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0121 BEECH LEAF ISLAND ROAD - Health
121 BEECH LEAF ISLAND RD, C'VILLE A= 187 063.001 /M JAgECYC(F�Co UPC 12543 tfAstmOs. MN f oFr Town of Barnstable Inspectional Services Department ` B"`MAS& ` Public Health Division i679• 'fin r9° 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7021 0350 0000 1549 3624 June 21, 2021 MATHIEU, GREGG E & DEBORAH J 121 BEECH LEAF ISLAND ROAD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 121 Beech Leaf Island Road, Centerville, MA was inspected on 06/04/2021 by Michael Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • H-10 septic tank and distribution box in driveway. See attached policy. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH omas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\121 Beech Leaf Island Road Centerville.doc Tomin of Barnstable BARMA� g Inspectional Services Department lfDMn� Public Health Division 200 Main Street; I lyannis MA 02601 1 pumas A ML KCif11. I N utli.c SoX-862,404 I AX SUg-79o-h304 Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS Code §360-44 and "I itle \ . 31 O C An -x'- marked in the o is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA o Discharge or ponding of effluent to the surface. of the ground o Pumping more than 4 times during the last year not due to clogged or o!)structed Ripe. use due to an overloaded or clogged SAS or cesspool Back, of se��age into the ho u Structurally unsound septic tank or SAS ONE 1 YEAR DEADLINE CRITERIA n Static liquid level in the distribution box is above the outlet mvei-i due to an overloaded or clogged SAS or cesspool t below the high groundwater elevation A portion o the SAS. cesspool. or privy is f A portion of the cesspool is located within a lone 1 to a public well of a A portion i�f the cesspool is located \\-ithin SC�i� st stemh�assee ifilee Water>anal yIsis %,Vith no acceptable Water cualit) analysis. ( I I 1 I indicates the well is 1-ree from pollution). 1'\N/U 2 YEAR DEADLINE CRITERIA Single Cesspool r, Ally ..conditionally passed systems" (broken cover. relocation of a pipe. relocation of a drlve\wa� flue to 11-1 O components etc) Leaching Facility with standing liquid level at ()I- i'l)o e the insert pipe leer I own Co(le §360-20 h) ()TNER o r 1 I Repair deadline: 0\SEPTIC',,DEADLINES 10 REPAIR FAILED SYSI EMS doc Commonwealth of Massachusetts ou 3-ool Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name / information is required for every Centerville y Ma. 02632 6-4-21 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. Inspector Information 51#. 164S'( on the computer, Michael Sears use only the tab key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. ,Q Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 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 X����NOFthjgq 2. ® Conditionally Passes MI EL g: o: SEARS 3. ❑ Needs Further Evaluation by the Local Approving Authority 10: No.SI14430 :*` O c 4. ❑ Fails 6-4-21 Inspector's Sig 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. 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 1 of 18 Commonwealth of Massachusetts ► Title 5 Official Inspection Form '' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. Cityrrown 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: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank and D box are both H10 and are located under stone driveway 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. Cityrrown 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 obstructedpipe(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 Forth:Subsurface Sewage Disposal System-Page 3 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. City/Town State Zip Code Date of Ins P ection 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Ip Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. Citylrown 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 Y2 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. CityrTown 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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): 660 Description: Design flow on plan is 330x2% 660 gpd 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2019- 80000 gal g ( y g (gpd))' 2020- 85000 gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 f Commonwealth of Massachusetts :. Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. City/Town 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: May 2019 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. City/Town 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 ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from,system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2- 500 gal chambers 3-9-01 #2001-166 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 26"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 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 ,4.p Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 16" I! Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape, plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gal tank H10 with in and out tees in place, covers are 16" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form J. