__..._.......-----__—......... Property Address Frances 8igda Owner ____ __._....:_... _ _.....__._._. Owner's Name _.� information is Centerville requ4ed for every __..__.__.�. MA 026.32 5a-6-15 _._ page. Gtylr`own State zip Code Date of Inspection B. Certification (cont.) —� Yes No ❑ Required pumping more than 4 times in the last year N07"d ue to clogged or obstructed pipe(s). Number of times purarped; ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Ul Any portion of a cesspool or privy is within a Zone 1 of a public Well. ❑ Ill 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 altrogen and nitrate nitrogen is equal to or less tharr 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 of2000gpd- 10,000gpd. ❑ ® The system fails.i have determined that one or more of the above failure criteria exist as descn'bed in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Wealth 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 20C feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—11NPA)or a mapped Zone it 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 CMF2 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3!^ "fine 5 official lnspscnm Fain suosurfece savage Disposal symem•pege 5 of 17 d dbg:Co g t Ol item i f�� Y Commonwealth of Massachusetts: V r Title 5 Official Inspection Form .._. Subsurface Sewage Disposal System- 9 rn !~orrr► -Not for Vol untary Iunta Y ry Assessments 101 Ansel Howland � o and Road _ _......._..__.___......._._._..__ _Property Address .............__...,. ..... —.._....--- _.... __........__.....__, Frances Bigda Owner Owner's Name _.._..._.._.._ _. ._.r information is required for every Centervilie MA 02 . ................ _. 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 E [_.: Pumping information was provided by the owner, occupant, or Board of Health ❑ 01 Were any of the system components pumped out in the previous two weeks? 9 ❑ 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? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) E ❑ 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 E ❑ Existing information. For example,.a plan at the Board of Heath_ ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CUIR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms{design): Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(foe example: 110 gpd x#of bedrooms). 330 isirs.3113 Td'c 5 Office!Inspection Form:Skk+surtaan Sewage Dis,nosar System+P7g-ii 6 of 17 d dttq:Z0 q L 0 r ejq 'r r Commonwealth of Massachusetts % ,. ✓ -_ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 101 Ansel Howland Road Property Address ��rances Buda Owner -.__ _ _._..... —u. _—.-..-_.._..__......_. --.. ---dwner's Name information is required for every CentervNe.___... __ _�___ �'! 02632_. page. Cityfrown qe-- ateof1.._. ;_C1_.__...�_ _ State Zip Corte Date of tnspedion— D. System Information Description: _._....._ _... The system is a 1000 Gal, Tank D Box and Pit. Number of current residents: Does residence have a garbage grinder? [] Yes 0 No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes M No Laundry system inspected? ❑ Yes, ® No Seasonal use? Yes ,}❑. No Water meter readings, if available Mast 2 years usage(gpd)): 2013-26;OOOGals 2014-25,00OGal's Detail- . _..._ ... Sump pump? ❑ Yes ® No Last date of occupancy: Present _ bate- � Commercialllndustrial Flow Conditions Type of Establishment: _._............__—__..._... ._...._._Design flow(based on 310 CtNFZ 15.203): ______.. _..__..._ GaDoris per day(gpd) Basis of design flow(seatstpersonsisci t., etc;,): Grease trap present? Ej 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: _._..-..._ 'Title 5 G1iHcel fnepeenon Fwm: :sUrfaee 5mva9 e iitaoo5ai.5ys{ont•page 7 of e7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 101 Ansel Howland Road PropertyActdress ........... .......... ............- Frances Bioda Ommer Ovinee,s_.Nam._ .e information is required for every Centerville ...... ...................... MA 02632 5-6-15 page. CQyRcwn State Zip Code Wile of Ins on D. System Information (cont.) Last date of occupancyluse: .............. Date Other(describe below): 1-1-1...................."................ ........ ............. ................................................................ ...................--.—............. .......... ............ ................. .................. ................. ......... General Information Pumping Records: Source of information: 2012........... ............................ Was system pumped as part of the inspection? [] Yes 21 No If yes,volume pumped: .......... ............ gallons How was quantity pumped determined? .............. ................. Reason for pumping-. ....................--................. Type of System: M Septic tank,distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 11A system by system operator under contract EJ Tight tank. Attach a copy of the DEP approval. Other(describe): .......................... '11166 5 Ohdallnspe�fion Poem:Subsurface SeAmga Uisposal Syutam-Flage 9&t� q d dqg:E0 g 1, 06 AeVj 4 I Commonwealth of Massachusetts sfr Title 5 Official Inspection Form x, -- Subsurface Sewage Disposal System Form -Not For Voluntary Assessments .. 