HomeMy WebLinkAbout0155 BEECH LEAF ISLAND ROAD - Health 155 BEACH LEAF ISLAND ROAD, CENTERVILLE
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UPC 12543
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HASTINGS, MN
f Commonwealth of Massachusetts
-� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner Owners Name
information is required for every Centerville MA 02632 June 22, 2011
page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
n
an the computer,
use only the tab 1. Inspector: Wco
key to move your
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Environmental
4:1 Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
Cityrrown State Zip Code
508 364 0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2S June 22, 2011
Inspectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. coil
t5fns-0201 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts '
-- Title 5 official Inspection Form
WESubsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluui
Owner Owner's Flame
information is required for every Centerville MA 02632 June 22, 2011
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
155 Beech Leaf Island Road.
Property Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 02632 June 2.2, 2011
page. Cityrrown State. Zip Code Date of,Inspection
B. Certification (cont,).
B) System Conditionally Passes (cont.)
❑ Observation of sewage backup or break;out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken„settled or uneven distribution box. System will
pass inspection if(With approval of Board of Health):;
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below),-
El obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more,than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is;removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by-the Board of Health:
❑ Conditions exist Which require further,evaluation,by the Board of Health in order to determine if
the system is failing to protect public.health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with M CMR
15.303(1)(b)that thesystem is not functioning in a manner which will protect public health,
safety and the environment:
Cesspool or privy is within 50 feet of a surface water
❑, Cesspool or privy is.within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins r ogiw Title 5.0rficial Inspection Form:Subswface Sewage.Disposal System•Page 3'of 17
Commonwealth of Massachusetts '
== Title 5 Official Inspection .Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'155 Beech Leaf Island Road
Property.Address
John and Gretchun'Ciluzzi
Owner Owner`s Name
information is
required for every Centerville MA 02632 June 22, 2011
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)'
2. System will fail unless the Board of_Health (and Public Water Supplier, if any)
determines that_the system is functioning in.a manner that protects the public health,
,safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water,supply or tributary to a surface water supply.
❑ The system has a:septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of,a private water
supply well.
❑ The system has a septic tank and:SAS and the.SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used.to determine distance:
*'This system passes.if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of`ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems.;
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ z Backup of sewage into facility orsystem component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent>,to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6 below invert or available volume is less
than '/2 day flow
15ins-09108 Title 5-0fficial,Inspection Form:Subsurface Sewage Disposal System•Page 4 oP17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 02632 June 22,2011
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins-09= TRte 5 Official In
spection Form:Subsurface Sewage Disposal System•Page 5 of 17
N Commonwealth of'Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 026.32 June 22, 2011
page. GityfTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"'yes" or"no" as to each of the following:
Yes No
0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
El 0 Were any of-the system components pumped out in the previous two weeks?
E Has the system received normal flows in the previous two week period?
❑ 0 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?
0 ❑ Were all system components; excluding the SAS, located on site?
0 ❑ 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?
z ❑ 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:
0 ❑ Existing information, For example, a plan at the Board of Health.
0 ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms,(design): 34 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example',110.,gpd x#of bedrooms.): 495 gpd
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
' Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluui
Owner Owner's Name
information is required for every Centerville MA 02632 June 22, 2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
System components exceed 440 gpd design flow required for 4 bedroom design.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 501 gpd
Detail:
2009-2010-irrigation system in use
Sump pump? ❑ Yes ® No
Last date of occupancy: 1 month ago
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow.(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
tsins-09M Title 5 Official Inspection Form:Subsurfece Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 02632 June 22, 2011
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes.,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
N Septic tank, distribution box, soil absorption system
❑ Single cesspool
El 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):
r5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
g p Y rY
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 02632 June 22 2011.
page. Cityrrown 'State Zip.Code Date.of Inspection
D. System Information (cone:)
Approximate age of all components, date installed (if known)'and source of information`
Age 17+ years. Disposal Works Permit issued 12/5/1994 (permit 94-703).
Were sewage odors detected when arriving at the.site? ❑ Yes i] No
Building Sewer(locate on site plan):;
Depth below grader feet
Material of construction:
❑ cast iron Q 40 PVC ❑ other(explain):
Distance from private water supply well-or suction line: feet
Comments.(on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of backup or leakage into dwelling.