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. City/Town 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 Title 5 Official Inspection Form _ I; Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. City/Town 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.): D Box is 16x16 H10 with 2 outlet pipes, box is 28" below grade t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. City/Town 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: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ 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 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is Centerville Ma. 02632 6-4-21 required for every 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.): SAS is 3 flowdiffussors and 2- 500 gal drywells, all chambers are clean and dry with no sign of failure 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 Commonwealth of Massachusetts Title 5 Official Inspection Form r, 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. Cityfrown 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 ondin condition of vegetation, 9 Y P 9, 9 i etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form - �1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is Centerville Ma. 02632 6-4-21 required for every 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 A g OI g �- la p .X -a© t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l; u 121 Beach Leaf Island Rd. Property Address Deborah Mathieu Owner Owner's Name information is required for every Centerville Ma. 02632 6-4-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water Check cellar ® Shallow wells 9' Estimated depth to high ground water: 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: 11-13-85 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Ground water at 9' per plan bottom of SAS 6' 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 121 Beach Leaf Island Rd. _ u� Property Address Deborah Mathieu Owner Owner's Name information is Centerville Ma. 02632 6-4-21 required for every _ - - - -- page. Cityfrown 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 C�.tt ecy3sr 3` Gcv�n svq�-tr t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No.� 4(0 Fee $ 5 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for ;igpoof bpgtem Construction Vermit Application for a Permit to Construct( )Repair4X)Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No-1 21 Beach 1 ea f Island Owner's Name,Address and Tel.No. Road Centerville,Mass. 02632 Annely Hannan Assessor'sMap/Parcel G6� 121 Beach Leaf Island Road eentervi 02632 Installer's Name,Address,and Tel.No.5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 lBox 66 Centerville,Mass. 02632 Type of Building: DwellingXX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Loamy sand to hard black -gci 1 to sand Nature of Repairs or Alterations(Answer when applicable)Add in g 2-5 0 0 gallon le a c h i nrT leaching chambers packed in 4 ' of 1 "' stone.Existin 1 —septic tank and 4-flow diffussors.and one distribution box_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this B d He lth. Signed - Date -9 Application Approved by Date I Application Disapproved for the following reasons Permit No. Date Issued ' — 46 50.00 No. C� Fee THE COMMONWEA H OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS rication for �Diooar *Proem Construction Permit Application for a Permit to Construct( )RepairYX )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No l 21 Beach 1 e a f Island Owner's Name,Address and Tel.No. Road Centerville,Mass.02632 Annely Hannan Assessor'sMap/Parcel /CM 63 G 6/ 121 Beach Leaf Island Road 0 Centerville Mass- 02632 Installer's Name,Address,and Tel.No.5 0 8—7 7 5—.3 V, 8 Designer's Name,Address and Tel.No. J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: DwellingXX, No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Loamy sand to hard black soil to sand. Nature of Repairs or Alterations(Answer when applicable)Adding 2-�-500 ~gallon leaching leaching chambers packed in 4 ' of 11" stone.Existing 1000 gallon septic rank ana 4-tiow dittussors.and one distribution box., 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 atertifi- cate of Compliance has been issuey by this B xd He lth. Signed Date Application Approved by Date- d) Application Disapproved for the following reasons Permit No. Date Issued ------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Z&VI C'ertificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(XX)Upgraded( ) Ab dd ed( )byJ.P.Macomber & Son Inc. at 12 Beachlear IsIanct Road Centerville,Mass. has been constructed in acc rdance with the provisions of Title 5 and the for Disposal System Construction Permit No.�� I `� dated Z! v / Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & Son Inc, The issuance of this_permit shoJI not be construed as a guarantee that the syste ill�netion s desi ned. Date 2/ ® t Inspector. r r W G ---------- No. /G 6 /��� �6 �-OQ� ---- Fe� 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS liopoal *pgtem Conotruction Permit Permission is hereby granted to Construct( )Repair�X)Upgrade( )Abandon( ) Systemlocatedat 121 Beach Leaf Island Road Centerville,Mass, . and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three ears of the date of s- t. ` Date: ���� p y Approved by./M l/6/99 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, Joseph P. Macomber Jx hereby certify that the application for disposal works construction permit signed by me dated 3/9/01 concerning the property located at 121 Beach Leaf Island Road Centervil4&ts all of the following criteria: /The failed system is connected to a residential dwelling only. There are no commercial or business cues associated with the dwelling. +' The soil is classified as CLASS I and the percolation rate is less than or equal to S minutes per inch. b' There are no wetlands within 100 feet of the proposed septic system VThere are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. /T-he bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor �ethod when applicable) t✓ If the S.A.S. will be located with 250 feet of an vegetated wetlands the bottom of the proposed Y g � P Po leaching facility will no be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) ` /, B) G.W. Elevation +the MAX. High G.W. Adjustment. D1FERENCE BETWEEN A and B 1/ / SIGNED : DATE: (Sketch proposed plan of system on back). Q:health folder,cen i Existing 3-flow diffussors Side to side A. Distributio Two new 500 gallon Box 1000 , gallo leaching chambers. Tank. 25 'X13 'X2 ' _ r R TOWN OF BARNS TABLE (� LOCATION./z/ eAc/l L eA l 15 ( ',41j?RAEWAGE #` Z?0/ - / 6 VILLAGE C ewleR y111e ASSESSOR'S MAP & LOT/9'7- INSTALLER'S NAME&PHONE NO. J 114 A C o"4 ell r S C SEPTIC TANK CAPACITY LEACHING FACII.I'I'Y: (type).x-FL 0 40 C f,/ ,4f8 ef/ s (size) rU O. G NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 3 " _v COMPLIANCE DATE: — Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If,any wells exist. on site.or.within 200 feet of leaching facility). Feet Edge of Wetland and Leaching Facility(If any wetlands exist j within 300'feet of leaching facility) Feet i . Furnished by Oil i I 3 ' �.. Sc 1 r-r- .