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HomeMy WebLinkAbout0043 BEECHWOOD ROAD - Health LA =: erville 252 - 007 UPC 12534 No. 2� 153LOR csr.coNS�`�� ll HASTINGS, MN i Commonwealth of Massachusetts 0?5a 00-7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% -s 43 Beechwood Dr Property Address _S Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 10 every page. City/Town State Zip Code Date of Inspection : g;. IX-, 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: A. Inspector Information When filling out I� c..)hw forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address r� Centerville Ma 02632 City/Town State Zip Code 508-420-4534 S14297 r�DO Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails �6 2-6-2020 Inspe is 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 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.7/2 61201 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At time of inspection this system met or exceeded all minimum passing requirements. This report can not predict the future performance under the same or increased usage. this system was installed in 1990. This report is not to be used for bedroom count determination. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^ � 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ry P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. CityTTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering.vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 1 Commonwealth of Massachusetts �u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. City/Town 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 '/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 �v lF Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Beechwood Dr v Property Address Robert Fisher inform Owneration is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ,? Title 5 Official Inspection Form i il° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V� 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: According to as-built card this system consists of a 1000 gallon septic tank, distribution box, and a 1000 gallon leach pit Number of current residents: 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 years usage (gpd)): Detail 2018 and 2019 average gpd was 98 gallons Sump pump? ❑ Yes ❑ No Last date of occupancy: seasonal Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts IR Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 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 Commonwealth of Massachusetts ,P Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form Not for Voluntary Assessments v 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ 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: 1990 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 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 l Title 5 Official Inspection. Form (11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' 43 Beechwood Dr V Property Address Robert Fisher Owner information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank looked structurally sound. there were no pumping records so I recommend pumping at time of transfer and every 2-3 yrs there after for maintenance. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: • ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Lt5,r,rp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts rm lip Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown 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.): Box was viewed by camera and was functioning properly at time of inspection with some signs of corossion typical for its age t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown 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.): Leach pit was opened and was dry with a definate stain line at about 3 ft. 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 �4 l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L 43 Beechwood Dr Property Address Robert Fisher Owner information is Owner's Name required for Centerville Ma 02632 2-6-2020 every 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 ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts �u I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Beechwood Dr Property Address owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �. w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 43 Beechwood Dr Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: property is way above lake Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �. �P Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Beechwood Dr v Property Address Owner Robert Fisher information is Owner's Name required for Centerville Ma 02632 2-6-2020 every page. CitylTown 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 8& 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATIO L SEWAGE # LAGS � �Q�yU- " ASSESSOR'SMA�OT _ VILLAGE C � l INSTALLER'S NAME & PHONE NO. tCi�C`i C'or�ST `� I SEPTIC TANK CAPACITY 10� 660 LEACHING FACILITY:(tM) -7 PRIVATE WE R PUBLIC WATER. No.OF BEDROOMS` BUILDER 0 OWNER DATE PERMIT ISSUED. DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yeses NO t i F a�L I ij 11 y� I I hps://townofbamstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappa... 2/6/2020 i Assessing As-Built Cards Page 2 of 2 https://townofbamstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappa... 2/6/2020 I FORM 30 C&w HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOA D OF HEALTH ^` CITYITOWN WLLQ YTA I v. DEPART eta l rJ -,�. - NT 1 s 4 �o ,M ADDRESS ///„/ /O/ �/ ,,s TELEPHONE Address ` 3 ,o )Xa _ _ Occupan Floor Apartmenj No. No.of Occupts No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units .Stories Name and ddress of owner QZ 1 �� �'��lCf'a)5' Ilya oe, a emarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: .K BASEMENT Gen.Sanitation: p Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, F es,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub.- Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI P J " INSPECTOR TITLE j� A. . DATE ( v TIME c P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. s. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. 4 (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. O An of the following conditions which remain uncorrected for a period of five or more days following the notice to or ( ) Y 9 knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes.and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. LA r � i I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information (� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones TitleV Septic Inspection ' Company Name 74 Beldan Ln. AV Company Address W , Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® .Passes ❑ Conditionally Passes Fail 3o ❑ Needs Further Evaluation by the Local Approving Authority C:: 3/27/2013 =Z cr? Inspector's Signature Date � rx� 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. t5ins•11r10 Title 5 Official I p lion Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 43 Beechwood Rd. Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leaching pit. The system was found to be in proper working condition at the time of inspection. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 o Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M s 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less day flow than '/2 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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. i 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•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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? ® ElWas the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed 1990 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 1 feeett Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 1feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5ins•11/10 Title 5 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 G M s 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet invert, tank was not leaking and was structurally sound. 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owners Name information is required for every Centerville Ma 02632 3/27/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day � Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M , 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 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.): D box was in good condition. No rot, water level was at bottom of outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 x 1000 gallons El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had approx 1' of standing water with a stain line only 6" higher indicating that it has never been hydraulically overloaded. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � 7 O I O 37 A-Z - Z� 3�� 00 3 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 1 . Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated high depth to round water: 12'+ P g g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: in: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property is elevated compared to lake Wequaquet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 43 Beechwood Rd Property Address Robin Perkins& Regina Hourihan Owner Owner's Name information is required for every Centerville Ma 02632 3/27/2013 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 09:12 From:BARNST HEALTH 15 To:50886279S�i r•i OCT�,2�-2010 ; 087906304 i; g I . i .�N i Dace To Whom It May COMM' ! voluntarily grant permission to the Town (Occupant~name) of Barnstable Board'of Health(Agent or Realtln Inspector) to inspect my dwelling unit located at�C sec-I�.�x' cx� . � e�v b(`� in accorcli>nce (House ,[A�1t t1t)nit#if applicabtle],street,village) with the'1'owti ofBarnstable Co c(Chapters 59 and 170)and the State Sanitary Code (1.05 CMR 410.000) on ' 1 hereby authorize and name (gate Of inspection) to be my tenant representative for the (QCCIlp$At 18�leSentiltlVe)I� is an adult person pwPose of this inspection, w (Oecuparmt representative) is designated and duly authorized to act on nny behalf and will he accompanying the Town of Barnstable Board of Health fax the inspection,granting access to any and all locations (including;bedro( mis,bathrooms;;cl()sels, etc.,)allowing the use ot•photographs and answering que;;tions.This authoIization is only valid for the insl�ectiom�date specilicd above,and must be renewed for PY filture b1spection(s.) is ;a4 s nature 1 Date Occupants Representative Signature 1 Date Q:Ut+;nta1 Ordinunceli�ispcction pcnnisimi 2.dnc TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date / I U Time: In Out Owner l Tenant Address 1 Address Compliance Remarks or Regulation# Yes YNO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water SupplyQ�� ' 5. Hot Water Facilities " 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use - 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing JV 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here FORM 30 C&W HOBBS&WARREN rM THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH CITY/TOW q ^ D PARTM NT Cyr —r® ADDRESS 1 "��Jv✓�" TEL HONE er Address `13 _ _ Occupant Floor Apartment No. No.of Occupants No.of Habitable Rooms No.Sleeping Rooms_—� No.dwelling or rooming units--No.Stories Name and address of owner ` 1_70 Nt W o, Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: 4 Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: A op r Hall, Floor,Wall,Ceiling: — �- Hall Lighting: i �® Hall Windows: HEATING - Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom(1). Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REP T IS SIGNED AND CERTIFIED UNDER THE PAINS AND -_..._ PENALTIES OF PERJ &A� INSPECTOR TITLE DATE 6 —^� _O U TIME A. . A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMRF4101,00 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a-food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public_ Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural def'ects,that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. period f five r more following th n ti t r 0 An of the following conditions which remain uncorrected for e od o e o o e dayse notice o 0 O Y 9 p Y knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) -Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. Health Master Detail Page I of I c Health Master Det-a;..3li APD icat on CE'nber Pa -cel .. .:r 'aa` Scic;tion 4tems, Farce! re. Fuel Tank Parcel: 252-007 Location: 43 BEECH WOOD ROAD, CENTER' ILLE Owner: HOURIHAN, REGINA & PERKINS, Business name: Business phone Rental property: 7 Deed restricted: Number of bedrooms �. Contaminant released: F Fuel storage tank permit: i Save Parcel Changes, Re#urn to E ookup Parcel Infra Parcc D: 2.52-007 Developer lot:LOT 44 LT- ion:43 BEECH WOOD ROAD Primary frontage:60 Secondary r d: Secondary frontage: Villa :CENTERVILLE Fire district:C,O-MM Sewer acct: Road index:0111 Interactive map: POR Town zone of contribution:SPLIT (parcel is split between districts and should State zone of contribution:SPI...IT be looked up on the map) Owner Info Owner: NOJRIHAN, REGINA & PERKINS, ROBIN Co-Owner:C/O RENZI, 7E Streetl: 170 PLAINS RD Street2: City:Vet BARNSTABLE State:MA Zip: 026E Country: Deed date:8/25/12000 Deed reference: 13201/201 Land Info Acres: 0.30 Use: Single Fam MDL-01 Zoning: RD 1. Neighbor PF07 Topography:Level Road:Paved Utilities:Public Water,Gas,Septic Location: Lake/Pond Frc Vievv Construction Info Building oyea .iBu,t ffiec-tiv 1 1932 1549 12 Bedroom 1 Full Buildings value:$1.43,100.00 Extra features: $3,000,00 Land value: S585,000.00 http://issgl/intranet/healthMaster/HealthMasterDetall.aspx?ID=252007 6/3/2008 r Qtizen Web Request Page 1 of 3 kp p + E his 4 M€ R .. K,� Y $. 7tkaAM 0,91 rC it i ze n Request Management a r.. ..... > ._..�...... ..:L c. ... :?oa :: .c.:.;i.;ery�S Tie ......... Request information I Request ID: 21859 Created: 6/2/2008 9:37:01 AM Status: Assigned To Staff Assigned To: O'Connell, Timothy ( Health Office Anonymous: No Request Category: Chapter II : Housing Substandard edit _ ._...- ......__.......-- - _..__._.._...__......_.................................................... Estimated 6/4/2008 Change Estimated " June 2008 Jul Completion Completion Date: I Date: Sun Mon Tue Wed Thu Fri Sat 25 26 27 28 29 30 31 1 2 3 4 5 6 7 ( 8 9 10 1 11 12 13 14 I( 15 16 17 18 19 20 21 22 23 24 25 26 27 28 j 29 30 1 2 3 4 5 i ..... ........................ ................................. ..._..............................._......_....__._.........._..._.....____._-_.........................._........_...__....._........._... Created By: Couto, Melissa Priority: Medium e_d__.it Health Office Citation Numbers: edit Requestor Information Requestor Centerville, Ma 02632 Request Parcel Number I CALLER IS TENANT OF PROPERTY Map: 252 Block: 007 Lot: 000 IAND HAS A ANT INFESTATION. SHE NOTIFIED THE OWNER OF THE Parcel Lookup PROBLEM ON SATURDAY 5/31/08 ( AND NOTHING HAS BEEN DONE. TENANT HAS GRANDDAUGHTER I LIVING WITH HER AND THEY ARE http://issgl2/IntemalWRS/WRequest.aspx?ID=21859 6/2/2008 i Citizen Web Request Page 2 of 3 UNABLE TO SLEEP IN THEIR BEDS DUE TO THE ANTS. SHE HAS ALSO 'NOTICED THE LARGE AMOUNT OF HORNETS BEING FOUND IN THE _ _.................._..........................................._...................... .......... ..................... HOUSE. Email: Edit Req.u..es..to..rInformation Track Request Progress Request Work History: Internal Note History: Entered on 6/2/2008 9:37:01 AM by Couto, Melissa 201-396-0583 508-957-2600 System entry on 6/2/2008 9:37:01 AM: Assigned to O'Connell,Timothy Enter work progress: Enter internal note: (Viewed byeverybody) (Viewed internally only) f V. i F i SpeIlClieckSpetl Check E[ { Add document or image link: Browse..: I You can also pc, io a fc.1d r narre to see everything in the foi€der Current Links: Time worked on request 0 Response time. Time ent,,jes are, in t lours xan" es : s linie £furies 25, O '. ' < 25, 0 1 RP1s or,1,sC Jane: Mrasuredi fterr th-? :.-r atior, (ate tD e+(;lur first actions cn t.,e request. 3 http://issgl2/lntemalWRS/WRequest.aspx?ID=21859 6/2/2008 Citizen Web Request Page 3 of 3 �, l)o no indu e nigh s, e ket grid €�dl in '_ � �3fns €.ine fog Amos; de �3i ii � tL ......_....._......_........_......_......._......_...._..._................................................................._..................._._.................._......................._...................._.........._....................._...._....... ...._........._.__....................._.__............__..........._.......__......._.........._.._....... Save changes Check to notify town employee below to review this request. Save changes and notify citizen* Health Office Barrett, Caitlin Close request Brief message to reviewer Close request and notify citizen* - - - --notify works it email ad, ress%,%,,as give � SpeliCheck Update;: { Public Use: Printer Friendly.._Version Internal Use: Printer Friendly Version http://issgl2/lntemalWRS/WRequest.aspx?ID=21859 6/2/2008 TOWN OF BARNSTABLE LOCATION"4 1Zlf-c iWaD� SEWAGE # VILLAGE �E07 V-V iLLG ASSESSOR'S MAP LOT 0 J INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 60 LEACHING FACILITY:(type) 1°C' �(size=��a l NO. OF BEDROOMS PRIVATE WE �RPUBLIC WATER} BUILDER O OWNER va �.1L i�LZ-1 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ��� t 3� t� o �� I � y� G + ASSESSORS MAP NO: -- �-� ,PARCEL NO: Fins.... Q:.--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Disposal Works Toustrurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ,4� an Individual Sewage Disposal System at: - 41 3 ��woty ----- �'.f ___...._......... ------•----- - - - --------------------------------------•----------------------------------.---------•-•------- Locationr Address or Lot No. Owner Address Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -----•------------------------------------•--- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width----_........... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------------_- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I-----------_....minutes per inch Depth of Test Pit.................... Depth to ground water........................ (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ---•-•--•----------------------•------------------•-----....----------------.............---'-----__......................................................... O Description of Soil.--. _ ....... v.rd.............• ................. /rt ------S'�^� .................................................' teAJ x -- c., •-•••-•-•--•-•---•---------------•--•-•.....•--------------------------------------••-.......••---------...----------------•-------------------•.....------------------"----------.......-------------- w UNature of Repairs or Alterations—Answer when applica.ble.._t-,�!��tt�.-_____-___ 4!;to ?-.....57..._.._..©-_----- _. -----4-------- ,{4Q� ` `^'/ 2( S i a wc= Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental 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 ..... -------------- .........--451G0...----- ApplicationApproved BY ------- --------------------------------------------------------------- ---------------"�e-. Application Disapproved for the following reasons- -------------------------------------------------------------------------------- ------- --------------------------------------- ------------------------------------------------------------------............................-----------......................------------------------'---.-..........................I..,............... ........ qDace PermitNo- ............. `--F_----------------------_ Issued .........................................................----------- Dace ai No.. O-. .. Fps..... ......._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrnr#ion Vrrmit ` Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: �- ` �tbd�AJT 21d ...1..../) .. ............................................... -- -----•----•----------------------...-...--- - Location-Address _ _ or Lot No. ------------------- ---�-�...)_�_t..Qt..h� ,-�"- ----------•-----------------... Owner Address ,-] ........................... = ..........• -----•----------•---------• •-----.... ---. . _ ..--------•---=-- Installer Address -, � Type of Building Size Lot............................S q. feet Dwelling—No. of Bedrooms____.___._ ................................, Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building .............. No. of ersons._.........._...._.......... Showers — Cafeteria Ga YP g -------------- P ( ) ( ) QI Other fixtures -------------------------------•-- -.. .----.. -- -- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ ` x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area................... ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_____________-__-____--- Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ..--••----------------••-••-•-•--•-----•---.....-----•---------------.........-----------------........----------•--•--...--------•-----------....--_--•-- O Description of Soil... ...............--__-�---t------------ f�-C -•---- '�" =`f G 1e/!J_L�--.. x W ..................................................---•---- ------------------------------------------------------------------------------------------------------------•---'............... U Nature of Repairs or Alterations—Answer when applicable---lfxut� uF -------}4_,S>.o __...-- -- =.' ?�__. ....... .�... 4 S iZI T..�......-= ............................... ------------------------- ---------•--- Agreement: The undersigned agrees to install the aforedescribed.Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental 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 .,,:-::\ +�i } —c' .. F - -------- ---- ----- --------- �,.,.. t Date ` Application Approved BY .. ... �------- -- ---------------------------------------------- ------ --------------.................. ` Uate Application Disapproved for the following reasons- ...............-------------------------------------------------------------------------------------------------�-1---------------------- ..."...---------'---------------------------— —- """.................................--- -". ..""................................................- ..--.....-------".. ---------------- ------ -----------.........................'.- qllate PermitNo- ------------A ------� ....-- Date---------- Issued ----------------------.. ate.--.......----------- --- ate------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Q-Tez#tftcate of CIOntyliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (Ab) by 1,Cbw�t. 44(- " Installer at ..... ..... ..... � ...--------------------------------------------------------- .............1 ? . ...." " has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..........19 - 9�":r dated .........sl.."""_-".---"----_--------------- PP P -' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU�D AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE .'0?-3`— d---------------------------------.......................... Inspector w ........ ---------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �� n TOWN OF BARNSTABLE r-- No...............•--....-.. FEE....................... Disposal Vorks Twalustrurtion Hermit Permission is hereby granted.... A+..................................... to Construct ( ) or Repair an Individual Sewage Disposal System at No....!'AP-•----._ g � K?: acaau.... 1Q ), -•---•---.�:..c rt'TC' .N Street as shown on the application for Disposal Works Construction Permit No..gG.:.U Dated.._...-�.. ' I. ....................................Q, .............................................. •--------•---..-......... .. .......----- Board of Health DATE................................................................................ V FORM 3850E HOBBS&WARREN,INC.,PUBLISHERS