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HomeMy WebLinkAbout0152 ANSEL HOWLAND ROAD - Health 152 Ansel Howland Road Centerville A= 171 - 263 i U UPC 12534 : No.21_ I ww NA8TINGS.UN I i , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your JW7 1 cursor-do not James Ford U use the return Name of Inspector key. 3" ren Company Name P.O. Box 49 Company Address eam Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further aluat ion by the Local Approving Authority \JNW4 l 10/15/13 Inspe or's Signature Date The s tem inspector shali submit a copy of this inspection report to the Approving Authority(Board of H th or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspe Con orm:Subsurface Sewage Disposal System-Page 1 of 17 i' C Commonwealth of Massachusetts . Title 5 OfficialAnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is ; required for every Centerville MA 02632 10/10/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: {; ` ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 orjn:310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. 11 Comments: R 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.I. The septic tank is metal aril 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 4 the tank is less than 20 years old is available. : ❑ Y ❑ N I ❑ ND (Explain below): i� I t; t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ry Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •' 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)t 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): q , ❑ 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): r C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist whichgrequire 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 f` i Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal!'System Form - Not for Voluntary Assessments 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information fired is every Centerville re wired for eve MA 02632 10/10/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the s�.stem 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 determ' 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: s a. a Y� I Y 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 El ® Discha ge 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/?.day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 Ansel Howland Road i! Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville r MA 02632 10/10/13 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. 1' 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 fq any question in Section E the system is considered a significant threat, or answered "yes" in Secti 9 rr 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 Depar„tment. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Mass�.chusetts W Title 5Official-Inspection Form Subsurface Sewage Disposal;,System Form - Not for Voluntary Assessments 152 Ansel Howland Road Property Address FI Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 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�ny of the system components pumped out in the previous two weeks? t; ® ❑ 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 sing 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. ® ElDetermined 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 Condition's:. 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 !' H t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f. '. II ry Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage DisposkSystem Form -Not for Voluntary Assessments a 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 page. City/Town State Zip Code Date of Inspection D. System Information } Description: 9 Number of current residents: 2 Does residence have a garbage grinder? El Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) " Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? El Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: i Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 y: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 152 Ansel Howland Road j Property Address , Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 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: pumped 2 years ago- per owner 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 9 ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) E ❑ 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 ' x ❑ Tight tank:Attach a copy of the DEP approval. ❑ Other(describe): I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 gF : I Commonwealth of Massachusetts W Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�a,•'`� 152 Ansel Howland Road Property Address Ron Mezzano { . Owner Owner's Name information is Centerville required for every MA 02632 10/10/13 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: installed -3/7/06 Were sewage odors detected when arriving at the site? ❑ Yes ® No i Building Sewer(locate on site plan): t Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): i. Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): j Depth below grade: 15" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Ei If tank is metal, list age: tl years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: i i 1000 gal. 2" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t i ; d Commonwealth of Massachusetts Title 5 Official" Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville , MA 02632 10/10/13 page. Cltyfrown 4 State Zip Code Date of Inspection D. System Information (cont.) f Septic Tank(cont.) S Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6 II � Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present. No sigh of leakage. 9 Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal: ❑ fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments r ,.' 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is Centerville MA 02632 10/10/13 required for every i page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): p is f; 4 .1 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): N/a 1 is Dimensions: Capacity: gallons Design Flow: j` gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r :f Commonwealth of Massachusetts W Title 5 Official;:Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,,M a,•'�• 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level aboveloutlet invert even i 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 normal Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* a , Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/a l t if * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 r 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 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-with stone ❑ 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.): There were no signs of failure. A camera was used for the inspection. 1 i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/a k Depth—top of Liquid to inlet invert Depth of solids layer i Depth of scum layer Dimensions of cesspool + Materials of construction 1 .k . Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 r ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A,•'' 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 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.): 1 ' nH Privy(locate on site plan): Materials of construction: 4 Dimensions Depth of solids fl .q Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a t, f i M ' t5ins-3/13 { Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °' ,••''• 152 Ansel Howland Road I Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 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 refe're`nce 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 1 A . I `f o 4 '3 a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •'�• 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 page. Cltyfrown State Zip Code Date of Inspection D. System Information_(cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar , ❑ Shallow wells Estimated depth to high gro,,und water: 30' 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: Using topo 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: see above J: r` 1i i r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �'°M a,•'t 152 Ansel Howland Road Property Address Ron Mezzano Owner Owner's Name information is required for every Centerville MA 02632 10/10/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 13, 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 A. i tl 1. a,M1 I• i J y 4 t.' 4' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 9 �j THE COMMONWEALTVI OF 16ASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for Miq;posSal *V5tem Cow5truction Permit Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) Complete System 561ndividual Components Location Addressor Lot No.1 5 2 Ansel Howland Rd Owner's Name,Address,and Tel.No. 7 7 5—81 01 Centerville Ronald Mezzano Assessor'sMap/parcel 171 84 Rolling. Hitch Rd, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 7 9 0—9 2.7 0 Wm E Robinson Sr Septic Lisa Lyons PO Box 1089 , Centervillp 162 W Hyport Cir, Hyannis I)pe of Building: Dwelling No,of Bedrooms 3 Lot Size sq.ft. Garbage Grinder i(o) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -30 gpd Design flow provided 3 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 leach system to plans of Lisa Lyons, dated 2-20-06 Date last inspected: Agreement: The undersigned agrees to ensure the construction and t paiaten-6fice of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of te Env' ental Code and not to place the system in operation until a Certificate of Compliance has been issued by is o a th. Signed A Date 2,--6,o ia Application Approved by Date 7-3-0 Application Disapproved by: Date for the following reasons Permit No. Date Issued 3 "-3 —U 1 1 No. P1 t .3 4 ---i 1 0 0.0 0 e t _ A�SSACHUSETTS Entered in computer: r� THE