� c,Ci M co 4 VA V v� r cp � r i )3aT H I I- Cj i TOWN OF BARNSTABLE (� 1 LOCATION/A/ ReAcIl L eA l= 15 L A V,0,9AEWAGE #10 VILLAGE C eNfieR IV//le ASSESSOR'S MAP & LOT 7-63' INSTALLER'S NAME&PHONE NO. _rR A4 A C CJ-,4 IQ M t SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Z—A4 040 C&d-4fl_4 e,6 (size) d_a O° C NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: V COMPLIANCE DATE: 3—Z Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 2 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 c �, TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE d1V ZeP1&4. ASSESSOR'S MAP & LOT2$ 6 00 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) td mdr^o (size) NO. OF BEDROOMS BUILDER OR OWNER °Lf ti9 - PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility I Feet. Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) V Feet Edge of Wetland and Leaching Facility(If any wetlands a st within 300 fe of leac g f ) Feet Furnishe N V, RECEIVED as' A P R 2 7 1998 TOWN T OFBARNS ABLE �•,� HEALTH DEPT. J �P ��6 E, a Fps... '... ` THE COMMON EALT.JH OF MASSACHUSETTS BOARD OF HEALTH SUBJECT TO APPROVAL OF J' — BA!';NST ............Cf .M......................OF rL1�3�S ,Cr..._...----------------•--...-_.-.--.-ABLE CONSERVATION _ 3` 1 COMMISSION Aliptiration for Bisposal IVorkii Tnwitrnrtion Frrutit Application is hereby made for a Permit to Construct ( D�, or Repair ( ) an Individual Sewage Disposal System at: Location-Address .l.!-v.l 14. ---•- w i A........................................... �.kJ.�.'�. k��---�'-=�—o caner Address \` Installer Address t- Q Type of Building Size Lot_ , ------Sq. feet U Dwelling—No. of Bedrooms.______._ __ Expansion Attic 40 Garbage Grinder YE)S '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ............................................... W Design Flow______ti`Sfi ............gallons per person per day. Total daily flow......` 4 ---••••-__.------•---•--•-gallons. WSeptic Tank—Liquid capacityl5LOgallons Length.1.0�__CCa... Width.5.i_Z r_ Diameter-_-=7 ".. Depth -.•--. x Disposal Trench—No. .................... Width..._1.(p......... Total Length.Z? S......... Total leaching area.._AC._.1.....sq. ft. 3 Seepage Pit No..............A..).... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box q45 Dosin tank (Ky '—' Percolation Test Results Performed by i ` ..1. ��.__� ................... Date..��.`..� ...................... a Test Pit No. 1../— .._..minutes per inch Depth of Test Pit.....ID......... Depth to ground water--- .................. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------•--------------------------------------------------------•--•-------......._-•--........-----•......................................................... 0 Description of Soil---0. --Z.--A `1IQ=L...A=X10...mia5AMAD x V --- .------------------- ------------------------- ..... ----------- ----------------- •--------------------------- ----------------- •----------------------------------------------- W •-•••-----------------------------------------•-•-•-----------•-----•-----•-•-----------•--•••---•-•---•••-•---•-----•------•---------••----•••-•--------•--•--•••••--••••-••......------•---•----.--•-- 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 TITiE 5 of the State Sanitary Code— The un sign f rther a e of to place the system in operation until a Certificate of Compliance has be ssued by the o rd alth. Signed....... ........ . . .......................•• .............. _. Date Application Approved BYac :l Date Application Disapproved for the following reasons:-------•----------------------------•-----------------------••------------------•------------------------------- -•---------•-------••...............•-----•-•-------••••.......---•----••-----•••--......---------••-----•-••-••-•-••-•--•--••-----•••-••--••••••----------•-----••-••----•----•----••--•••------....... Date Permit No. ----- Issued ....................................................... Z. No..... .. ... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH �Ov i r.A.. ................OF �Z�V�`�': ��?L-C�. Appliratinn for Diiipaa al Morks Tonstrurtion Permit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: �-L-I-\r N5 :�� �.c! may. .. t=. _'—Location-Address _ �L� _or,-,Lot No. 7�? �_\i 1 1A D 1 L_\) I ,� ° \y{1 li� w \ �l ti-1 e7� �—C ..............'.................••.......-----.................................. •••--•-----•........._.......---................................ .............. ©caner l Address Installer Address _ Type of Building / Size Lot__5 ;:,1 ......Sq. feetT Dwelling—No. of Bedrooms..........5...............................Expansion Attic ( �j Garbage Grinder (` 16 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) QI Other fixtures ............................... .. W Design Flow.......5_��_._ �6..........._gallons per person per day. Total daily flow.......`{ .............................gallons. 1:4 Septic Tank—Liquid capacityAal—'gallons Length.A'•_-�_._� Width._ _.' .. Diameter..._--" Depth.:Ss'..