3 101 Ansel Howland Road_ Property Address >=rances ftigda Owner Owner's--Name €ntormation is regoi;Cd Tor every Centerville MA 02632 5-6-15_____.._ page. Cityfrown State Zip Code Date of inspection D. System Information (cant.) Approximate age of all components, date installed (if known)and source of information: 1982 Permit #82-772 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 9 ' Depth below grade, 2 ._� ._- _ _.._... �... ....._ _._ ... teat Material of construction' [� cast iron Z 40 PVC ❑ other (explain): �_.__._ __.._. ...................... ......... Distance from private water supply well or suction line: ....-...—_........._.........._............._ feet Comments(on condition of joints, venting,evidence of leakage, etc_): Peeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 14" _.._ feet Material of construction: Q concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) ._...._.___.........._.....__._ If tank is metal, list age`. years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal, Precast H-10 Sludge depth: Xr t5irs•3113 roe:oRciel 1r'pemon Farm:Subsurface Savage Ots rssa'System-Page 9 of 17 6' - :77- _ - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 101 Ansel Howland Road Prop arty Address ................ Frances Bicida ......................... ............ ............ Owner 0,,Pmer's Name information is required for every Centerville..__.___. VA 02632 5-6-15 page. O1tylTown State date of tnSWCi�6n**­____ D. System Information (cont.) Septic Tank(cont.) 27" Distance from top of sludge to bottom of outlet tee or baffle .................. Scum thickness .................................. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle ........... How were dimensions determined? Asbuilt-Tape scud edge ' Comments (on pumping recommendations, inlet and outlet tee or baffle condition,-structural-integrity, - liquid levels as related to outlet invert, evidence of leakage, etc.).* Tank at working level. Tank and covers at 14'below grade. In and outlet feels. No sign of jPja .................................................... .............................. .........................__... ........................................... ........... ........................................... ............................ ............ Grease Trap(locate on site plan).- Depth below grade: feet Material of construction-. U concrete 0 metal ❑ fiberglass El 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: ......... Dale !Sins 3Jt3 Title 5 Official lilzipeclion Form:Subsuface S&A;age Disposed S V91". •Page 10 of 17 d d9g:p0 9 t 0 1, Aet,%, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn -Not for Voluntary Assessments 101 Ansel Howland Road Property Address Frances Bigda Owner Owner's Name Information Is CERtefVlirB required for every centers MA 02632 5-&15 slate Zip Code Dale of Inspection D. System Information (corn.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene y ❑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 Title 5 OSidd tvpaction Farr 8ubwrtwa sewage Oiepaasi sysum•Papa 11 d 17 a ��' d95:s0 9 1, 0 l,Aew Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 101 Ansel Howland Road Property Address Frances Bigda Owner Owner's Name requir required a Centemifi'e MA 02632 5-6-15 required for every Page. City[Ton Stale Zip Code Dale of Inspechon D. System Information (cont.) i Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 - Comments(note If box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D Box is W"x1V'-1Y'below grade. Box is dean and solid Wone line out. No sign of over loading or solid carry over. PumpI Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): *if pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain why: I t"m'3N3 TOW 5 Midi he Faction.=orm Su6curtt3oe Sawega DicpDSY Systrm•Page t 2 d 17 ZL,d d9g:C09L 0L AeIN Commonwealth of Massachusetts - �- - - Title 5 Official Inspection Farm r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments K y 101 Ansel Howland Road Property Address Frances Bigda Owner . .__-Name.. -__ __..,_. t)wner'.s Nam® _.___ _._..._..,._...__.._�. . informationeicedfor Centerville NIA 02632 5-6-15 required for every _ .._.. .__ __._.-_._......._ __.__._ __._- .,....__ page, Cs y(Fown State Zip Code C7a1e of InspetYion D. System Information (coat.) _._. Type: leaching pits number: �. -.. ... ❑ leaching chambers number: _.___.__..__.......__: ❑ leaching galleries number_ _.._._............ ❑ leaching trenches number, length: -........._.-__._.....____....__.... _ ❑ leaching fields number, dimensions: -- - --------- ❑ overflow Cesspool number: -- Cl innovative/alternative system Type/name of technology' ---....._.............. _. -b ............ Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.),- Leaching is a 1000 Gal.Precast Pit_w/1'stone- Pit and cover at 26" below grade. 