Septic Tank(locate on site plan):
Depth below grade:, 2feet
Material of construction:
® concrete ❑ metal ❑.fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal,list age years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
10.5 ftx6ftx5ft(1500 gal)
Dimensions:
Sludge depth;. 6 in
t5ins+,o*68 Tilla's Official Inspection Form:Subsurface;Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner owner's Name
information is required for every Centerville MA 02632 June 22 2011
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28 in
Scum thickness 6 in
Distance from top of scum to top of outlet tee or baffle 7 in
Distance from bottom of scum to bottom of outlet tee or baffle 11 in
How were dimensions determined? Design 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.):
Pumping is recommended at this time and maintenance pumping is recommended every two years.
Tank appears structurally sound and functioning as intended. No evidence of leakage in or out was
observed.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-0901 Idle 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 02632 June 22,2011
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09foa Tale 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 02632 June 22,2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 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.):
No adverse conditions observed.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in workingorder: Yes No
❑ ❑
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09M Title 5 Official tnspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
uiTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 02632 June 22,2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. Leaching pit was uncovered and
found to contain 16 inches of effluent with no effluent contact staining observed into riser.
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
t5hs.Dam Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts.
Title 5 Offil.cial Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 155 Beech Leaf Island Road
Property Address
John and.Gretch_un Cluzzi
Owner owner's Narne.
information i e required for every
Centerville: MA 02632 June 22, 2011.
page, Citylrown State Zip Code Date of Inspection
D. System lnformation (cunt.)
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.):
Isins-09108 Title-5.Official Inspection Form:Subsudace,Sewage Disposal.System-Page 14 of 11
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-.Not for Voluntary:Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchen Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 02632 June 22, 2011
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a,view of the sewage.disposal system, including ties to
at least two permanent reference landmarks or`benchmark& Locate all wellswithin 101OJeet. Locate
where public water supply enters the building. Check one of the boxes below-.
hand-sketch in the area below
❑ drawing attached separately:
I
r
f d3
t`q
2�
t5fns>•-06/08 Title 5 Official lnspeclion Form-Subsurface.-:Sewage,oisposal System-Paged 15017
Commonwealth of Massachusetts
_ Title 5 official Inspection Form
4i
Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments.
155 Beech Leaf Island Road
Property.Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required,for every Centerville MA 02632- June 22. 2011
page. City/Town State. Zip,Code Date of Inspection
D. System Information (cost)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
Shallow
❑ a ow wells
� Estimated depth to high ground water: 20+ ftfeet
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: 12/5/1994
Date
❑ Observed site (abutting.property/observation hole within 150 feet of.SAS)
❑ Checked with local Board of Health =explain:
El Checked with local excavators, installers-(attach documentation)
0 Accessed USGS database-explain:
Barnstable GIS Department records.
You must describe how you established the high-ground.water elevation:
Septic design plan shows bottom of leaching gallery to be 4.2 feet above the bottom of a witnessed
test pit in which no groundwater mottling was notedJown of Barnstable GIS Department records
indicate that the property is over 20 feet above groundwater table.
Before filing this Inspection Report,please see.Report Completeness.Checklist on next page.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Beech Leaf Island Road
Property Address
John and Gretchun Ciluzzi
Owner Owner's Name
information is required for every Centerville MA 02632 June 22, 2011
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09108 We 5 Official Inspection Form:Subsurface pe Sewage Disposal System•Page 17 0!17
(0
No..-Ft�-.....4- g '( FEB...7.6.:-'.
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH SUBJECT TO APPROVAL OF
.°�....--.....OF..... N,..... ... L'G - Pr�7l� L�e CONSER�OgPION
._
I
Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal
S tem at
--. .. .. �E V tL ........................- .....................................
t�.� .. Location Address
..�'...
... I�IY.K'a.((.'r-- _ -. .��J_!__=_� j! ,_._ �GA•A � �Z:�:
.. .. f a f \ ..............................................................
