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HomeMy WebLinkAbout0048 AUTUMN DRIVE - Health 48 AUTUMN DR. , CENTERVILLE A=168-028 - 4 No. 4210 1/3 ORA u � 0�� ESSELT{E 10% (5 0 0 0 0 _. Commonwealth of Massachusetts -a°Z R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Autumn Dr. Property Address Owner Reilly } information is Owner shame / �/ required for every Centerville MA 02632 5/22/19; page. City/Town State Zip Code Date of Inspection lJ"a 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. A. Inspector Information 893 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/22/19 Inspec o—Ps igna ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. I Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �a 153 Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. City(rown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 18 i Commonwealth of Massachusetts P Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is owner's Name required for every Centerville MA 02632 5/22/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L� 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2018 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: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Priv ❑ Y ❑ 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): Approximate age of all components, date installed (if known)and source of information: original septic tank per age of home, new D-box and SAS 1997 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 4 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: Outlet end 6", inlet approx.3' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form 1° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts - ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'y 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): H-10 D-box is 3' below grade, carryover in box, no indication of backup t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 30x20 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owners Name required for every Centerville MA 02632 5/22/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Perf pipe field was video inspected, no indication of past hydraulic failure, piping is damp at this time 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts 1p Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner Owner's Name information is required for every Centerville MA 02632 5/22/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 TOWN OF BARNSTABLE LOCATION $ �� � SEWAGE ri 97_ i :VR LArE G_G��I'�J�l� ,ASSESSOR'S MAP&LOT -6- INSTALLE[t'S NAME&PHONE NO, 7/-93P9 SEPTIC TANK CAPACITY /ay—Ga L LEACHING FACII.TfY:(type) Fie (size) x30 XV. / NO.OF BEDROOMS " BURDER C 03 PERMITDATE. ZI31�7 COMPLIANCE DATE: y Separation Distance Between the: Maximum Adjusted GrotmdwaterTable and Bottom of Leaching Facility t'3F Feet Private Water Supply Well and Leaching Facility (If any wells exist. on site or within 200 feet of leaching facility) #- Feet -I Edge of Wetland sand Leaching Facility(If any wetlands exist within 300 fat of leaching facility) Feet Furnished by R Soo(,t� o R.Aw, �xd i q• . t h 1 'Ve , l I 30•,w• I . � I Commonwealth of Massachusetts - ig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 p g 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: 5+ft seperation per compliance on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping , site is at 30'msl and nearby surface water is at 8' You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Autumn Dr. Property Address Reilly Owner information is Owner's Name required for every Centerville MA 02632 5/22/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Y Commonwealth of Massa rhosetts =�=, Title 5 Offid ial Inspection Form i�cl Subsurface Sewage Disposal System Form Not for Voln: ^�� ary Asses srn,.o r,ts Property Address - ---- ----- t _ ✓ 6 klir�y ��cisT In O� ay i Owner ----- 7— ----- N am ,. — formation, is It I ,jeGuired for (.� f'C Y_1 �E-.----- — AW Vd O„ery pace. City.