COMMONWEAL40 t .. E PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 'ZIPPYication for �N-5po5a[ *r5tem Construction Derma Application for a Permit to Construct O .Repair(X) Upgrade O Abandon O 0 Complete,System [ Individual Components Location Address or Lot No. 1 5 2 Ansel Howland Rd Owner's Name,Address,and Tel.No. 7 7 5—81 01 Centerville Ronald Mezzano Assessor'sMap/parcel 171 263 84 Rolling. Hitdsh Rd, Centerville ti Installer's Name,Address,and Tel.No. 7.7 5—8 7 7 6 Designer's Name,Address and Tel.No. 7 9 0—9 2 7 0 Wm E Robinson Sr Septic Lisa Lyons PO Box 1089 Centerville 62 W H port Cir Hyannis Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder (10) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �j -30 gpd Design flow provided 330 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 leach system to plans of Lisa Lyons, dated 2-20-06 Date last inspected: Agreement: The undersigned agrees to ensure the construction a aintenance of the afore described on-site sewage disposal system in 4, accordance with the provisions of Title 5 of t e Env' ental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boa , V� ah. - Signed Date Application Approved by qll Rj Date ?—J?^O 6 Application Disapproved by: Date T for the following reasons Permit No. Date Issued 3 — 3 o 6 --------------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS Mezzano BARNSTABLE, MASSACHUSETTS Certificate of Compliance y THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (X ) Upgraded ( ) Abandoned( )by Wm E Robinson Sr Septic Service at 152 Ansel Howland Road, Centerville has been constructed in accordance with the provisions of Titles 5-and the for Disposal System Construction Permit No. 2 o06—0 92- dated —3-U 6 Installer V`PJ b(r'�t'lYl Designer #bedrooms 3 Approved design flow 3 U gpd The issuance of this permit shay no be construed as a guarantee that the system will unctio s es�n d.�i Date 3 IQInspector -------------------------------------------- No. �Uub -okoZ ;Jp0.00 THE COMMONWEALTH OF MASSACHUSETTS MezzFftLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1 1=igont *p5tem Clore.5tructiou permit Permission is hereby granted to Construct ( ) Repair ( X ) . Upgrade ( ) Abandon ( ) System located at 152 Ansel Howland Road, Centerville s 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: Constructio must be completed within three years of the date of thiMe . itln Date � /�7ok Approved by ' Town of Barnstable Regulatory Services Thomas F.• Geiler,Director BAMMBLE. Public Health Division rED A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644' Fax: 508-790-6304 Installer &Designer Certification Form Date: g b b Designer: U1<11q LY (S Installer: GIJM. P0"b'1n(S6Y'J Address: . 2 W Address: MAP- b2 P t On was issued a permit to install a (date) (installer) septic system at 152-*5q k6J6-4) 0 &Ak* 4e based on a design drawn by (address) -- �_______.�_.r..._•�S�•�-�`�b�5;---. _ dated �� - - - _ ..� - . .�,,.> . - - _ (designer) I certify that,the septic system referenced 'above was installed substantially according to 4 the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or c 'fled as-built by designer_�o-fc�llo ,,, P::N OF,M;Ssgc�j� (Installer's ;lit. iity0a (Designer's ' ature) (Affix Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form iw 7 � .'ti � � w.- �3 G "S-�. �� �' ..]iiw 9✓�,. MM ....i rr W �,' � r� . � I e TOWN OF BARNSTABLE LG ATION -2 ZP, �fY.u)�ce;nc� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT -� INSTALLER'S NAME&PHONE NO+ SEPTIC 1'r CAPACITY LEACHING FA'.'b�,�'I'Y: (type) �-r •�/��S (size) 10,3 Y7 2 S'-X L NO.OF BEDROOMS i- BUILDER OR OWNER PERMIT DATE: e�-Z-ID V COMPLIANCE DATE: _Z_ 3'0 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 , o� TOWN OF BARNSTABLE I LOCATION '-' 4r)6"' / r�^���-� � SEWAGE # 77 VILLAGE C,Q'1fi ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 4 2c SEPTIC TtiNF CAPACITY r&72�C �'xs LEACHING FAi"Ti Y: (type) C O�GvM �j.z .'S (size) 1 V 3 X l Z .�- X- NO.OF BEDROOMS BUILDER OR OWNER IL t� Any PERMTTDATE: -r COMPLIANCE DATE: 0 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 ` i Furnished by i Owl ell 1 �� • a C. I- Fri, r r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS OF BARN DEPARTMENT.OF ENVIRONMENTAL PROTECTION 2006 JAW —4 PM 7003 16 go 000 q sqsg uIvIsIO 2�J TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 152 Ansel Howland Road Centerville, MA 02632 Owner's Name: Paul Brunelle Owner's Address:Date of of Inspection: November 30, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 .Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 Needs Further Evaluation by the Local Approving Authority ✓ F Inspector's Signature: Date: December 11, 2005 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 H OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 152 Ansel Howland Road Centerville MA Owner: Paul Brunelle Date of Inspection: November 30 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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: 152 Ansel Howland Road Centerville, MA Owner: Paul Brunelle Date of Inspection: November 30 2005 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 detennine distance **This system passes if the well water analysis,performed at a DEP Y �P certified laborator y, for colifonn 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 Y to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 152 Ansel Howland Road Centerville, MA Owner: Paul Brunelle Date of Inspection: November 30, 2005 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.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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 drinkingwater supply Pp Y — 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 152 Ansel Howland Road Centerville MA Owner: Paul Brunelle Date of Inspection: November 30, 2005 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 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 152 Ansel Howland Road Centerville, MA Owner: Paul Brunelle Date of Inspection: November 30, 2005 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 Number of current residents: I Does residence have a garbage grinder(yes or no): Yes Is laundry.on a separate sewage system(yes or no): n/a [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 COMMERCIAL/INDUSTRIAL 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: Pumped in 2004-per owner 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: Installed on Oct. 20182-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 f Page 7 of 11 "r t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 Ansel Howland Road Centerville MA Owner: Paul Brunelle Date of Inspection: November 30 2005 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: 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: -- 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: 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.): The liquid level was above the tees and un to the cover. Liquid was backing up from the leach nit 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 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 Ansel Howland Road Centerville MA Owner: Paul Brunelle Date of Inspection: November 30 2015 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: eallons 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: 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 under water. 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: 152 Ansel Howland Road Centerville, MA Owner: Paul Brunelle Date of Inspection: November 30 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6'w/2'stone(per design plans) 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 liquid was above the cover and filling the hole I could not access the cover. The leach nit was in hydraulic failure. 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: 152 Ansel Howland Road _Centerville. MA Owner: Paul Brunelle Date of Inspection: November 30 2005 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 w—here public water supply enters the building. A B � k 417 as a y9 3 L 3 a 3 a� 10 Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 Ansel Howland Road Centerville, MA Owner: Paul Brunelle Date of Inspection: November 30, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: 418182 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: Using the design plans on file, no water was observed 12'below Qrade. This report has been prepared and the system inspected and failed 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, g, xp essed, written or implied,relating to the s stem the ins pection section a g Y p nd/or this report. 11 TOWN OF BARNSTABLE Lnk�'ATION o� Ans,] P I owl* SEWAGE # VELLAGE (,Q�"ro/v►I� ASSESSOR'S MAP & LOT /'7/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /= LEACHING FACILITY: (type) P' (oX 6+ (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: <0 COMPLIANCE DATE: Separation Distance Between thee: 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 S/1 SIG Joe) �D� a Y�iE COMMONWEALTH OF MASSACHUSETTS BOARD/)OF HEALTH /_!er?. .................0 F.. ....... ...... ............................ Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Sy a4 ner JZ Installer Type of Building Size Lot.... feet W Y-1 Z Other Distribution box ( ) Dosing tank ( ) 0.4 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE 5 of the State Sanitary Code—The undersig d f rther agrees not to place the system in 0 eration until a Certificate of Compliance has been jEp�p , Ith. .4 . ... ..... vi Date Application Approved By..................... 4g.;?...0L_-4501e_P;00E ........................ .........::?�� Date ` Date PermitNn......................................................... ....................................................... No..... . ----.. Fx$....,.�r. ....`.�...... 