- .. .................V��..neW L� �`�•�i�\�I Gc���T.Ad
Installer Address
Type of Building Size LotV`�........Sq. f t
Dwelling—No. of Bedrooms...... .................................Expansion Attic (� Garbage Grinder 4s
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---•-------------------------.....-------------------------------------•-----
W Design Flow..... �s9...____gallons per person per day. Total daily 4ow...... ...�........................gallons.,
WSeptic Tank—Liquid'capacity.UMallons Length.�Q."!;�_.. Width.f.70.. Diameter._._.__.__—.... Depth.. _:�_- _
x Disposal Trench—No..................... AAidth.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........,_---------- Diameter.....�.�___..._. Depth below inlet.....�.!5..... Total leaching area--- :6.._sq. ft.
Z Other Distribution box N65 Dosing tank (94
Percolation Test Results Performed by I�-2 .. 1E l q.!� ...................... Date. 4 .... _).5. _.._.
'4 LZ -A
Test Pit No. 1..._....:._.._..minutes per lnch Depth of Test Pit._.�`�..__....... Depth to ground water.__. ..
GX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Pr' --------------------- --- ---------....................
O Description of Soil.....P I1�Wl vC�a lL' YT.._1.A�.#.c1d,64
U ----•--•-••--••-----•--------•-------�_N.5....M.-' ... ! 1 ---------------------------------------------------------------------------------------------------------
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beep issued b L
the bo of
Signed...P3 ..... --•-
D __.._
Date
Application Approved B /•-._' �,---�.- �9 q
PP PP y n�.. -x��\-'! . Dater
Application Disapproved for the following reasons-----------------------•----...------•-----------•------•-----------------------•------------------........._....
Date
PermitNo... ----•------•-•----- Issued.........................................................
I
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAMIGNING ENGINEER MUST SUPERVISE
AND CERTIFY IN WRITINC............OF......... ftLATION
S1't=itR"WAS'INSTALLED IN STRiC�
vurr#ifiratr of �ji � a( �10E TO PLAN.
THIS AS T C RTIFY, That the Individual Sewage Disposal System constructed (�<) or Repaired ( )
by.............. ........ x ............................-------•-------......-.
Int�tallu ^
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........ .. ..�•....... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SMALL CONSTRUED AS A GUARANTEE THAT THE
SYSTEM W L FUNCTION SATISFACTORY. /" � 70? /,a. -�e f
Z� "
DATE..............'.'......................�----...... Inspector....................................................................................
i
b Y
• e_�i t a-i
No..... ti tFEB
,..-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Uhiposal Works Tonstrnrtion Prrafit
Application is hereby made for a Permit to Construct ( k) or Repair ( ) an Individual Sewage Disposal
�Y,st1em at: i
- .................................................. .................................................... _ ------•----
S LrV\ 1 ocat1 n-Address Iyo Lot —
.... �. ............... ..`a----------------------------:_...------------ `. 1 1 �t"t�-' -C`� �r�� \( � t_r`�
..
_ Owner' \ Addr ` `
a = -------- ......
Installer Address Z'A
Type of Building Size Lot........ :.................Sq. feet
Dwelling—No. of Bedrooms-------�.................................Expansion Attic ( �).; Garbage Grinder (t CF_5
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -------------------•--------------•--------------------• ---...................................
W Design Flow___...5�` ....`t_ �_.._.__gallons per person per day. Total daily flaw___.... � .�........................talons. ,
WSeptic Tank—Liquid capacity_�-��. allons Length.�Q.�.. Width.5.'J . Diameter................ Depth._-5_'
x Disposal Trench—No..................... Width.................... Total Length................. .. Total leaching area_._..;...........sq. ft.
Seepage Pit No..__...._I...._____.. Diameter......�.A------- Depth below inlet..... .'. .... Total leaching area...- ��..B..sq. ft.
Z Other Distribution box (yam Dosi tank ( t )p _
'-' Percolation Test Results Performed by_ !`�k � .. `�` L.� �-..................... Date.40,4_�4.1. -
W P P P gr �0, ►'%LOV1a�.Cv�Test Pit No. 1----- 2._.minutes per inch De th of Test Pit.......J___....._. Depth to ound water______________ ________
0-4
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.`- ............................................................... .................................................
O Description of Soil......C � L tJt�,�Ut .......vSO L- "� -
c.� ---------------------------------------------•-------------
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.....................................................................