30"water in pit w/stain Ifne f'"above wate_�. No sign of over loading or solid carry over, No high stain line. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration _.______.__.______.-......... _____.__..----- Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer _............_............__.................. Dimensions of cesspool Materials of construction - --- Indication of groundwater inflow ❑ Yes ❑ No 16in3•Y13- Ting 5 official subsurlaw suwagH Disp�cu'sysigw•page,3 d 17 t d d9S:00 S l,0 4 As4,,a 1 I - i Commonwealth of Massachusetts i Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Ansel HoWand Road Property Address Frances Blgda Owner Owner's Name information is Centerville required for every MA 02632 5-6-f 5 page. QrWTown state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ms-3113 TMIs 5 olRdsl tsspodcn Fomt Subs gme Swags 040"!SYM&"•P"s 14 or 17 �6`d dZ9:C091, 06 AeN Commonwealth of Massachusetts a _ Tale 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Ansel Howland Road Property Address Frances Bgda _....____ _ _ . ...__ OwnerNa f?wmer's me equirdfor 5 Centerville MA 02632 5-6-15 required tr,r every �._Y _. _.._.......�. ..,__ page. Cityffovrn State Zip Code Date of Inspection D. System information {cost.} 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: Q hand-sketch in the area below J I AMC 04 A 32 a 3 GGAiCft Qta L -y c!S , s!>:5 C)1fiCi91 ktspedonroine sj ibsurfao+Smxaga Disirmat system•paps'sS vt 17 Sins-t w o l, d ;;,0 c 0, AetPq Commonwealth of Massachusetts Title 5 Official Inspection Form . ......... Subsurface Sewage Disposal Syr-tam Form-Not for Voluntary Assessments 101 Ansel Howland Road t'roperty Address Frances_qigda Owner Owner's Name information is required for every nterville MA 02632 5-6-15 page. G.i.ty/Town State Zip Code Date of Inspection D. System Information (cont,) Site Exam: Check Slope ❑ Surf-ace water ❑ Check cellar ❑ Shallow wells Estimated depth tfhigh ground water, _204I...... feet Please indicate all methods used to determine the high ground water elevation: D; Obtained from system design plans on record If checked, date of design plan reviewed: Date El Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Town G.W. MAPS. ..................... ................... ........... ❑ Checked with local excavators,installers- (attach documentation) ❑ Accessed USGS database -explain-, .......... You must describe how you established the high ground water elevation: .,g.w.20'+ Per Town G.W. MAPS and past report. ................ ................... ......... ...............................- ............. ...............................-- ............ ........ ........................... ................. ------- ................ ..................... ... ................................... ................_.............. ........... .............. ................. ....................... Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lris>2113 title 5 Official lrc' clicn Farm;SuosLrfat*Somage Disposal System-pme 16 of 17 9 t'd dZg:�OSL Ol, A.eVJ r s Commonwealth of Massachusetts Title 5 Official Inspection Form UIVSubsurfaca Sawaga Disposal System Form -Not for Voluntary Assessments 101 Ansel Howland Road Property Address Frances Bigda Owner Owners Name information a required for eery Centerville AAA 02632 5-6-15 page, Cityrrown Stall® 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 t51ns-3(13 TIIIe B Official Inspection form:Subw-lew Sv*vp DWpmel System•Pape 17 of 17 it LL'd d89:009L 0L AeN oFrt"�r Town of Barnstable Office: 508-862-4644 Fax: 508-790-6304 , .� Regulatory Services Department snMNrn Public Health Division Maw Thomas A. McKean,CHO 200 Main Street, Hyannis, MA 02601 Payment Receipt Septic Inspection Payment received: $25.00 (Check) on 5/13/2015 Permit number: 10860 w I Check number: 32435 Check amount: $25.00 Name on check: Capewide Enterprises, LLC i Owner: Frances Bigda Address: 101 Ansel Howard Road, Centerville No. 0 .Z Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:�L PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Di!5potar 6potem Construction 3dermit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon O ❑ Complete System lindividual Components Location Address or Lot No. © j A rl s E i O�owjw.,d v7 Owner's Name,Address,and Tel.No. L i rl/)11 ce,_rtrz Ott i roe �lns�l r�a,.AaM� Assessor's Map/Parcel i —7 1_( •ZZ Installer's Name,Address,and Tel.No. C4r as.;aL 6371vp,ye> Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size i�t S sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 2,1,C ! Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: J1"t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boas&of Health. Signed Date I— q— 2,D t�— Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. a--u Z 13 l - Date Issued No. v , - o z Fee _ _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pprtcation for �Bigogal *pgtem Congtruction Permit 1--11Application for a Permit to Construct( ) Repair()(' Upgrade( ) Abandon( ) ❑ Complete System (Individual Components Location Address or Lot No. 101 V) Owner's Name,Address,and Tel.No. C rl d n C4w-,f O n < C`e,,.t'/✓cilt'4- lot t`4ns�( ibq_„AA-J Assessor's Map/Parcel 1 -1 1- P 2'L ,f (�, (( Installer's Name,Address,and Tel.No. C✓qp&ia, 6ir?P-S r> Designer's Name,Address and Tel.No. !J-7 / ST /iIn Type of Building: �j Dwelling No.of Bedrooms Z Lot Size D, 2 rO 5 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) -`,-Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date,- - Zo( 1 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) x" Date last inspected: J 4vk 7,y 0— Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of " Compliance has been issued by this Boa Health. Signed Date Z o (X Application Approved by Date2- Application Disapproved by: Date for the following reasons r Permit No. '2-u j - oil Date Issued J - y _( Z. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( /Q_ Upgraded ( ) Abandoned( )by t d-g- 6'�- dv t I C u- at (0 ( Q 1 has been constructed in accordance Y with the provisions of Title 5 and the for Disposal System Construction Permit No. z°1 Z- G 1�-- dated Installer i( l I --f L L Designs 4 #bedrooms or,1, &�rv+r� r 8d-� T Approv, d design-flow 1,/`� gpd The issuance of this permit sha17`not be construed as a guarantee that the system will,functionffes'ighed. Date t1 Inspector No. (1 i - C 1 Fee l JU THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS lwigogal *pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair (/",/C) Upgrade ( ) Abandon ( ) System located at l o ( 1�Y1 S4( kL w 14y,A (� LA,,�p 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 completed within three years of the date of this p rm't/ Date r °f i; Approved by 1 4 ' I i q ;+ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for every Centerville Ma 02632 1/9/2011 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: b I key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. Capewide Enterprises Company Name 153 Commercial St. Company Address low Mashpee Ma. 02649 City/Town State Zip Code 508-477-8877 SI 4522 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: 0 Passes ❑ Conditionally Passes ❑ fails G y ❑ Needs Further Evaluation by the Local Approving Authority t 1/9/2011 Inspector's Signature Date Tle system inspector shall submit a copy of this inspection report to the Approving Authority(Board E" 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-11/10 Title 5 Official Ins t � Inspection Form:Subsurfaa ce I;ewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11110 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 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required.pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 every P9 a e. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 1/2 day flow t5ins-11/10 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 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection. Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form : Not for Voluntary Assessments M 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 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? E ❑ 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 gpd l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes E No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2010= 70,000 total = 192 gpd 2011= 54,000 total= 148 gpd "includes irrigation system Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 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 ,M 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011. every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 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: original system Were sewage odors detected when arriving at the site? ❑ Yes ® No . Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof 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: 1000 gallons Sludge depth: 5„ t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 every page. CitylTown 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 3.5'. 2" 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 10.1 How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was found to be rotted, it was replaced with a pvc tee, permit#2012-012 Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 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 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 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: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Oil 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.): Box was video inspected and found to be in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's'Name information is required for Centerville Ma 02632 1/9/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leach pit had 1' of standing water at time of inspection with no signs of past hydraulic overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 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 °M 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yy. 