7 o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.......................................................................................... ApptirFa#ion for M-4paii al Workii Tonitratr#ion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................-................................................................................ --•--•-----•-------•----•......----........... .......................................... Location-Address } or Lot No. ......................—.......................................................................... ..........--...................................................................................... Owner Address ...................................................................•--•-........._................ ---•--•-•-•-••-----•----....._.__....--------------••----•------•-•...._.._....................... � Installer Address U Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures -------------------------•-••-•---•----•--•-- W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid"capacity............gallons Length................ Width................ Diameter------.......... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit--.--............... Depth to ground water---------------......... fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•------------------------------••----•-------•------••-•---.............---.....--------...........-•--•---•--...........---._....---..........•----...... 0 Description of Soil..............................................---------•--------••----....-•--•--------------------•-••----...-----------------•-----------------------._.._...._•--••- x x -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•- U Nature of Repairs or Alterations—Answer when applicable..................................................................................._............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT r,;�. 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 Application Approved BY ...;;:::. ' :� -•-•------.--•--- ------ ' ' D t te Application Disapproved for the following reasons-------------------------•-••--•------------------------------•-----------------•---•--•--•--••---•---------•--- ................•.......................................................................................................................................................................................... Date PermitNo:"-------------------------------•--------•--------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... 0rrtifiratr of TontpliFanrr THIS IS RTIFY, That the Individual Sewage Disposal System constructed ( 4.1or Repaired ( ) bY----.....--- --------------------------- ------------------------------- -------- ---------------------•-------------------•------:. ,p In taller /�. at.................. ` {: r..... ...... '` A------------------------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the ' application for Disposal Works Construction Permit No......492±--t2...l.4..... dated................................................ THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONSTR S A GUARANTEE THAT THE SYSTEM WILL U TION SATISFACTORY. DATE...... ..-� Inspector.-•-•----. .. ---------------------------------•------...........-----•--.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF................... _,,Y.--'' No... FEE..... i o aal ork Torngtrnrti�an rrntit Permission i eby granted........ ......... .IL-=------------------••-•-----------...............-----•--.....--•---• to Construct Re air ( ) an dividual ew i pos Syst atNo................. �•- .. _...... Street as shown on the application for Disposal Works Construction P No..................... Dated.......................................... �. Boar of Health DATE................................ r,+' ` ,-- FORM 1255 HOBBS & WARREN. 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APPLICATION FOR PE .COLATION ` EST AAjN,D ObSE✓RVATION PITS LOCATION��� e�}/I� � lf �/ /'1/�� s�%• N0. .VILLAGE �''�1 ��j'C�� DATE APPLICANT I (Non-refundable) ADDRESS i ' GL TELEPHONE NO ENGINEE Rase tz7g-t TELEPHONE NOygl — DATE SCHEDULED 9" / 7 a s b (Applicant's signature) SOIL LOG SUB-DIVISION N�_ ,��/// 6/5���},(//�5 DATE // lel 'DIME E EXPANSION AREA: YES L,-�O )kj - l+J,9 "NGINEER F ; TOWN WATER Z,- PRIVATE WELL - BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test h1ples) ` NOTES: &o - - - TW i I �y fi it __ _ • .. .. PERCOLATION RATE: /iJ TEST HOLE; NO: ELEVATION: '. TEST HOLE NO: ELEVATION: 2 3 3 5 5 6 PigUZt 6 7 7 'i 8 9 , 10 10 t 12 �N tab `� �� . "12 13 13 j 14 14 ` 15 15 - 16 16 - SUITABLE -!FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING ITS ' LEACHING TRENCHES S h UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: '! NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION , •a ORIGINAL: COMPLETED IN ENTIRETY BY P . E. AND RETURNED TO BOARD OF HF.ALTFi :•i COPY: RETAINED BY APPLICANT L E G E P CONCRETE N C RETE BO FN�P")REBAR (FND) a \ � lu 4 \ v C/B FND S LOCUS MAP LOT 37 PLAN REF: 343-85 DEED REF: 1 7 2 —169 Q; ASSESSOR'S MAP: 1 71 /263 — — — — — _ — 1���� ZONING: RC `j — — — — — — — — SETBACKS: 20'—10'—10' c�`L rL a — — — — — — — — — FLOOD ZONE: X 152 _ �o PANEL NUMBER: 25001C 0561 J — — — 6, DATED: 7/16/14 RB FND `�S a — — — — — — — — _ OVERLAY DISTRICTS: GP, STATE ZONE II 9, e / — — — — — — — — RPOD -_-___-__-- PLOT PLAN 0E LAND BRICK TO LOCATED AT: BE REMOVED — — DECK 152 ANSEL HOWLAND ROAD CENTERVILLE, MA PROPOSED / LOT 38 ADDITION ��° ,��� ��� j ;, lL 15, 116± S. F. PREPARED FOR: 0. 