Date �
Application Approved B L _/!% ')--
PP PP Y u.... ��.- -------------== ------
Date �1
Application Disapproved for the following reasons-------------------------------------•--•------------------------------------•--•----------------•-----........._
i
.. ... .. ... ..... •---------•-•---------------------------•••-------
Date
Permit No........ .�5
---=-• ....................... Issued Issued-..................-----................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/( .(•1:2............OF.........- ;�e..-,��-.�1. ..................................
Tnrtifiratr of f omplittn.rr
THIS ISTO C RTIFY, That the Individual Sewage Disposal System constructed (� or Repaired ( )
byf ,- ..........0......................................--....................................................................................................
nn Installer ,� (�
at (t 't_Z----.-%'-. .- « -�-----Q• -----_-----•--- -----------------------------------•---------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........ .__.. .... ....... dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE-THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............ ................... Inspecto - f
....................... ..... .._._.. :..-.-.-�� ---- -....-ts'e!ram..-------•---- •- •-
THE COMMONWEALTH OF MASSACHUSETTS
If `](> BOARD OF HEALTH
N15 ,..-........OF........ _ro,n.- 1C al� _(.:...
... - FEE..��e�....e.^..:::..
Dispimal Workii TFUnntr ion amit
Permission is hereby granted...------ ------ -----------------------••----...-•-•---------•-------•-••-•------...................-----
to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem
at No........�-a.._ ... .�:.� ... o t= •--•---..Q . . .A-�-_Q� 1. Wiz•
`tg Street 'J L� ra
as shown on the application for Disposal Works Construction Permit No.._19 _: .�.�� Dated........--.................................
..................•------------------•------------------------------•------••--------.......---........_
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
No.: v Fps ....
THE COMMONWEALTH OF MASSACHUSETTS
SUBJECT TO APPROVAL OF
�., ®!�R® OF HEALTH SUBJECT
CONSERIJAT!C'i
I o... ...................oF.... 7 Q,�4.S.- �D -�---------------.......--------- " MPAISS10e4
Apphrafiu or lliupunal Works Tons*nrfiun .erntit
Application is hereby made for Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
SEem at
.I. LEAcal!-! 0. CE"TC-2\3<< ' A --- -. ---
Location Address
C, Lot No.
y o.11.... 5 -1 - A i!�,b,...r.. �!�-�-��- U.I ..-
Owner AaOess
a .. 4 : .► -------------•--•-••---..........---•-•....... . -- • --..•.....�.G- .. ..Q. cC .....
M Installer Address
VType of Building Size Lot.2 .)917_7........Sq. f t
., Dwelling—No. of Bedrooms..... ................................Expansion Attic (U6 Garbage Grinder S
aOther—Type of Building ... ....................... No. of pe ons............................ Showers ( ) — Cafeteria ( )
Otherfixtures - ------------•-----------------------•--------•-••------............................
g S S g P P P Y gallons.
W ---------
Design Flow................t_ � gallons per person per da Total daily flow___'��_.�0..�_._._____....__._........gallons.
Septic Tank-Liquidfcapacity.A. ...gallons Length_("..._. dth '8�.___ Diameter...---'......... Depths. -A_
111
xDisposal Trench-,,.No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit N,o__________________ __ Diameter......11--------- Depth below inlet._r5 a........ Total leaching area.—NO ...sq. ft.
Z Other Distribution box (Y� Dosing—tank ( 4
Percolation Test Results Performed by. Q Date... �-.k4 `6 �_ ' --. N .._..
Test Pit No. 1...LZ -_-minutes per inch Depth of Test Pit....113........ Depth to ground water.,��4CXJ �
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -----------•---------- ............................................................--............._..----- -----...3...
Description of Soil..�.`zc ._ ..- �3 9�4 �..tS P --! $ . .... , �
x
V
W ---•-----------------------------------------------------------------------------------•-------•---.----- ----
V Nature of Repairs or Alterations—An when applicable...—)......... �
-- .... ....... :�:_._ .:�..... ....`09?