-I crm - -- -- -------- Stare 7_ip Code C)2t2AT Inspacto 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. I I Important:when filling out A. General Information - -- -- forms the ` I computer, r, use 1_ Inspector: 11 only the tab key to move your cursor-do not ----- - - ---- --------------------—------------- ---- ---- - -,use the return Name of inspector 4ey. _ Z-Vk'/o - J"L G0-� Ccmpa iy Names ----- --------- ------ ------------ Company Address - - - ---- ------ � �✓h i tm _ City y/To ron - -- — --- —-- ---- ---- St21 Zia Ccde Telephone Limber 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 or:. my training and ex, erience in the proper function and maintenarge 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: I Passes ❑ Conditionally Passes [l Fails Needs Further Evaluation: by t :e Local Approving Authority O&A Inspector's S'• nature ------------ -- - -- page ---- - ` The system inspector s :all submit a copy of=his inspection report to the �.pproving Aut :Drily (Board t of Health or DEP) within 30 uays of completing this inspection. If the system is a shared system or has a design flow of 10,000 opd or greater, `he inspector and the syostem owner sha'l submit -he report to the appropriate regional office of the DEP. The original shuld be Sent to tie 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. L IV � �!ia=Orri_i�;Iris seci.;r.•Fcrr;:�ucs_.:2�e I �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Vojuntary Assessments It Properv/A,�idre­, Owner inform2;on is Owner's Name requi,required for 10 47 every page. Citly/Town State Zip Code Da- c i S e c•ion B. Certification (conf') inspection Summary: Check A,B,C,D or E 11'aiways complete all of Section D A) System Passes: Eerl'have not found any information v,,h'Ich indicates teat any of the failure criteria described in failure ' 310 CMR 15.303 or in 310 CMR 15.304 exist. any fa -e criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: E, One or more system components as described in the `Conditional Pass" section need to tn- replaced or repaired. The system, i-:-pcn completion of the replacement or repair, as 2,ppioved ny the Board of Health, will pass. -mined" fY, N, ND)for the Vlovving statements.Check the box for"yes", "no"or"not determined" if .iCt 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 immi-"ien'.. sysztem will Pass inspection if the existing tank is reolaced with a complying septic tank ES 20Y ov d '3. Board of Health. Ametal septic lank vAl Pass inspec'Jon i!: it is structu�r2lly SOUnd. not leaking and 2 of Compliance indicating that the tank is less than 20 year.-- old iiS'aVail2ble. F, Y F-1 N ❑ ND (Explain below): ' Commonwealth of Massachusetts Ties 5 Official Inspection norm — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments P 01 Property Address v a tOvinerOwner's Name information is �`' 1 required for _ _ ( . aL/7�Y iTi '_"✓ tL �L _—_ `�S �v ---- li f I every^z e City/Town sta`e Z.io Code Oata'o` B. Certification (coat.) �•�lll , 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 abserotion system (SAS) and the SAS is with!-, 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and ttle SAS Is within a Zone I cf 2 ou llC',':'cter supply. The system has a septic tank and SAS and :he SAS is with n 50 feet of a pri ate :i u:er supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fee:or more frorn P- private water supply well``*. Vieth od esed to deter;mi:,e distance: This system passes if the well water analysis, performed at a DE? ce tified laboratcry, for Coif rr bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to o- less than 5 ppm, provided that no other failure criteria. are triggered. A copy of the analysis m.:st be (i attached to ':his form. 3. Other: I f lj . II l D) System Failure Criteria Applicable to Ali Systems: r You must indicate "Yes" or"No" to each of the following for all inspections: it :I as N ' ❑ r� Backup Of Sewage into faCil'ty or SySter"; component due t0 0\'E11s:Ce- :. C. do ged SAS or cesspool Discharge or ponding of effluent to the curfa e of the Ground cc ❑ L� due to an overoaded or clogged SAS or cesspool n -�r Static lia0d level in the distribution box above out et i=V due - - or cogged SAS or cesspool y (� r� Liquid depth In GSSSpO'Ci is less than F" helfoi-' Invert G; GVvi cC'c than �z day row i - -.;O`c.zllcs f� r � Commonwealth of Massachusetts Title~�^~'�8�� �� �^�����~~��B Inspection ����N~D-�� ~~ `=~ ^ " = ~~===" "" ~=��un~=om Form [ 8ubsu�acoSovvageDisposal System Form _Not for Voluntary Assessments +c/07 Owner infonnouoois | required for A�- *��page. uy /ov-in sa�e ZipCodo B. Certification (cont.) ��Yes No No ` Required pumping more than 4 times in the last year NOT due tocioggecor obstructed pipe(u) Number oftimes pumped: — �] ��' Any portion of the SAS, cesspool or privy is be!ow,high ground vvotsr