-'d.r. Disposal Trench—No..................... Width..... ........ Total Length....- ........ Total leaching area___--A ....sq. ft. Seepage Pit No---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( 5 Dosing,fank ( _ Percolation Test Results Performed by..._l'1 ?_ � _._ _.�? _________________ Date.._.��`_� a aTest Pit No. 1..f-_Z__....minutes per inch Depth of Test Pit_____-Q........ Depth to ground water----)................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ............................... •-•--•••--•-••••--••••••---•-•---••.......••-•------•--•-•-......----••..................•--•--...-••-•-------•--•----•.--•- 0 Description of Soil--- J A K t 7:pF\fut� U ----•-•••••--•----•••-•-•-•-•-•--••--•---••-•-•------------•.................•••-............-•-•••-----•---••--•------.....•-•-.....----•--•••-----••--••-..........-•--•...._---------•-•...........-- W -•--•------•----......--•---•--•-••••-••----•••-••-••--••----------•----•---•----------------•••-••-----------••••••••-----•••••--------••-•-•-••--••-•---------•--•••--•-......--•••-......-••---.-•--- 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 TITS 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...................................................................................... ................................ ate A lication Approved B �-' � •f/ ! `-- � -~. - .___r1/� PP PP y---••------t x-m-�.. ..4 f-x! ....................... �1 Date Application Disapproved for the following reasons:-----•---------------------------------------------------...................................................... --------------------••••-•---•-•----••--••••--••••--••••-•-•..................--•------------•-----•••-•---------....._.....----••-••---•---••••--------------•---••-••--•••••••-----•-••••----•-----•-- e� Date PermitNo......'-g- -7" ---------•---•---•--• Issued................................................•--•---- < � kt 70 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD yOF HEALTH ........7 1.................OF...........1."e cz-,!^ f ......................................... Tnrtif iratr of Tomph anre THIS IS TO ERTIFY, That the Individual Sewage Disposal System constructed ()<) or Repaired ( ) t In taller o has been installed in accordance with the provisioYfs of TITIE 5 of The State Sanitary Code,( od as described in the application for Disposal Works Construction Permit No.......... SP dated_....9//L' �. ` .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................... -a� ................................ Inspector........... - .r-?. ........................................................ y THE COMMONWEALTH OF MASSACHUSETTS �jD BOARD OF HEALTH c.� ...........OF............. s No- ------ _ FEE... �- - Dilyaliaal Ivor ii Tnnstrnrtion ermit Permission is hereby granted.............4�''-----... ,.....--- *`" ..............................--...................................................... to Construct ( ) or Repair ( ) an Individual Sewage Di posal System at No.. d?" eZ._ *r s ......... �'.�Sl......Nk......C..�, „�................... Street �/ E as shown on the application for Disposal Works Construction Permit No.__ E =_ •��Dated....._._ __f' `3 ............... aL# ..................................................... ............................................. Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS L 00K%�1 CA THE COMMONWdEALT,H2OF MASSACHUSETTS `. §UDJECT TO APPROVAL OF B -RD OF HEALTH MRNOTABLE CONtERVATION FISSION .......-- F... , !3S -C� Appliration for Bt ; 0-rks :Tnnstrur inn ramit Application is hereby made for a rmit to Co t.u_ct X or Repair ( ) an Individual Sewage Disposal S tem at: n r jjg _ Lo'lion- ddress ------------ 1l� Owner dress a 7a T. ...Q �Z............... ... .............•------•-- .----...r ..- J 1T tA(.. ........... Installer Address UType of Building Size Lot._ na�..._..Sq. f et,-q Dwelling—No. of Bedrooms......................................Expansion ttic (� age Grinder `T�' '4 Other—Type T e of Building No. of ersons..........__ P-i YP g --•----------------••-----•• P ----- --------- Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------•--••-------•-------•-----•-•--••••-----------• ------••----.....•--------------•-.....----.....------•------_.. Design Flow........ .........gallons per person per day. Total daily �w------- .........................gallons. Septic Tank—Liquid"capacity.1, _____.galIons Length_Wm(p... Width.5.-B•-- Diameter....^........ Depth- ----- -•.- r '''' Disposal Trench—No...__..... ......... Width-.....S.'P....... Total Length...20........ Total leaching area.._'J_&i_'j._-.sq. ft. Seepage Pit No...............Y--- ... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (�(��j DosipS tank (kja> aPercolation Test Results Performed by. I �-_..1 .-__________________ Date._Il--- - �_•------_-- Test Pit No. 1.....4%-_-minutes per inch Depth of Test Pit----It>........ Depth to ground water.._................ Gz., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ........... -- ---- .......................................... • --------•-------------•---•...-----.----- O Description of Soil....-.... x W -----•--•--•..............•---•----•---•--.--•-•-•••-----•----•-----•--•-•-----•-•--------••-•-••------. . •----•--•---....-------•---•------------.....-•-...---------•--•-•---..........------ V Nature of Repairs or Alte tions—Answer when applicable. t�NIN& I AJSS -4vvjS _ n -------------- Agreement: `''S- P ILfNN The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 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.................... ................................................................ Application Approved By--------- •. ----•-cam!_ .------. 12 ..