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for every Centerville Ma 02632 1/9/2011 page. Cityrrown 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 YPIC I AW p t A-1 NS °&" ZY f? r r � r ,A`Z . 03 y8° Zed 0 °4 52 0 6� 32 8-Y �s t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water.elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 101 Ansel Howland Rd Property Address Linda Cameron Owner Owner's Name information is required for Centerville Ma 02632 1/9/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® .Inspection Summary: A, B, C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 4 COMMONWEALTH OF MASSACHUSE iTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RE V E D DEC 0 5 2002 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 101 Ansel Howland Road Centerville, MA 02632 Owner's Name: PeQ Murphy Owner's Address: 1 5 Date of Inspection: November 13, 2002 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map:172 Osterville,MA 02655-0049 Parcel.224 Telephone Number: (S08)862-9400 Lot.13 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes N urther Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: November 21, 2002 The system inspector shall sub ' 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 101 Ansel Howland Road Centerville, MA Owner: Peg Murphy Date of Inspection: November 13, 2002 Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 101 Ansel Howland Road Centerville,MA Owner: Peg Murphy Date of Inspection: November 13, 2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 v Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 101 Ansel Howland Road Centerville,MA Owner: Peg-Murphy Date of Inspection: November 13, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 101 Ansel Howland Road Centerville,MA Owner: Peg Murphy Date of Inspection: November 13, 2002 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 f Page 6 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 101 Ansel Howland Road Centerville, MA Owner: Pei Murphy Date of Inspection: November 13, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: I Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage 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 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAIA NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 114183-as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 101 Ansel Howland Road Centerville, AM Owner: Peg Murphy Date of Inspection: November 13, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 12" 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 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping every 3 years GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom.of scum to bottom.of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 I Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 101 Ansel Howland Road Centerville, W Owner: Pegg Murphy Date of Inspection: November 13, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-Box was broken down structurally and a new D-Box was installed. Permit#2002-550 PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 ` Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 101 Ansel Howland Road Centerville, MA Owner: Peg Murphy Date of Inspection: November 13, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓. (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6' 1000 gal. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The pit had Y ofwater on the bottom. The scum line was at the same level. There were no signs of failure. The bottom to grade was approximately 9. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 ` • Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 101 Ansel Howland Road Centerville, AM Owner: Pez Murphy Date of Inspection: November 13, 2002 Map:172 Parcel.224 Lot: 13 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. BAD gs, a 3 A B y i �s ay 3 sa 3a 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: 101 Ansel Howland Road Centerville, MA Owner: Peg Murphy Date of Inspection: November 13, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 9. Using the Barnstable topographic and water contours maps, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 �00 No. 550 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes 01pplication for �Dtgaal *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ••1 CEI ^�t ��� W A� 0�ne�r's Name,Address / ti ss and Tel.No. j Assessor's Map/Pazcel �IQIa►� '`' �b� �� /�/ Install s Name,Address,and Tel.No. Designer's Name,Address and Tel.No. w. &16XA6/c R0( ds Flo,llc (sod) 410-S6yo 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil y Nature of Repairs or Alteratio (Answer when licable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this Board of He h. Sign Date Application Approved by Date Application Disapproved for the following re so Permit No. Date Issued 4 l No.