o|e%,ation ' F-1 --''~- AnypV�ionof cesspool nrpr�y |nv�thin10O feet ofesu�ace water aup�tyo/ �� tributary to a surface water aupp|y __ . �l �� Any ofscesspool or privy is within a Zone 1 of pub!ione|! �� � Any portion ofo cesspool orprk yiswbhinSO feet ufa private water sup�P|y�o!. LJ �� Any portion ofaoenspoo or pi-ivy ie less than 1o0 feet but greoter than, 5Ofeet � from a private water supply well vvi�h no -3coeptab|e water quality analysis. [This ' � system passes if the-. waR water ana|y-3is' performed at a DEp certified laboratory,for fecal co|ifnrm bacteria indicates absent and the presence ofammonia nitrogen and nitrate nitrogen is equal toor less than 5ppm. provided that no other tai|urecMteho are triggered. A copy of the analysis and chain nfcuStOdy must be, attached to this fornn] �l �� The nystem is a oesypool serving a facility with o design f|nw of2O0Ogpd �� �� 10.000gpd. The systemyails. | havedetennined that one ormore offlhe abovefai|ure ontoria exist esdescribed in 310 CMR 15,303. th*�efo/a 'the system fails. The syatarn owner should contact the Board of Hoaith -u determine wha�vi|! �e neoeo�ary�000rrooithofai|ure . � E) Large Systems: To be cmns[dered a|argo system the syutern must serve a faci|ityxith s � design flow of1D,ODOgpdbo1S.OUOgpd. � | � For large systems, you must indicate either^ves" or"no" bzoaoh of the oUovng, n sd questions in Section D. d �on to ^ Yes No ` -- �� the yo�/ ia��h� 400fo*tnfa nu�aoe dhnki:g �aierauoo|y E, 'he myxham is within 200feet of hibutsryho s nu�ece d�nk|niq vate/ a, �,!y r7 �� theaystem is located in anitrngen sensi�ivo area (!nte�ir� VVe||hes� Pro!p��ion ^~ �� Area — |VVPA) oramapped Zone || ofa public water supply vveU ` If you have answered "yes" to anyqunotion in Section Ethe nyn m in cons :d o c{cni-icon� Or answered "yes" in Section D above the large systemha3fi�� �d The ovvner or ��sr��o' nf��y!srga systern considered o nignilic8nt f.hneot under Section E Orfai|�d Und8r G�CUDn � Shs|| upgrE�n \�a ayutenninacoordonmawidh31OCK4R15.3O4. Th� �ynter� O�ner3hOukƒ CO��a[t �� ' regione| office of the Department. ' N ' � , '&0 � h ' � Commonwealth uf :Ma9SaChU58tts It � Title 5 Official NnsPOGtion Form Subsurface Sewage Disposal System Form - Not forVo|untaryAosessments _- ---__' _'___-_-- pmpo��_*Jureos Owner ------ ------------------------- - - inirnaioni, /~ /n repv/reum, everypaoe. ug^/oen x�� Zip Code -ate of|nspa�xon �����' K�' ��' <�<�' U'��t Check if the foUowino have beeni'done. You must indicate ^vas~ or ^no^ aato each of the fo!!o*in�� . Yes Nm '~~ ��. Pumping infovmabnn *eo provided by the owner, ououpant. or oarc of Hec|t [] Ln VVere any oft�e system onmponenc pumped out in -the previous ;�oweeks? Has the system received honna| flows in the pnevioun �/o week period? Fl r�^_ Have |arca volumes of water been in�oduo*dto�hesyat*m reoe�t|y or as p-� ol -� .� this inspection? Were as built plans of the xyoham obtained and examined? (|f they�ere not ~~ �~ available note ou N/4) ' Was -thofacility or dwelling inspacte�for signs nf sewage back up? �] [] Was tihe site inupaCted for oignsof break ouI? VVene all system components, ex:|Vdingthe SAS, located onsite? Were the septic tank manholes unroverad. openod, and the interior ofthe ta i-,k | ' inopo��ed for oondi�ion oft-he ba�|�o orieoa. ms�*ri�| of construot|on. dimensions, depthof!iquid, depth of sludge and depth ofscum? Was ,he facility owner(and occupants il different frorn owner) provided 1,vi-Th information nn �hap/oper maintenance Vf subsurface uevvecedinpoos! sys'ens' `i The size and location of the SVi/ Absorption System (S/\S) on 'heai'e -hes , been determined based on: l �1 Existing infnnnoUon. Forexnmp|e. a plan aithe Bcsrd of � Do&�nnin�d in the Me|d /��ny of the fei|un* �hberi� ne|�ted to Part, C is a' issue � ^� �~ approximation of�iutanoeinunaooaotob|e) [31OCN,11'R15.302(5)i D. Systern Information Residential Flow Conditions: / �unnberof bedrooms (desk]n): --------- Number of bedrooms (ao-us|)- -1----jj ----- l ' DESi(3N flow based onS1000R152O3 �or�xump|e� 11Ogpdx�ofb�dr�or�a�- �--!