•-----. Date Application Disapproved for the following reasons:-•--------•-----•••-------•--------------------•----•-----••--•-•-------------•----------•-•--•-•---...---....-- ...............................•--•-•---.......--•--------•-••--•---------...--------........------....--------•--..._...-----------•-----------•--••----------•----••----------•----•-•------------•-•- Date PermitNo. ..�.� -..------••--------------- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..CJ. !n................OF.... f ............................. ...... .... . (9rdifirFatr of ToutpfiFanrr T. S TO qERTIFY, That the Individual Sewage Disposal System constructed ( Lam. Repaired ( ) by............. ............................•----.. -------•------•------------------------......---------------..._......--------•---....----- Installer I has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._ ...... dated----- 1r:R 6P.......... .... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 232 �wn.................OF......... r-n. .-----•------..................---•. _ No ........•-•-•- ...E� nrkg TIn#rnrtion rrutit Permission is hereby granted------ -?6... ..................•-------•-•------W&4;;;----------------------------------------------------- to Construes/ Repair ( an In ivldual S age Disposal Syst �" atNo... ------• ------... Street ''• �n as shown on the application for Disposal Works Construction Permit N ......Z F,CF ' ? led.. _2&2 .................. ........- d o e......._ .................� s DATE................................................................................. FORM .1255 HOBBS & WARREN. INC., PUBLISHERS J No. . ......... FEB.. ........;.. THE COMMONWEALTH OF MASSACHUSETTS __--- BOARD OF HEALTH ..................OF....... t: t�NS6 ��( Cam..... ...... Appliratiou for Disposal Works Toes rurtiun Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal S tem at: Location-Address orwLot No. .........................=-�'°.-�---.....��u�.----.-'-��------------- �z ..............` � �yv.j�t��1 LAC�. Owner r a •!-it kl !� b �f� 4� _...... xtC� �t� :`air=t :..� ss �._.... 1( .` .... ... ---------- .......- -•---------------------- Installer Address yU Type of Building Size Lot_., ot_.. 1�_.�.....Sq. feet ,.. � Dwelling—No. of Bedrooms.___`_-.....................................Expansion Attic ( �..,��� Garbage Grinder (V - aOther,—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ----------------------------------------- W Design Flow...-.....::.................................gallons per person per day. Total daily flow__.......+....._.........__._..._...........gallons. G4 Septic Tank—Liquid capacity_.!-S� gallons Length._�SJ:'_(>#.. Width._ +: '?__ Diameter____._....... Depth...����_.. x Disposal Trench—No. ____......a......._. Width........l-ira...... Total Length..... ....... Total leaching area--- t.. --.sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosigg)tank �+ '-' Percolation Test Results Performed by...%'4X ..1 .(r=....=. :-.................. Date_._ ._ . 2d e)_� W i - '----- I -T- -: ';--------- Test Pit No. 1......4.-!._minutes per inch Depth of Test Pit......:............ Depth to ground water............ ____..__.__. rZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ri ----•-.... ----•----------------•--.................... ---•-----------•---------•--•----•--------- O Description of Soil '-� -�: �.: 4 �,u� � --�� H,. ✓ !-r:2s_ i - 1_ �'_'�; l4; ~.l Atu 1D x ---•- . - V --------------------------- •............... -------------------------- •--------------------------------------------------------------------------------------------- .----•-------•-----•-----•----------- W U Nature of Repairs or Alterations—Answer when applicable ! �16t4 .. tA,145s. li(1a s-r_. Agreement: 14t-5 I J1J.:5,r M C l N - I The undersigned agrees to install the aforedescribed ndividual Sewage Disposal System in accordance with the provisions of TITiZ- 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........ .. r .4�!._....._ l ate Application Disapproved for the following reasons-----------------•-----•---------•-------------------•-•------------------------•--------------•----...---.••--- ..............................----------------------•-•--------•----•••-•-------•------•--•--•---------------------------•--•---t-------------------------•---••---------------------------•----------. Date PermitNo. �'_.r��.:�...................•-•-----...... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f' - ta..............OF......\ .!. ....................................... (9rdifirate of Tontpliam THL.F IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) epaired ( ) by.............. `�.• �"--•-----•--------------- Installer has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... .'"`e ' ...... dated__-.._7-__ /2,o_/. ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTSfN -'Azar BOARD OF HEALTH . r,.............._OF.......... ................................... Dispoti tQmurk$ 011nstr ion rrutit Permission is hereby granted........._ , ------C)A-w" to Construct (%,,)r�r Repair ( )_an Individual Sewage Disposal System atNo. . .. ` .... . . .i = -----•---- rs)--•---------------------------•-------.----- reet as shown on the application for Disposal Works Construction Permit N °=......'.�:.. Dated.._ ��2�---------------- ----------- �_ .--------••-•-•------.. Board of 'Health DATE................................................................................ r , 4 P-ORM 1255 .HOBBS & WARREN. INC.. PUBLISHERS BAXTER &' NYE, INC. Professional Land Surveyors and Civil Engineers 812 Main Street •Osterville, Massachusetts_ 02655 Tel. (508) 428-9131 FAX (508) 428-3750 WILLIAM C.NYE, P.L.S. -President PETER SULLIVAN, P.E. -Vice President-Engineering RICHARD A. BAXTER, P.L.S.