+ f Fee Entered in computer: r , P THE COMMONWEALTH OF MASSACHUSETTS ✓ " 7 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplication for Oigoaf *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. l O' A N ' �Ib W lA JJ Owner's Name,Address and Tel.No. Assessor's Map/Parcel /u!£R�'°' /G IVUR?by - o tvl Rd G�r►��Q�'r Installer's Name,Address,an 1.Por Designer's Name,Address and Tel.No. w P'/4R16 (YA6Jc q t, 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title 1 x Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. / Signe Lfff71 Date j O Application Approved by ;,�� / , �i Date Application Disapproved tPeol Jowing re on Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certif irate of Com riance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(k Repaired( )Upgraded( ) Abandoned( )by at h It I r, MCI has been constructed in accordance with the provisions o ' itle an�d� a orr Dis o a System Construction Pe t No��d Installer Designer The issuanc o tiffs permit a fin* a construed as a guarantee that the system will function as designed. Date Inspector IC-11 . .A.I A,� - n r --------------------------------------- No.. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS i C 'Wi5po5ai *p5tem Con!trurtion ermit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at _ 1 n /D i ► 1�_U 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: Cons tion mu t be completed within three years of the date of this Date: Approved by i j TOWN OF BARNSTABLE /n 11 c �1�• LOCATION /O I Al e.] I AOWIAA SEW GE # CAa- SS6 VILLAGE Co.,Zt V t `� ASSESSOR'S MAP & LOT a 2,22 INSTALLER'S NAME&PHONE NO. GOr8d, f U~US SEPTIC TANK CAPACITY ��JW 1�X re PAi r . LEACHING FACILITY: (type) �►- &X(o , (size) l UUb NO. OF BEDROOMS BUILDER OR 0 R �� r PERMITDATE: El s d oZ COMPLIAN DATE: Separation Distance Between the: I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 'i I a Yge- sy� a yS a8 3 Sa 3 TOWN OF BARNSTABLE LG� SEWAGE # 7 1 �w n D�CJda� SS6 VIi.LAC.E-N L9�1 t.�V t�k. ASSESSOR'S MAP & LOT a:2 INSTALLER'S NAME&PHONE NO. (oor8a1 (�>nU`rMAUS SEPTIC TANK CAPACITY . I CJW ' '�C7X R Q A f +, LEACHING FACILITY: (type) 1 ►1 (l X fo + (size) OM NO. OF BEDROOMS BUILDER OR OWNER tot r PERMTTDATE: �COMPLIAN DATE:—(1 o Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by l j a 3 a yg a8 3 Sa 3 TOWN OF B/ARN)STABLE LOCATION t 0 1 A,iss, ( UI�✓/ABC SEWAGE # VILLAGE CR-►T2AA ASSESSOR'S MAP & LOT /7;L o�a� INSTALLER'S NAME&PHONE NO. LGT 13 SEPTIC TANK CAPACITY I WO LEACHING FACILITY: (type) �,T (ox!or (size) C0 SA NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIINCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well.and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet.of leachi g facility) Feet Furnished by -L n 5,0 r0/C-i oa 3 A B y i vs ay. s Sa 3a y y� ys sox IOU, , to :j i 'r 00 NOD S I pill, j t t GAY On f ` � i d t 1r s pp I i c z L £ppp{j` a � I 1 r, F !> ! 141, vt -r v: f � ! CO 1 t No...... .a:�/~' FR$.......... ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /(.............O F......,...�...... .............................................. Appliration for Diipusal Works Corm rnrtion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .._/ '..5;.�2=-•-•Z cal% iuJ...k/.Z?....... f'z = : ...._.._.. ...... ................ Location-Address or Loot No. •-- �"•••-`--................................................. ......... ��.A._L. ....................................._---... . •a ....... i ✓ :---•..................................... ? i i ..•----- -•--•--••-•----. .....-.............0.....--- Installer Address d Type of Building Size Lot...--"? .Z=...Sq. feet U Dwelling—No. of Bedrooms--->,?................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a, Other fixtures .................................................................................................................................................... W Design Flow.........-./74..-g ..................gallons per person per day. Total daily flow............. T�...............gallons. WSeptic Tank—Liquid capacity .gallons Length................ Width................ Diameter.................Depth................ x Disposal Trench—No. .................... Width........j............ Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No._.. f--.�'.- Diameter....__?-__..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �_4 Percolation Test Results Performed by.......................................................................... Date......•............................•-- aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..._..................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' .---•--•---•-••-----•--•••-•--•--------------•-...------------------.._....0...0..........---•-------......................................................... 0 Description of Soil........................................................................................................................•............................................... x W -----•-•-------------------------•••......•--•-•---••--••--------------•--••...._..