Agreement: �/c - f�ftFlT�cD Gam«�/ 1/V �2�<<ovG _ZZ.1pi 2.M
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance withi a, 'AA u
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in"�---ccx-a-cef
operation until a Certificate of Compliance has been issued by the board of health.
v �Ld
Dat
------------•-- --------------••••------
-
Application Approved BY --- `�/`
Date
Application Disapproved for the following reasons---------------•----------------•----•---- .....................................................................
------------------------------------------------•-•-------....-------•--•---------•••------•-•-------........._......---------------------•----------------•-------------•-...-----------•----------••---
Date
PermitNo........... ............. ----------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................I................OF.....................................................................................
C�ler�ifir�a#e of f�unt�rlinnrr
TH 0,CERTIFY That the Individual Sewage Disposal System constructed ( �epaired ( )
by .............••---
------
J
at.---•--------... .....ceI
leer 1 --•----�--`-,�?�''�1IL
has been installed in accordance with the provisions of TITj 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... t?.-- ..... dated-.------ �/ 16;1----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector......................................................................
--------------
THE COMMONWEALTH OF MASSACHUSETTS � � 6M IN 6 �- y61'U5.6'�
BOAR OF HEALTH
........OF............. s.M Q-.c -..........-...
............
Mop urku �unn#r ion rranit � c�-�, y ;,I
�I IN
Permission is hereby granted............ 7 -... t.4lS� 6 S��'7
to Constrict or Repair } an ndividual g Dish Sys em i A-�1h r, •v
-------
:.... .� � KTa I P_
Street
as shown on the application for Disposal Works Construction Permit No.__�._n...: a_ jted___7�!/2.s/�*�`�._........
.......•. ----•-------••-------------••-
DATE_ _. _.______ Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r
No. ..........._....... Fxs.. ...............
r THE COMMONWEALTH OF MASSACHUSETTS
C�V BOARD OF HEALTH
... .......I ... r...l..................OF..... ... !�<_1 .�..J �.JQk-.
Appliration for Disposal Works Tonstrnrtion Pumit
Application is hereby made for a Permit to Construct ( A or Repair ( ) an Individual Sewage Disposal
•. rr �l_.�_' .t:! - -tom`=`�' �� -�.....(-=-� ...L�u�t t..............................:.. .�?� ----•-----------------•-.........--------•
�- .:. -
Location-;Address or Lot No.
...................... •-•---•--.........._.__...........................------•--------------
_ Owner f AdOess
Installer Address _
Q Type of Building Size 17-------Sq. feet
V Dwelling—No. of Bedrooms. .....................................Expansion Attic (t,,js Garbage Grinder (has
PL4Other—T e of Building No. of persons............................ Showers — Cafeteria
G I Other fixtures ----------•---• -•-••-----•-... -
Design Flow......._�. '._.c +�%'a..._.._...gallons per person per day. Total daily flow____:' . ............................gal
W _ Ions.
WSeptic Tank—Liquid capacity.!:7%.1-ti allons Length_i�? . ___ Width=`a".: ' Diameter____----------- Depth_5..=.�...
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------- -•,.. Diameter......�'`�........ Depth below inlet___s.:.'_?....... Total leaching area..�Y, .. .-.-sq. ft.
Z Other Distribution box (\J t�5 Dosin ank ( 40 _ 1
Percolation Test Results Performed by.... ..k �- :►�,_. ._ _'l.�%...t`.4J.�-..___...... Date____ _ o_�` .6 Pam_ _._....
aTest Pit No. 1... _..minutes per inch Depth of Test Pit.... . .......... Depth to ground water__"`:3c...�v_ UQ-7k;E 7r
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil ��--- C' `'"ate: 1 '------` } !?�iU"a_`�...0 'Z_ , �t- -� T \ -Vi-E')SAuD
x
W ----••----••..................-------------•--••--------------•••-•-•••••••••---•-•-•--.....•----•------......•-•--••••---••••••-• ----•--•-•----------•--•-------••-----•-••-•-----......------------...
txj Nature of.rRe rs or Alterations—Answer when a livable__• ....... .:......(cc-.��Aj` �_.__..`-' .�`"....................' .I p
-ttl'= -It '1J
Agreement: `" ! %- f I tV vJ4:;�!_t,nr
s ��� •
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witki,;
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system iL3�crct•�,�.t
operation until a Certificate of Compliance has been issued by the board of health.