-Vice President September 30 , 1993 Mr . Gerry Dunning Board of Health Town of Barnstable P.Q. Box 534 Hyannis , Ma 02601 Re: Lot 29 Beech Leaf Island , Cent . Dear Gerry: I At the request of Peter Brown , James Driscoll Excavating , Baxter & Nye I.nc . made an inspection on this date of the septic system installed on the subject lot . The septic system has been installed in accordance with the Board of Health Plan dated Feb 14 , 1986 for Thornberry Inc . - Very truly yours , 00 B er & N e I cO et�ullivan , P. E . Vice President cc : Bayside Building Co. • ���P�,ZH OF ��S°9 . 0 PETERS, ; SULLIVAN t''' No. 29733 xel s�`�'I,�A� 6P�vf MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS Itih/ 'o• — - t IuV I��G�D IuV pvG — � 13.1 7- OL �y t TAO� • Co��G'['ED 1. N __ .. . _. _ ..: Oc3SEawt� Ems• 5,a--� - �o , d - _ W a.T bj7— q _ ..._._. PETER _ I U SULLIVAN TN I ^ .No: 29733. t' JSIONaL E FLA r-l of L A kJ-i:D x '2 C)C)� GpD CEI2`11LL�FofZ /�/�� ►USwdl�. �IZL gO 5 F )41TE: n>cT G:Z [ YE I IJG LA w D S�ra�eyc�R-S 1 = �✓ (ter�� N OF O SQL`/I LL C MAZA �o tAL_ �Lor u ti �4S G�i RicH AD � K-A� I 11J Z"*j .O(ZL SAXT:R � Nn 14046 f rN -- _ LD �--10 � � v�.� � �' •- ' ' � � � : Ili ' 20 TOWN OF BARNSTABLE ��- LOCATION101 �d?� Qeedt L�a�t6lw SEWAGE # � V•ILI:AGE�j ,�,0_'V/L -C ASSESSOR'S MAP & LOT INSTALLER'S NAME &r PHONE NO.�,J, �r`1SCO// 77/-/640 SEPTIC TANK CAPACITY f 22 LEACHING FACILITY:(type) 4'4X zr-'lov i; so ize) 2o x 16 NO OF BEDROOMS ,3 PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER B 1 ld DATE.PERMIT ISSUED: 9-30- 23 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1/ 2Z' 43 41 y3' , 33� ,: r OWN OF BARNSTABLE LOCATION Lb1 , e ec�t Zea.� 1'5d4d SEWAGE # Pf-3S-1 VILLAGE C,-'AIZ�jeV/L X- ASSESSOR'S MAP 6 LOT 10 -60 _D0 - r 1 INSTALLER'S.NAME & PHONE NOJA P r)SCo1/ 771-to 4o SEPTIC TANK CAPACITY /5-00 g,dl LEACHING FACILITY:(type) 4_4X S� /oc�d�f �usv ize) 20 x 16 NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER R,» /JWJ o DATE PERMIT ISSUED: 2-30 - 23 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes. No i l3 r . `s 33 3� ` -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS z r� DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617.292.5500 'ILLIAy1 F N ELD Gos cmo: ARGEO PAUL CELLUCCI D .''• Sia Lt.Goscmot SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM . Cc.T_,""' PART A CERTIFICATION Property Address: 121 Beechlaef Island Road Address of Owner: 1/0� off' Date of Inspec1ion4/15/9 8 (If different) Name of Inspector: �TT I am a DEP appro SyjNi s ElSe em inspector pursuSn 10 Section 15.340 of Title,5 (310 CMR 15.00D) Company Name: J.P.Macomber & Son Inc. 1c9� 44 Mailing Address: BOX 66 Centervi 1 1 P, MaSG 02 32 Telephone Number: \c'•/ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the in eported Belo s and complete as of the time of inspection. The inspection was performed based on my training and experience in the prooer maintenance of on-site sewage disposal systems. The system: _/passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails 'Ins ectors Si nalur /' '� / Date:P g , The System.lnspecto all submit a copy of this inspection report to the Approving Authority within thirty (30) days of comp4e:,r,3 t inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system o r sra:1 s-D,m the repon to the appropriate regional office of the Department of Environmental Protection. The original should oe sent !o .7--, s,,>er- ow, and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D. A]/)SYSTEM PASSES: /rD I have not found any information which indicates that the system violates any of the failure criteria as deiined it- 3•.0 Cr.,: 30 ---tit---- --- 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 repairec. "ne completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes. no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined', exa a ^ r , ')ot The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Ce- , cite w Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date o' :-r r -c or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or emil.ra: c.r :a failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conform,,n,; as approved by the Board of Health. Ir•vis•d 01/15/97) Pr•p• 1 of 10 DEP on the World Wide Web: hrp.rrwww.magnet sate ma us cep Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR,m PART A CERTIFICATION (continued) Properly Address: 121 Beechlaef Island Road Centerville,Mass . Or net: Gerard Hill Date of inspection:4/1 5/98 BJ SYSTEM CONDITIONALLY PASSES (continued) ,.Z�) Sewage backup or breakout or high static water level obse-ed in the distribution box is due orolen Or r_s pipets) or due to a broken, sealed or uneven distribution box. The system will pass inspection if (w,!r) ao c• Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced B,y. The system required pumping more than (our times a year due to broken or obstfucled P,;. s: Tne s.steT rnspecl.on if (with approval of'the Board of Health): broken pipe(s) are replaced obstruction is removed FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ,� Conditions exist which require funher evaluation by the Board of Health in order to determine if the s,s:em is :a, r,. . publ,c health• safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUN'CTION'I�C I� WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: uF Cesspool or pr ry is within SO feet of a surface water G_lJ 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 APPROPR,ATE, DEI:z "•:`. '.�+ THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAF Tl AND TH.' ENVIRONMENT: Aj0 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 fee: .c a s..ri3ce mac.. _ = tributary to a surface water supply. /LA The system has a septic tank and soil absorption system and the SAS is within a Zone I of a c.o' c ate s_a L1!, The system has a septic tank and soil absorption system and the SAS is within 50 feet of a cry-ate . a:er s_== The system has a septic tank and soil absorption system and the SAS is less than 100 feet Du'. 