3 ACRES DONALD O'SHEA jo k JU LY 16, 2015 LOT 48 � � L 0 T 39 �o °`� tx REV: 6Q � OID' REV: ^'^ REV: R Y LLC. 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P AN TR BUT ❑N BOX ❑LEACH IT D DIS I I :, NOT ALE_ TO SC 3_ ` EXISTING BEDROOM O 110 G.P.0. , S A A LL L n n In H OC ONS OF U L E SOWN AR BE REM❑VED ,' S E AS 4 330 G.P.D. f _+ ,. .IMARKED BY DIG SAFE AND ARE TO BE RI I .I-�.I-..lI_.,,VE FlED 8Y NSTALLER PRIOR TO .I 1I .-��I L IIII EII­�I�,�L� IIII I. 1�I- ­. I. III I II �I�l �,I�I�. II II Ii I r I n coNsn:u oN N NIT 3 c , A T NOTIFY DESIGNER 24 HOURS O. OFU S I INST LLER ❑ s " DEPTH BELOW INV. 2 THERE ARE NO KNOWN WE AN WI s _ ' TL DS TH N NAT ,` _ � _ ;NN N F - ❑ TO C❑�RDI E c , PRI❑R TO BEGI I G ❑ J B <1 15o OF,THE PROPo A H f WIDTH 0 5 SED LE C INC FACILITY I ,: N P T NS' U LESS SHO . INS EC IO 28 5_ , .. . LENGTH - FIRST FLOOR , I , 6 ' THER ARE N K WN P TA E 0 NO 0 BLE WELLS WITHI I 1 P2 SIDEWALL AREA I t z-- 1�i1 � 100 OF.THE PROPOSED A HIN AL E C G F CIUTY. : 7 3 s I BOTTOM AR A 299.3 E s r THER A N KN E E E O OWN IRRIGAnEA 484 SF WELLS , TOTALSWARE FEET R :. .: .y - :. , I , I , BH WITHIN 50 OF THE PROPOSED LEACHING P..# .11' 2 FAc1uTY _ r , APA 1 I A 115.4 G.P.D.C C TY S DEW Ll 00.74 _ Tlil ` S PR ERTY N T _ � APA '221.4 G.P.D.. OP DOES 0 FAU. WITHIN`'A , C CITY BOTTOM O 0.74 f N A , f ACRES L000 ZO E S SHOWN ON FlRM MAP I P _ CAPACITY TOTAL 338 8 G .D. 35 sATx DIIdING EN BATH KTPCH _ ROOM PATIO THI N l S DESIG DOES NOT REQUIRE VARIAN _ CES BEDROOMS T (0 n 1 .MR-1 AE 5 3 0 C 5.00 ARN A ORB ST8 t THIS SYSTEM NOT IGN Sapp M NTA R An DES ED TQ LEE L EGUL oNS. - ' - A M AT CCO OD E A ' AR A G B GE ALL coN TRu noN� - r` S C SHALL 8E IN ACCORDANC - WITH TI AN AR _ DISP A TiE S 0 B NSTABLE SUPPUcMENTA _ A _ , OS L R N c EGULATIONS. V E L H ', 0 w LA N D IN LINE ELEVATI P FD B R 0 I ✓�' � _ oNs xOros AS- iJILT SURVEY INFORMATION D . GARAGE . 4 i 62 3 .` .` w , P I , RO RTY N 6 INV, O HOUSE 97.4 I nN E L E DATA FROM i ,3 6 BEDROOM INV IN TANK FAMII.Y TO 98.85 EXI nNC S eoxter do Inc 4, � � ) N 8 82 , °I Ye / / LNINO ROOM ; IN V T OF TANK I ,. , : BEDROOM � OU 96 8 EX STING .' . I . ROOM h , : P A T L N 0 BE'USE F R N D O I STAL ATI N , :INV INTO D BOX ,r8.1 L 0 . PTI OF SE C SYSTEM ONLY ' 1NV OUT OF -BOX , L I , � -- D 93.9 I NV NT HAM R_ O C aE 93.8 .. it . ,E NOT FOR ETERMININ PR� __, 0 G OPERTY IN, 1 L ES $OTTOM OF CHAMBER 9 .8 , �V s 3 G , - B NC MAR E K, _ W`. ,, . .._ H _ T M POOL _• { 1 a� ro oF_aas � .. R F PATI i 0 N R O O 100.0 ASSUM . - c WATER .TABLE NONE ENCOUNTERED E EO E - r :. ,:.., ......:1 , 4 _ :. ^` .. } ' , OB ER Y AT S VED B WITNESSED BY•- i -_ D E. IL L SO 0 GS DON MARA F L SA C.'' YONS, DES c I eb 2 2006 I � .:L AR ,, SOIL:EVALUATOR BO D OF HEALTH 4 �B S. HOLE #1 S. „^ ELE OB HOLE '! DE EL V. PTH EV. ##��2� �'13BP1'Ii :: :. p r 8 9 .7 0 99.2 _ LOWS . q AMY AND LOAMY SAND I OYR 4/4 " 10YR 4/ , A A 4 R GE g ! „ 9 .4 4 98.8 4 - , :; LOAMY SAND :: , :LOAMY SA ND a g f lOYR S/6 H 10 / i YR56 f : _ , 4 2 n . .0 1 , f.> Cl 97• 21 _ _ AND FINE S_ FINE SAND , ; 1 0 6/ I 9S:2 1 YR 6 1 YR 6/6 P T s 42 %.1 A I❑ , 37 2 LO .SAND AMY 45 _'. 1,, AMY d' 2 SY S/4 LO SAND �0 � 57_ _ 2.SY S/4 _, ,,`� 91.8 - " 89 o �0 „ O s. 1.5 86 d t C3 MED/COARSE SAND r+ MED/COARSE SAND r_ _ 2 Y ('7 _` w _ : 2 SY 6/6 S 6/6 ,. . . , „ 88.7 I 88.7 20 >. 2 6 w w'T N R N A R N N R NO CROON WA R N 0 G OU D TE E COU TE ED _ ! D TE E COUNTERED i N _, a �: t�I E . : I _ O , -'), • ,,, 9 , TH 1 / BENCHMARK SET K , , /` i O PERC TB.CI 1�IIN INCIi I ., itA 8.75 9 ; f rn of nto ; EE_ , Le t co P . , n :.. PERC RATS A P F !: ASSUMED PER D0 D S , S S S EC I IC S ..M� s x MAitns �. o Assu�, a� ti i E 100 e _� ❑ _ . 0 A CHAMBERS IN A I , .. 350 GL I _ <; , . 10,5 X 28.5 TRENC WI r f I� TON N N a, T NE N SIDES _.1.5 S ❑ E E DS 28 S ❑ D , . :, A TH , . 99.2 3 E , , Ix� .:. :.., s 1 ,. ,<� ! ` t,' { X T❑LEACH PIT AND DBO : V , , F REM ED BE ❑ 0 MA i _ �. s 4 s_ . ♦ . ,, • ✓ 1 kw tT .: ♦ , q I.�N sxownacr.I o . F _ C. , , , , A L 1 S 96,74 ■ _., ■ CA U ., ow . i .:':.FOR . . DRAWN BY. USA C. LYONS t� r r I y „ 4 _ � DESIGNED,dt CHECKED Y. 1 t # RON MEZZANO • ♦ 1 A Y N s LOCATION.., ✓ k Q . r• f.. ' • -DATE r ,.. ✓ E • 9 A • v F , ♦ E E 1ST • Q� ;; r _ 152:'✓ . ANSEL HOWLAND RD CENTERVb f r G •,.a 'k► x �► p 1 oT*. 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