---....--•--------••--------.........-••-•••. -•-------••-----•--•----------••-----••••----------•-----...._......-- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ••------------------•--•-------•----•-----------------------------------------------.....................---....----------------------•----------------•----------------------••---•---•---------------• Agreement: The undersigned agrees to install the aforedescribed Individual Sew e Disposal System in accordance with the provisions of ii`:'Z- 5 of the State Sanitary Code—The undersigne further agrees not to pl cl the system in operation until a Certificate of Compliance has been is u by their health. 2, Signed.. tr.... tom..'...._ -------------•-• ....... ----- ._.... Date Application Approved By............ ., o_...... .- _- -- . Date Application Disapproved for the following reasons:-----•.........................•-•------...------------•----•------------------•-----------------....--------- r ........--•---------------•••----•--•----------....-----•------------•--•-.......-------•--....••.--------------•---------------------...----------------------------------------------------- Date PermitNo......................................................... Issued---.............................------------ ate Date ,a s No................_....... ............... fr 2.- �y�Z THE COMMONWEALTH OF MASSACHUSETTS V BOARD OF HEALTH ...........................................O F.......................................................................................... Appliration for Disposal Works Tontrurtion 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -•-•----•---...................................•-•----.........-•---............................ •--•-...'---"-'--•----....-------•---•.......--•--...-----•-•--•--•----•--------.........----.... Location-Address or Lot No. ...•-•-•.............._...................... " .. Owner A ^----• •---••............................. -•-••..... ...••............................. ddress------•••••---•---....-•-•-.................-'- W Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) ............... No. of ersons............................ Showers — Cafeteria p,,, Other—Type of Building ............. p ( ) ( ) 04 Other fixtures ---------------------------••••. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2_..........I.....minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------- - --------------•--•----------------------•-----............._......._.._._.......•.....'•-••-•••--•----•-.........................••••...... ODescription of 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 T T'f s». 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. Signed....................•'----------•-..................----'--'•--••••..............---•- .........................._.... Date ApplicationApproved By......................................................... .. M ........................................ An � �,,./ d•• Date Application Disapproved for the f a.�ons.--------•--- ............__.................................................................D•--_.............. ....................................................... -----------------•-----------------•------------........------------------------------------------------•--------------------------•-••'-" Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................I.............................................. Trrtifiratr of TontpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) •�"��'ti u 01101— - Installer at...................... .- . .c.-.._ _ ... '. ...... ?' ........ ----- •�' �.�% .............................................. • has been installadc - coorCfance rpte piovisions of TITIZ 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No............. ------------.................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR A GUARANTEE THAT THE SYSTEM I L FUNCTION SATISFACTORY. DATE... ...T� ................................... Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... No............... FEE........... Disposal Works Tuon#rurtion Vvrrmit Permission is hereby granted................ --- ......- -!---------------------------------------..........------....................--- to Construct ( ) or Repair ( ) an Indivldua ewage Disposal System as shown on the app ication for Disposal Works Construction Permit No..................... Dated.....:: ........__.................... Boarf�of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS , � 4�V Cj LO- AT NQ SEWAGE PERMIT NO. ,ot 13 _ Ansel Howland 82-772 V I L L A G E Centerville, Mass. . ft= INSTA LLER'S NAME A ADDRESS Robert B. Our Co. Ino. Great Western Rd. North Harwich, Mass. 02645 SUI-LDER OR OWNER n1 Alan small D-A T E PERMIT ISSUED 7 D-ATE C0MPLILAKCE ISSUED 0 33 d 41 r pE.s►G►� � 9 Z1 ' 51►.JGLe FAMILY 140 GARBAGE 6wNDt=m __. L O T 13 - pAIL�( F�ow s Ito Y. 3= 3306.R0 . 5E•PTIG TANK 33Ox15C>% ='495b.P. 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