5 iet, Dr - private water supply well, unless a well water analysis for coliform bacteria and volatile organic com,,ourc, the well 15 free from pollution from that facility and the presence of ammonia nitrogen and r:::ra,e n :rcge- less than 5 ppm. Method used to determine distance o (approximation not val.d, }) OTHER Ir.v1..0 0�/7f/f71 V�q• 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 121 Beechleaf Island Road Centerville,Mass . Owner: Gerard Hill Date of Inspection: 4/1 5/9 8 D) SYSTEM FAILS: You must indicate ei; er "Yes" or "No" as to each of the following: /v ) I have determined that the system violates one or more of the following failure criteria as defined in 310 CtitR 15.303 one ba-is for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to (o-rec7 the failure. Yes No � Backup of sewage into facility or system component due to an 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 o cesspool. Static liquid r clogged i li id level in the istri ution box above outlet invert due to an overloaded o c gg ed SAS or cesspool ool u sup-y ()N,v4.7—t vy 4.r )Qvyjei^ AW4, e4. Liquid depth in ca49" is less than 6" below invert or available volume is less than 1!2 day floe. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped Q Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributartir to a suriace water supp:, Any portion of a cesspool or privy is within a Zone I 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 wii h no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis or coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist Yes No the system is within 400 feet of a surface drinking water supply ✓�1/� 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 o; a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment Program requirements of 314 CMR 5.00 and 6.00, Please consult the local regional office of the Depanment for further information (revised 04/25/97) Pegs 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 6 CHECKLIST Property Address: 121 Beechleaf Island Road Centerville,Mass . Owner: Gerard Hill Date of Inspection: 4/1 5/98 Check if the following have bee. done: You must indicate either "Yes" or "No" as to each of the following: Yes No i _-!L/ Pumping inic rmation was provided by the owner, occupant, or Board of Health. 2 None of the system components have been pumped for at least two weeks and the system has been receiving norrna! flow rates during that period. Large volumes of water have not been introduced into the system recenth or as part of th,E inspection. _ As built plan, have been obtained and examined. Note if they are not available with N/A _ The facility o dwelling was inspected for signs of sewage back-up. The system does not receive non sanitary or industrial waste flow. The site "vas :nspected for signs of breakout. _ All system cc:nponents, 41 luding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for cond,tion o-, baffles or :e,:, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum / The size and Icca: rn of the Soil Absorption System on the site has been determined based on. The facility o• ner (and occupants, if different from owner) were provided with information on the proper maimena-rice of Sub-Suriace (Asposal System. Existing fnfor nation. Ex. Plan at B.O.H. _ Determined I i the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unaeceptaol,� (13.302(3)(b)] (revised 04/25/97) Pago 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 121 Beechleaf Island Road Centerville,Mass. Owner: Gerard Hill Date of Inspection: 4/1 5/98 FLOW CONDITIONS RESIDENTIAL: Design flow.f6O g.P../bedroom for S.A.S. Number of bedrooms: Number of current residents Garbage grinder (yes or no)jLV Laundry connected to system (yes or no): Seasonal use (yes or no).&� Water meter readings, if available (last two (2) year usage (gpo): !Fi}y6 Y �//�C� % y..j� 4nf`1 �7� Sump Pump (yes or no): 0M �l D lrS 9N, Last date of occupancy:.� J-7 -- COMMERCIAUINDUSTRIAL: Type of establishment: d2d Design flow-:_ A allons/day Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)-Z2-1� Non-sanitary waste discharged to the Title 5 system: (yes or no)j",�' Water meter readings, if available: ill¢ 4A Last date of occupancy: OTHER: ;Describe) &4 Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS ands urc of informal on b - el System pumped as part of inspection: (yes or noted If yes, volume pumped: gallons Reason for pumping: TYPE Ofi'SYSTEM Septic tank/distribution box/soil absorption system 4)LA Single cesspool Overflow cesspool /VLF Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other AP/ OXI AT���all components, date installed (if known) and source of information: �'-7— Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 M7 jVA PO VXI r x � i GOMMoN �C' L zca x o C D 9fZ �1 � M 'o o .y n r � C liv z Z. 1 L d m �\ I I . i t it •I I 1 I I � 't .i � ��.. ....__....�......_.. I ...... .._. V'I ice/ I' l w G + Ln -7R r I I . . . fn v NO ` �D �ti4 LAJ i d / CP \ 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 121 Beechleak Island Road Centerville,Mass . Owner: Gerard Hill Date of Inspection: 4/1 5/9 8 BUILDING SEWER: :Locate on site plan) Depth below grader �/ Material of construction: _cast iron PVC _ other (explain) Distance from private water supply well or suction line !A_ Diameter lqu Comments: (condition of joints, venting, evidence of leakage, etc.( SEPTIC TANKZ�/00 (locate on site plan) d Depth below grade._ ,material of construction: Z/concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age &)4 Is age confirmed by Certiiicate of Compliance �(Yes/No) Dimensions:%1 J(1 Sludge depth: Distance from top of sludge to bonom of outlet tee or baffle: Scum thickness:_ �� Distance from top of scum to top of outlet tee or baffle. Distance from bosom of scum to bosom of outlet tee or baffle:_ How dimensions were determined: A;4.W! Comments: (recommendation for pumping, condit n of inlet and outlet tees or hafflless,�, 'depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) /� `men i GREASE TRAP:[' (locate on site plan) Depth below grade:2-1 Material of con struction:41/koncrete,Vlhnetal�t fiberglass 4-)41Polyethylene�thedexplain) Dimensions: Scum thickness: 41 Distance from top of scum to top of outlet tee or baffle: X/,,) Distance from bottom of scum to bottom of outlet tee or baffle: A21 Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees of baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (r•vis•d 01-/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNti PART C SYSTEM INFORNIATION (continued) Property Address: 121 Beechleaf Island Road Centerville,Mass . Owner: Gerard Hill Date of Inspection:4/15/98 SOIL ABSORPTION SYSTEM (SAS):4—ti9� t V er'� f �` Jocaie on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type i leaching pits, number: —� p , leaching chambers, number: '°�,' J� leaching galleries, number:25— �/� leaching trenches, number,length:_01 _ leaching fields, number, dime)C ions: overflow cesspool, numbe : Alternative system: � Name of Technology: L /) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, Condit on of vegetation, tc ) ) r i CESSPOOLS:.��fl Ilocaie on site plan) Number and configuration: Depth-top of liquid to inlet invent: Depth of solids layer: Depth of scum layer: > Dimensions of cesspool: ,lJ materials of construnion: Indication of groundwater: ti inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: C/C' (locate on site plan) .v,aterials of construction: /rill pimens,on> Depth of solids Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) As trwU•d 04/25/97) D.9• a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR" PART C SYSTEM INFORMATION (continued; Propert, Address: 121 Beechleaf Island Road Centerville,Mass . O-ne` Gerard Hill De:e c1 irspectlon: 4/1 5/98 TIGHT OR HOLDING TAN'K:,��-frank must be pumped Pour to, or ai t,me. of nsoeci,on) liocj:e o., s.:e plan) Dep:n :,eID,v grade ?VA ma:er,al o, con struci,on:44concretexametaivAFlberglasseAPol ethyl eneoaAother(expla,n) 0'-ens'ors A)A '6A. gallons Des'gn o.. AA gallons/day .loan :e•e: A?A ,alarm ,n working order, Yes•.( NU Dale o prev'cvs pumping. C Omme r.:, Iconc,t,cn o) inlet tee, condition of alarm and float sw-tches. etc ) DISTRiE-0iON BOX: V 10<a:e .,. s•:e plan) Dec:r d level above outlet inyert iLfG' C orr+•"+e�:s inn -I level and distribution 1 equal, evidence of solids carryover, evidence of leakage Into or/out of box. e,: PUMP CHA.%iBER:&Ir c ;Ioc.a:e s,:e plan) Pimp, .r •.orking order. (Yes or No) -oo,,ng order (Yes or NO) COmmer.:s ,note :or.c•:,on of pump chamber, condition of pumps and appunenances. etc.) l�Ytr7lyJ '!^ L S1ve7 ray F.g. 7 of 10 SUBSURFACE SEVVACE DISPOSAL SYSTEM INSPECTION FOR.Ns PART C SYSTEM INFORMATION (continued) Propeny AC�fess: 121 Beechleaf Island Road Centerville,Mass . O, ner. Gerard Hill Date of ins oection:4/1 5/98 SKETCH OF SEWACE DISPOSAL SYSTEM: :I oe ties to al least two permanent references landmarks or benchmarks Io;a:e all wells within 100' (locate where public water supply comes into house) I �I I i P.q. 9 of 10 I SUBSURFACE SEWACE DISP : SfSTE,s INSPECTION' FOR., SYSTEh1 INFOI :.ON (continued) Proper AZ rr5s. 121 Beechleaf Island Road Centerville,Mass . O. 'e' Gerard Hill Dale o'. jn•s�)ee:-on:4/1 5/98 t Dep,n tc Croundwater L Feet Tease ,-.tale all the methods used to determine High Croundwa!C( EEC a On 4 C:-,a:nec from Design Plans on record ------------------------- -sera'.-on of Site (Abuning property, observation hole. baserncrr soma etc ) De:e .m ne iI from local condit.ons —:r) local Board of heailn FE,',A Maps p.;-pmg records vocal excavators, installers tse SCS Data :)esc,.oe o-,t own words now you established the High Crounck-,.rcr-: e,ation. Must be compie,e,i: See page 5A Used Water Contours Map. Gahrety & Miller Model 12/16/94 ... - ��...��..r♦t-.�.�T�IST.T..'tT.TT:•.'T"TT:TT....1'Ttit f"'tT.TL+.fly ... .. .. TOHN OF Barnstable BOARD OF HEALTH � StJHSURFACF SDiAGE DISPOSAL SYSTEM I N91'FCTION FORM - PART D uwrI F1 CAT 10,1 `�� I....-.•..T..•..•-�.!I'.^��1.T.1f•":fT:-.�+T.�^.f�TIT'1'�^•.'1�:.T�t-.TTJT'R"n1'C1T T'6 ISTt.I:'T'iT'lt'T[TTTrm� -r•�--..--.-. .-. �. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 121 Beechleaf Island Road Centerville Mass . ASSESSORS MAP , BLOCK AND PARCEL # 61 'c4� OWNER ' s NAME Gerard Hill PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sdfi 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City Stat 1CIP COMPANY TELEPHONE ( 508 775 - 3338 FAX ( 508 1 790- 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : �7stetn PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or file environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA sectio:I of this form . System FAILED* \ The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form ; Inspector Signature Date One copy of this c rt.ification must be provided to the OWNER , the BUYER ( where applicable ) and the 130ARD OF IIEAL1'II, • IC the inspection FAILED , the owner or operator shall upgrade the eyatem within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 15 . 305 , partci . dou . _ , , vp AMP _ _ r Q� .3a Tt Tor _ •` F INV '(7ISr I N 10 i i `N va _ _ - OASMatt, ,!5, - - n ate, P�JH Of 14, '14 PETER © SULLIVAN �U ..: . __ ` Na. 29733 ss�ONA z � , p'r L T _ >=s I 14. .F-L.0ifix► �r k y - . I . fz� Sr _ `i'TtaAA JAa i 3f -S- I LAND. TZ� �'a. : • er IL mAeA , v �443S__ RICH '.. lua 24048 ,