_' _-`Signed;--------------------'----•-•--------------------•-------•-------•••-----
� �.................i r_y Date
Application Approved By...........................------------------------•............_.......`=`:`:::—.....---•- -=`' 1� s-•-•------
Date
Application Disapproved for the following reasons:........................................................................ --------------------••-•---------------
...............•-----•-------------•-••......._....-------•---------•------•-••----......-----------...---•-------------•-----•---•--•-------------••-•-------•------••---••----•--------•---•........--
^ Date
PermitNo.-----.................................................. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trrtif iratr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( o Repaired ( )
r..
bY----------•-- ' ' ; ._..._ .. -----•--
��`"'> >'' �'� Installer at
has been installed in accordance with the provls>ons`of TTIE 5 of T eafe amtary Code as described in the
application for Disposal Works Construction Permit No----- _.-_•_ _ dated................:...
_
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS } 'SmIN
BOARD OF HEALTH
rr < tlUN�f—�U C Z
..............1 >-.�a ...... _ ti i-- r1r J't/
OF.............. .... ,. . .. _...t..�. .. `.._............ _.� ycti. i' /sr,C tiT
No-
Disposal Works 'onoir ion rrmi
Permission is hereby granted =
( = _ Dis orta�l-�--S.----s--t-e--m-----------------------------------------u
to Construct /r_or Repair an Individual Sewage
!
t
at No....... ------. r - ------ �,
`✓Y� �..-.1-'G' 1 —l=�.lc'=Stfbef.. ��� �-r�i.�(ViC __ :�-��r�%�<� !\: ,,s. 4�.
as shown on the application for Disposal Works Construction Permit ........._5 v��..
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r
. _
. ,3
_.. . —Pot 35 24;9�.7. a� �a tk Aue
Stu
N �'. �,O U.t2C�Cvt✓LOn M I
�q t
0
ew.ar9 to :
- - .
0
leech .teat 9 )� 12U... sT,c_ . l � She aept:c_4gdterx waii
' l bed acco u� to
.Co-t 33
_ the `ouncla ion a%.ov.,n on th i6. p tan i4 Located
on the 4owsd ai cown hetwn, and mee-t,. the
_. a.e tbaeh tequAAerw At i o f Vie clown o f I;atnd.tab•f e.
J)�e 7-21-9 S
► '?opt Chatted. MaaAr in
i l3ein* .a Lot .all-dhow . on..,'.C.. #41630 A _ -
Scate I "-40 )ate 7-21 -95
At Cape I rupineRAAA4
49 8acbot load . {
byann 4, M 02601
z. OF
cf
of NE
1`
�av- ma vkLU Ala V<
.775- 70 .
I -
ALL CAPE ENGINEERING
REGISTERED ENGINEERS AND
LAND SURVEYORS
49 HARBOR ROAD
HYANNIS. MA 02601
TEL.: (`Si18 778-0058
22, 1998
I S S beach .t%p�land goad
Centetu•i,�,be, 02632 /�£: Septic jot Mc� 187-063-07
6oa4,d o f ReattA
kganr", 1v19
Sh d. oijiee wary. aaked to impect the aeptir- ayatm at the above
wntioned a 4e", 4i to petm t -taken out 12-5-94 and are. now in
p.Cace and wo4ki.nr�. She 1yatenc w" imt4tted by 6'64tototti,
Coffin, acco4Jtj,4 to p-tan, and mee& the- a.etback..,ceg4it nzPn�
on ptan.
- �.ivacehp,C y,
�hn . M.i tne, 9.z s.
OWN OF BARNSTABLE f
LOCATION �Z 1*- Low ISt, SS AGE # !14-7a—1
VILLAGE ASSESSOR'S MAP&LOT/ G ( 'J Cr)
-
INSTALLER'S NAME&PHONE NO. nZe'd'�B�,�l
SEPTIC TANK CAPACITY , l-5 a U �r�C.►.
LEACHING FACILITY: (type) P l i (size) t
NO. OF BEDROOMS _3
BUILDER R OW�VNE A A,- ? tom!kd
PERMITDATE: RZ,I- COMPLIANCE DATE:
Separation Distance Between the:
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) 4, Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) I0—L Feet
Furnished by
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