-�----- | ` � . � � . , m=-oso TM 0"dalmoect D"F,_-_:������°�s�� � Comm. onweafth of Massachusetts iR Tive 5 Official Inspection Form &,Wr_j=MW Subsunface Sewage Disposal System Form -Not for Vofluntary Assessments 1-10 Prooerty Address Are-,)' Owner Owner's NO-rnp_ info,marion is required for "VI every p ge. CityfTown State zj� Code D, System Information Descripuon: 7 0 30 x Number of current Does residence have a garbage grinder? Yes No Is laundry on a separate se,,Ajage system? fif yes se pFrale inspection required-I Yes FPi". No Laundry system inspected-, Yes N o Seasona! Use? Yes iillll�o Water meter readings, if available (last 2 years usage (gpdA Detail: Sump Pump? V Last date of occupancy-. 1'. Cornmerciallindustrial Flow Conditions: j Type of Establishment: Design flow (base-O' on 3,1 n CIVIR 1 Basis of 1 1 Flow (seats/persons/sq.ftl., etc.): Grease trar) present? Industrial waste haolding tar-;� present? _7 Non-sanitary waste discharged to the Tifle - ,system? No V'Vat_er meter readings, if avallable: A' Commonwealth of Massachusetts To"Ve 5 Official Inspection Form Affi��;!704 g WE W, Subsurface Sewage Disposal System Form Not for VoIuWaryAssessiments C4 A4 1-1 Propestv Address A-;e-1 41 11 Owner's Name informallon is V7-t required for — ever,pace. Cit, State Zip Code Daze o', D. System Information (cent.) Last date of occupancy/use'. Other(describe below)* i114 43,t?neral Information Pumping Records: �i /7/Z:4 5' .4 cc- UGC? C', Source of:n Was sysiern pumped as parr of the inspection? Yes 11-<N lo If-yes, volume pumped: ------ gallons How was quantity Pumped determined? —-------- Rep-son for pumping: Type of Sys.tern: Septic tank. distribution box, soil absorption system I Single cesspool -J Overflow cesspool L Privy Shared system (yes or no (if ves, attach previous insc)ection 'ecorcs, ir 171 innovative/Alternative technology. Attach a copy of the curren-L op:ration and maintenance contract (to be obtained from system oviner) and 2 inspection of the I/A system by system oper2l',Dr under cor::ti act� he D P aQpr Tj E aht tank. kitach a copy fi. '. it Other (describe): t5ms•OG108 a]inzoe-ti=,=c,-,Q., .'--:'2C= Commonwealtfi of .Massachuset-Fs Title 5 Official Inspection Form Subsurface Sewage Disposaf System Form Not- for Voluntary Assessments 7�4 9-7 Property Address Owner Owners Name ----- information is racuifed for -e 6f 1, -ion every page. Citty!rTown Sta.e ZiP C--(f e Dare S:A_c, D Svstem Information lcont.� �jj 11tp- q approximate ace I of al! components, date insta!Ied Ofkn'known) analsource of informeflon: 199;), kA!ere sewage odors detected when arriving at'he site? Yes Building Sewer (locate on site plan), Depth below grade." fee Material of construction: �cast iron 'El-4-0"P V C 17 other (explain): Distance from private water, supply well or suction line: feet Comments (on condition ofjoints, venting, evidence of leakage, etc.): Septic Tank ;locate on site Nan): Depth below grade: _7 Material of construction: I V F�concrete ❑ metal fiberglass ❑ polveth%ileye ,her (exoiairO If tank is metal, list Pace: Is age confirmed by a. Certificate Gf Compliance? (attach a copy ti f at of cer V=s F_" 3 Dimensions: Sludge depth: t5ins-ogicis Titie Official is Commonwealth of Massachusetts Title "'e'al Inspection Form 5 00110 1 Subsurface Sewage Disposal System Form trot for Voluntary Avssessrn ent s Q, 11 -4 JV1 P_I'q Property Address Ire-4�i Oviner Owner's Nam, info"n afl,on is L 61 12 reqUireiJ for' every page. City/Town Sf.ate, Zip CoJe Date ol iris _=C*IJ05. D. Systern 11-9forrraflon. (,coint-) Septic Tank (con".) Distance from top of siudge 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 o.'outlet tee or baffle How were dimensions determined? It Comments (on pumping recommendations. inlet and outlet tee or baffle condition, structural liquid !evels as related to outlet invert, evidence of ieakage: etc.).- "I /16�1 C 7/4 f/P kn C/ Grease Trap (locate on site plan): De,-"�h below grade: feEi. Mater;al of construction: lilt 1 F , concrete- F-I metal ❑ iibergiass pohletnylenie 7! Dimensions: Scum, thickness Distance from trJp of scum to top of o1j,"Jet tee or baffle Distance from bottom of scurn to bottorr; of outlet tee Date of last p U MP:n g: it I L , Commonweafth of Massachusetts Title 5 Official inspection Form ri z) Subsurface Sewage Dispospi Sy stern Form - No.for Voli-mlary Assessments -7- Property Address Owner Owner's Narne inlor,-921ion is rec uired for eve ry page. Citvf'rw a or e on S lt Zip Cede D2teof!ns'_ D. Systern linformation (Ccn- t-) CQ,-­nMeni,s (on pumping recommendations, inlet and oi.;`Llet tee or baffle conditior structu,ai liquid levels as related to outlet invert, ev'dence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan!: Depth below grade: Material of co;sfruction: concrete metal '71 fiberglass ❑ polyethylene F-I other (explain, Dimensions: Cp.oacitv: Design Flow: gaflors per day Alarm present: :11 Yes I No Alarm level: Alarnn in v-(or�inc- ordder: Yes No pp Date of last o--jmDing.: Daie Comments (condition of alarm and float switches, etc.): Attach copy of current pi-'ri-,ping contract (required). Is copy attached? Ye 5ins-09!08 _i'e5 Officip!Irscec:7. �o� Zz n--- Commonwealth of Massach-usefts Tie 5 Offlicial Inspection Form 11 IIWM�-� Subsurface Sewage Disposal Systant Form -Not fer Voluntary Assessments X Property Address Owner Owners Name _-- - information is reqpred for C-C I,-) Or z every page. Clitv/1-own State Gip Code l-)ate ofAs,ne(nkr� D, SyStern Inforrnation (cons.; Distribution Box (if present must be opened) (locale on' site plan): Depth, of liquid level above outiet invert Z-kl:ekl Cllcmments (note if box is level and distribution,to oulats equal, any evidence of solids carryo-ver. arty evidence of leakage into or out of box, etc.),- 0 Pump Chamber (locate on site plan): T11 .�1,��1l il Pumps in working order: F7 Yes F-1 No Alarms in working order: Yes i I No Comments (note condidon of pump chamber, conditior), of pumps and alopur-tenances. etc.):. Soil Absorption System SAS) (locate an site plan, excavation not required): If SAS not located, explain ti�vhy: Commonwealth of Massachusetts JR�Wg Title 5 U"Mcial Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments HF§7,! ALA �141111_1 Property Address ll�il+ �) ^ h Owner I Ownei's Nam informations reouired for jl every page. aityTown state Zip Code Date of4nspec6on D. Systern Information (cont.) Type: lea- ching pits F� leaching chambers nu mo,e r: leaching galleries number: leaching trenches number, ienc*h: P c2c` U x leaching fields / / number, d'mensions: overflow cesspool number'. Li in nova tive/alterinative system i ype/name of technology: Comments (note condition of soil, signs of hydraulic failure. level ofoondinc. damp soil, cond; ;or of vegetation, etc.)., G7, i-1 _SO/ ii Cesspools (cesspool must be .ournped as part of inspection) ,;locate on, site clan): Number and configuration Deo-kh -too of liouid to inlet invert Depth o"solids laver Depth of scum laver Dimensions of cesspool NA'aterials of construction indication of groundwater inflow cos Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsur-face Sewage Disposai Systern Form - Not, for Voluntary Assessments \7:'�.Aiff Proper—Address -e;; Owne.- Owner's Na2rn� info,oration is e /? required Tor —— r-A! ----- eve�),ppge. CityiTo�vn State 4!o CoCodeDsDatens--eAc.n D. Systern Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition, of vege-le.;,on. etc.): Privv (locate on site plan): Materials of construction: Dimensions Depth of sclids Comments (note condition of soil, signs of hydraulic failure, levei of Pond'ng, condition of veceta ]"',',. e,tc.): if it till I MOB Tiz'le Commonvvealth of Massachusetts Title 5 Official Inspection Form PIMP Subsu,M -e Sewage Disposal System Forni - Not for Voluintgry Assessments X ....... I. Property Address Owner Owner's Name inforrnatio'n is Irequired. lor 096ZL every page. City/Town State Zip Code pate of lrSPe,:AiOn D. System, �,nforrnzifion (cont.) Site Exarn, 17 Check S'cpe �" N V, V11 Check CO Fl Shal:',Dvi wells- Estimated dept'r. to -ii'ch cround vveteF: get Please indicate evil methods used to determine the high ground water elevation: F-1 Obtained. from system design plans on record V checked, date of design plan revievied: Date Observed site (abutting property/observation hole within 150 feet of SAS) Ea: Checked-with local Board of Health - explair: --*, ❑ Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must descri�De how you established the high ground water elevatio!n.- 7411)t C e 4 4i Before fiiing this Inspection Report, Wease S r:gee Repo 't Completeness Checklist on next 9- ace. C71,�Ia;inspection.Fcrr-,: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Volunt- y Assessments a r -Proper`y Address Z?�je 6i Owner's Namq,� Owner 'Information is required for L 4J--4 every page. City,—1 own SStzte 7ip Code Date Inspec-lon f E. Report- Completeness Checklist D1- Inspection S,L11i-nm-qry,. A,,, B, C, D, or E checked FInspection Summary D (System Failure. C,riteria Applicable to All Systems) completes E S'Yst--m Information— Estimated depth to high groundwater 10111s,"ketch of Sewage Disposal System either drawn on page 15 or attached in separate file + {{ JI 7 TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In 2%/0 Out 0 e2p^l CO. -tC,/L7 Owner -�::�-14 MSS �fz 4,2 N Tenant 2-/ L-1-C �Ac¢ Address t-, o 2. Address 4f tzau l LL �fyfy Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply t, 5. Hot Water Facilities ✓ 6. Heating Facilities CJ Tv z C 7. Lighting and Electrical Facilities ��,TP_G'Cv� S 8. Ventilation C.LC 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use S i-f",-T , 12. Exits 13. Installation and Maintenance of Structural / Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposals N p►� 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition ©/�N�L� Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here Citizen Web Request Page 1 of 2 r.� I 45P 5.M."5{I �y� I Citizen Request Management - Internal Use I Request ID: 26074 Created: 7/10/2009 3:44:30 PM ' Status: Assigned To Staff Assigned To: Cabot, Jaime j Health Office I Anonymous: Yes Category: Chapter II : Housing Substandard E.C. Date: 7/24/2009 i Created By: Parvin, Lindsay Citations: '4 Health Office $_ Time Worked: 0 Response Time: 0 -� Requestor Details: �- Email: ,. Parcel Number: Map: 168 Block: 028 Lot: 000 Request: Requestor reports a person living in the home without gas or electricity. Request Work History: Internal Note History: System entry on 7/10/2009 3:44:30 PM: Assigned to Cabot, Jaime http://issgl2/IntemalWRS/WRequestPrint.aspx?ID=26074 7/13/2009 Parcel Detail Page 1 of 1 ' Parcel ID 168-028 Lot Developer LOT 43 L Location 48 AUTUMN DRIVE 1 Pri Frontage 162 Sec Sec Road BENT TREE DRIVE ( Frontage 139 village CENTERVILLE I Fire District IC-O-MM Sewer Acct I Road Index 0056 Asbuilt Septic Scan: Interactive 168028 1 Map ' *1 ` Owner Info Owner KEATING, JAMES J & VERONICA C Co-owner Streets 48 AUTUMN DRIVE Street2 city CENTERVILLE State MA zip 02632 Country ,US - Land Info Acres 0.38 use Single Fam MDL-01 zoning RC j Nghbd ,0106 Topography Above Street I Road Paved utilities Septic,Gas,Public Water I Location http://issgl2/Intranet/Propdata/ParcelDetail.aspx?ID=10941 7/10/2009 r COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION r oa � TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address• /—/ AA-�w k"i V7 Owners Name: T'Gt ole Owner's Address: &4 9"-/ t Date of Inspection: Name of Inspector•glease print) "/a!a k- o IS-611 J Company Name: l/'r; — jzEG` _ Mailing Address: Zz Telephone Number:�,� _ [ �= CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Fails Inspector's Signature: G�/?L� Date: The system inspector shall submit 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 f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: C4 44 M ✓� Qi" G v► �h O�-6 30� Owner: ��o� ✓) Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste ses: e 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 p replaced re aced.The system, paced or y m,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: Title G ►.,enartinn 1 nrm�ii�i�nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: UrL--l it t t M✓1 Z�?/ Owner: o7 ✓Date of Inspection: C. Further Evaluation is Required by the Board of Health: ZConditions exist which require further evaluation by the Board of Health in order to determine if the s st is failing to protect public health, safety or the environment. y em I. 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: T Rio ; ir�ro� ,�r Rnrm �ii;i�nnn 3 Page 4 of I 1 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: TO Z4UX 4 010 .2h �✓v�. e, 0a1-to 3d4, Owner: Go► t Date of Inspection: / D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No / - �p 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 ,plogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or spool id depth in cesspool is less than 6"below invert or available volume is less than%a.day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ,eflimes pumped �y 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 ter supply. ,ny portion of a cesspool or privy is within a Zone 1 of a public well. 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/Nio)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• 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 one 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. Tirin Tncncnfinn 17nrM All ci')nnn 4 Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Al M 41 e 06�r3— Owner: -ifcl+t✓! Date of Inspection: O Check if the following have been done.You must indicate "yes"or"no"as to each of the following: Yes o ZPumping information was provided by the owner,occupant,or Board of Health any of the system components pumped out in the previous two weeks? _ Has t system received normal flows in the previous two week period? _ e introduced to the system recently or as art of this inspection'? Have large volumes of water been y y p p _ 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? J _ Was the site inspected for signs of break out? v _ 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. 1,'�Deterrnined 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)] Titlo (ncnortinn 17- An;/Innn 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,Q SYSTEM INFORMATION Property Address: O !,f 4 t4A✓t Owner: lye t y Date of Inspection: FLOW CONDITIONS RESIDENTIAL ''!! n Number of bedrooms(design): `-�' Number of bedrooms(actual): 91 / DESIGN flow based on 310 CNM 15.203(for example: 110 gpd x#of bedrooms) T Number of current residents: Does residence have a garbage grinder(yes or no): / 'V Is laundry on a separate sewage system e .or no):�W[if yes separate inspection required] Laundry system inspected( e or no): Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):— Last date of occupancy: 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 1 Source of information: M4— '0;�7w ✓k d/ c) L'v lam✓ Was system pumped as part of the inspection(yes or no If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYP F 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 c mponents,date installed(if known) and so ce of informat' Were sewage odors detected when arriving at the site(yes or no): Itlo T rlo G �nCY�P *1lltl FArT ��I`�7 n11'1 6 f ' Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �tfTel tmo /�,•- L!Ol_ Owner: I Date of Inspection: 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: Material of construction:_cony/ Crete metal_fiberglass_polyethylene —other(explain) If tank is metal list age:T Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Q� Dimensions: x U Sludge depth: Distance from top of sledge to bottom of outlet tee or baffle: a 9 Scum thickness: vZ Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to botto of outlet tge or baffle: How were dimensions determined: o Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as re ated to outlet invert,evidence of leakage,et .): m 1n r o wf" G and e s ► �, VO C7 00 �vvi 0 -Po s GREASE TRAP:_(ocate 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.): TaIA fncr+arl nn Gnrm �n v�nnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Al ►M o 1-2/ ��— Owner• Date of Inspection: WoJ6 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/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: (40/0-1 al 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,et- 5 0 X il/0 Sm/i'js X 0 le C-5; PUMP CHAMBER: /r/ (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.): Talo ; fncnortinn Gnrm All;/1nnn 3 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 4 Orki O`er Owner: Date of Inspection: / SOIL ABSORPTION SYST M (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leac ' galleries,number:_ r c ' g trenches, number, length: leaching fields,number, dimensions: p2 L? )c- 3 overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(n to condition of soil, signs of hydraulic fai ure,level of ponding,damp soil,condition of vegetation, etc.): 7o 0C l(0 C �O! �l C��1 G�o tea, 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 or no): 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.): Titles S Inc„a�t:nn Gnrm A/7:nnnn 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: A-U vV7 h a- /9 0,- c 3J-, Owner: ti Date of Inspection: p�j 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. V 40 sco An - 3 11�- 39 �7 3 - 35 1 � w r /- 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: od--c 3,)-- Owner: Z �" Date of Inspection: 1 SITE EXAM Slope o l7 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: Qbscfved site(abutting property/observation hole within 15etof SA) Checked with local Board of Health-explain: // Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must descriy how you established the high r and waterflevatio1 p r e Q r . O G✓ o• / ok /`at e_ 0 11 �'�O�t w c✓ (,tea r / 5 /9 . T T:tlu G f--fi— 17—�i�si�nnn TOWN OF BARNSTABLE LOCATION ��f"u�1� �� SEWAGE # VILLAGE G eY7`r1'l 111e ASSESSOR'S MAP& LOT -�-�- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 000 6a L LEACHING FACILITY: (type) Ff t C (size)0QX 3d X l NO.OF BEDROOMS 7 BUILDER O �OWNE / PERMUDATE: Z/,3� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility r� 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 � 1 � 14 1 C/1 s4. t ,•n,LS V/7 ys 8h� No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETT Zippticatiou for Migozal braem Cow5truction Permit Application is hereby made for a Permit to Construct( )or Repair(VI)an On-site Sewage Disposal System at: Location Address or Lot No. !�" �yT- ON/, 4� Owner's Name,Address and Tel.No. Assessor's Map/Parcel q Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder(/to Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ,�/? gallons per day. Calculated daily flow '3 3O gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or_Mteratio s(Ans�w�r whe�aVhle, n 'G .l7,PiQI%d�fe�9 I`le, f"D LX;�Ti'�IC. �L'ZZO 72"'l � 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 iss%p B o e / Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued 6'1 -7 No. Fee j j" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS $w, 2p plication for Dio po0al *pgtem Cons&urtion Permit Application is hereby made for a Permit to Construct( )or Repair(v an On-site Sewage Disposal System at: t r Location Address or Lot No. 414,1— Vow dr Owner's Name,Address and Tel.No. Assessor's Map/Parcel yZ 33Z Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 61 xa Type of Building: ll�� Dwelling No.of Bedrooms 7 Garbage Grinder( � i Other Type of Building A!rAY^P No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ///7 gallons per day. Calculated daily flow 3✓3D gallons. Plan Date Number of sheets Revision Date Title r Description of Soil Nature of Repairs or Alterations(Answer when ap lic"ble) rC' , t� e4 s7f 17« t Date last inspected: Agreement: j 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 thi B099d o�?ealth.Signed � Date Application Approved by Date r Application Disapproved for the following reasons f - Permit No. Date Issued ---------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS t Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposq System in tailed( )or repaired/replaced(✓)on by l��iSS Installer r 457. at /f 1�)`Gl�I /. 1','e w 17_/Z/i/ /e' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Date Inspector t THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. E _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ;Dtgo!9a1 *pgtem Con! trurtion Permit - r Permission is hereby granted to 1v�r1a Z� to construct( ' )repair(y/j an On-site Sewage System located at No.# l6 dd711WW w c Street and as described in the above Application for Disposal System Construction Permit. q "7 17/3 A;7 No. Bate/ s The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction igust be completed within three years of the date below. Date: / 7 Approved by � Board of Health i �v l pry i 41LA L i I TOWN OF BARNSTABLE I.O:' ►T10N "� G� �l/ �'I �f SEWAGE # ✓L'+��AGE GGy! it'7/t�fG� _ASSESSOR'S MAP& LOT -�-� INS TALLER'S NAME&PHONE NO. G� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Fit C cL (size)r2:"3d X / NO.OF BEDROOMS BUILDER O OWNE �6 1 c5'S PERMITDATE: 2-13/P COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility r� 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 f pl ' TOWN OF BARNSTABLE -LOCATION ���''� SEWAGE # VILLAGE V l ' ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO.V yh So., L�C c7✓�V, . �yo� l se., SEPTIC TANK CAPACITY xS O n G LEACHING FACILITY:(type) /J (size) NO. OF BEDROOMS S PRIVATE WELL OR PUBLIC WATER U BUILDER OR OWNER /• S S DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r ' r ' y( �0 3 4-0 e � � 2 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, �o ® � � , hereby certify that the application for disposal works construction permit signed by me dated // 04 7 , concerning the property located at �� � n ��: meets all of the following criteria: /There w'are no wetlands within 300 feet of the proposed septic system /There are no private wells within 150 feet of the proposed septic system /The observed groundwater table is 14 feet or greater below the bottom of the leaching facility ere is no increase in flow and/or change in use proposed �7 There are no variances requested or needed. SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert