The URL can be used to link to this page

Home My WebLink About0075 BELDAN LANE - Health 75 BELDAN LANE, CENTERVILLE A= 189 031 �IIII 14gscvcfFp�o �J y2 NoP2E�OR �,,,co '�� HASTINGS, MN Ilk ' ' Commonwealth of Massachusetts zTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lug75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out t forms on the computer,use 1. Inspector only the tab key to move your Raymond Dumas cursor-do not Name of Inspector use the return key. Dumas Landscape Const. Company Name ffi 564 Old Stage Rd. Company Address Centerville Ma. :02632 -t rem Cityfrown State Zip Code 508-778-0249 S1437 Telephone Number License Number ?....J ITJ B. Certification M. :1 ; m I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority wL 7/9/2010 Inspects Signa ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. L14 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage D- jSyZ- of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every 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: Septc tank needs to be pumped 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•=08 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 M 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. Cityfrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins•CW08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts uTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Belden Lane Property Address William Kepnes Owner Owner's Flame information is required for Centerville Ma. 02632 7/9/20010 every 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•Og/W Title 5 official 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 - 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were 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 NIA) ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page_ City/Town State Zip Code Date of Inspection D. System Information Description: 1 1000 gallon septic tank with D-box and 1 1000 gallon precast leach pit 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2008-10000 gal 9 ( Y 9 (gpd)) 2009-23000 gal Detail: 2010 9000 gal Sump pump? ❑ Yes ® No Last date of occupancy: occupied now 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-09/08 Title 5 Official Inspection Fan: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 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 .719120010 every page. Citylrown 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: None on record 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 J ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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-09108 Title 5 Official Inspection Forth:Subsurface Sewage System-Page of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every 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: 1980 approx. 30 yrs. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 20' feet Comments(on condition of joints, venting, evidence of leakage, etc.): good Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) Q If tank is metal, list age: yeas Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'6"x4'10"w x5'7" h Sludge depth: 12" t5hu•09108 rue 5 official inspection Forth:subsurface Sewage Disposal System•rye 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every 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 26" Scum thickness 12" Distance from top of scum to top of outlet tee or baffle 1" Distance from bottom of scum to bottom of outlet tee or baffle 6" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): septic tank needs to be pumped 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•09/08 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 75 Belden Lane Property Address William Kepnes Owner Owner's(dame information is required for Centerville Ma. 02632 7/9/20010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): All good but septic tank needs to be pumped 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.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ® No t5ins•09/08 Title 5 Official Inspection Forth: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 yf 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. Citylrown 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 at level 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.): level and no signs of leaking 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.): N/A Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: 30" below grade, water 3' below pipe t5ins•09M 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 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. City/Town 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: Precast Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):. all good 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-09108 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 '< 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): none 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•09108 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 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M � 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Info on inspection repot on file at B.O.H. dated 10/20/1998 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09M 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 75 Belden Lane Property Address William Kepnes Owner Owner's Name information is required for Centerville Ma. 02632 7/9/20010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary:A, B, C, D, or E checked E Inspection Summary D(System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I r� TOWN OF BARNSTABLE f LGCA'1'ION �� ,J �L � L SEWAGE# VILLAGE E�r�'e L//,/L w ASSESSOR'S MAP&LOTr INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY mil/ LEACHING FACILITY: (type) �' a O (size) NO.OF BEDROOMS 3 i BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) SP� Furnished by � / � 5 �� ' J f COMMONWEALTH OF Pal ::�'ACHUSETTS EXECUTIVE OFFICE 01 RONMENTAL AFFAIRS r s DEPARTMENT OF E',v NMENTAL PROTECTION ONE WINTER STREET, BOS '.;' 02108 617.292•.<500 i WILLIAM F.WELD TRUDY C( Govcmor Sccrc ARGEO PAUL CELLUCCI DAVID B.STRI Lt.Governor SUBSURFACE SEWAGE DISPOS,. eM INSPECTION FORM Commissi. PA:: CERTIFIC_�1 Property Address: 75 Beldan Lane Centerville,Mass.,ess of Owner: Date of Inspection: /G'�� 98 ...Herent) Name of Inspector: j,,r 14 12, tuber Jr. I am a DEP approved system inspector pursuant to Section A Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 n Pryi 1 -Mass_ 02632 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system a: i, ;ess and that the information reported below is true, accurai and complete as of the time of inspection. The inspection was perforn :. i on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ,Passes _ Conditionally Passes Needs Further Evaluation By the Local Approv!; ,riry _ Fails // c Inspector's Signature: The System Inspector sh submit a copy of this inspection report to t',, ing Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of IC, ;r greater, the inspector and the system owner shall submi, the report to the appropriate regional office of the Department of Envi:. Protection. The original should be sent to the system own and copies sent to the buyer, if applicable, and the approving authorir,. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the sy _s any of the failure criteria as defined in 310 CMR 15.30. Any failure criteria not evaluated are indicated below. COMMENTS: M l 050 BI SYSTEM CONDITIONALLY PASSES: �v v One or more system components as described in the "Condi..;.. s" section need to be replaced or repaired. The system, up( completion of the replacement or repair, as approved by the iealth, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of c on in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or opera: Jded the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was thin twenty (20) years prior to the date of the inspection; c 4. the septic tank, whether or not metal, is cracked, st. .:nsound, shows substantial infiltration or exfiltration, or tan failure is imminent. The system will pass inspectioi. . , fisting septic tank is replaced with a conforming septic tank as approved by the Board of Health. (r•vi••d 04/25/97) P&y• DEP on the Wodd Wide Web: h; :t.SLa(e.ma.us/OeP Prinled on er o `n ar. •p 9 n RdK DATE:/d/,,2e/.9 8 n."PRC9P11R"TY DDRESS: f5 Be-ldan Lane m� TOWN t�CZSPTT Centerville,Mass. £ 4s '0 2 6 3 2 'yl'� 1 6 On the above date, I lnspected the septic system the address. This system conslsts of the following: or g 1 . 1 -1 000 gallon .septic tank'. 2 . 1 -Distribution box. � 3 . 1 -1000 gallon precast leaching pit. Based bn my Inscactlon, I certify the following conditions: 4 . This is a title Five Septic •Syste,n.'-"C' $• Code j 5 . The septic system is in working 'd$er at the present time. 6 . .The septic tank should be pumped. SIGNATUR`;: J Name J P Macomber Jr_ i , . - - ------- Company:_`. P_Macoalber & Son- 'Inc . ; • ' , Address:_-Baac-66—.-----a---..-- Cencgrv11le Ae s_gs_02b32 Phone: ' 33a------- •. 1 THIS CERTIFICATION DOES NOT CONSTfTUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC, Tank&-C#&-&pool&-Le&ch(Ields Pump*d 1, Instsllad ' Town Sower Connections P.O. Box 66' Centerville, MA 02632.0066 / 77.5.3335 775-6412 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Add(ess: 75 Beldan Lane Centerville,Mass. Owner: Henry Wilson Data of Inspection: hN A3/9 8 B) SYSTEM CONDITIONALLY PASSES (continued) I-6 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box Is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection If(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: V Conditions exist which require further evaluation by the Board of Health In order to determine if the system is (ailing to protect the. public health, salety and the environment. t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: IN Cesspool or privy is within SO feet of a surface water 4A Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: �0 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. �)Q The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the pre nce of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) OTHER trevteed Page 3 of 10 FiN SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 75 Beldan Lane Centerville,Mass. Owner: Henry Wilson Date of Inspection: dD/ale/9 8 D) SYSTEM FAILS: You must indicate eiv.er 'Yes' or'No' as to each of the following: y_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corTea the failure. Yes N.JL Backup of sewage into facility or system component due to an overloaded or clogged SA5 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 distr•r�on box above outlet invert due to an overloaded or clogged SAS or cesspool. � Liquid depth in cosspeet 1s less than 6' below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year,NOT due to clogged or obstructed pipets). Number of times pumped Q• Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. J Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either 'Yes' or 'No' as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply N� the system is located in a nitrogen sensitive area (Interim Wellhead Prote.o- ion Area• IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please.consult the local regional office of the Department for further information. (revised 04/7S/37) Pa0. 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropcnyAddress: 75 Beldan Lane Centerville,Mass. Owner: Henry Wilson ; Date of Inspection: AO/ad/98 Check if the following have been done: You must indicate either 'Yes' or,'No' as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal now rates during that period. Large volumes of water have not been Introduced into the system recently or as pan of this inspection. ZAs built plans have been obtained and examined. Note if they are not available with N/A. Z _ The facility or dwelling was Inspected for signs of sewage back-up. _ !, The system do-es not receive non-sanitary or Industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,4luding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened;and the Interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions;depth of liquid, depth of sludge, depth of scum. / — The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 75 Beldan Lane Centerville,Mass. Owner: Henry �W�is Wilson Date of Inspection: lblo�(/198 FLOW CONDITIONS RESIDENTIAL: Design flow: 516 g.p4./bedroom for S.A.S. Number of bedrooms: Number of current residents:w Garbage grinder (yes or no): 20 Laundry connected to system (yes or no):� Seasonal use (yes or no):Ai Water meter readings, if available (last two (2)year usage (gpd): ��d 'q a Sump Pump (yes or no):-AM Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: "gallons/day Grease trap present: (yes or no).& Industrial Waste Holding Tank present: (yes or no)- . Non-sanitary waste discharged to the Title S system: (yes or no)Ad Water meter readings, if available: N� Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING ORDS a d source of nformatio � System 6umped as pan of inspection: (yes or no)j,& If yes, volume pumped: D gallons Reason for pumping: TYPE OF�SYSTEM _�Septic tank/distribution box/soil absorption system ,4& Single cesspool 1)6 Overflow cesspool A'y Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) AJA VA Technology etc. Co y of up to date contract? Gather APPROXIMATE AGE of all components, date installed (if known) and source of information: j�Ytl'S O�iP Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/)7) Page 5 o1 10 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 75 Beldan Lane Centerville,Mass. Owner: Henry Wilson Date of Inspection:JO/ ""'/98 BUILDING SEWER: (locate on site plan) t( Depth below grade: Material ofcons{ruction: �Cas iron 0 PVC_other (explain) c�04))¢,6�V �p Distance from private water supply well or suction line /D Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) Joints appear tight No evidPnr•P of lf'akage System is vented thrnngh a holagg VeAt SEPTIC TANK:.Lo09AN� (locate on site plan) t Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age ALJ is age confirmed by Certificate of Compliance 4 L(Yes/No) Dimensions: $b�leUs y?d",i Ua 9'7''�i1� Sludge depth: `s y Distance from top QJ,�Iudge to bonom of outlet tee or baffler Scum thickness: 'j Distance from top of scum to top of outlet tee or baffle: �!1 Distance from bonom of scum to bottom of outlet t e or baffle: How dimensions were determined: /VMc r Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Pump septic tank every 2-3 3ZPars-Tnl pt and outlet tees are in l ar•P,TT ;1Tilid 1 ovel at the P�tI Pt }f3aer-t s fnri��t '�C�es. T-he septle tan( GREASE TRAP:Ab�e (locate on site plan) Depth below grade: Material of construction:A�4-concretel()4—metaV)A Fiberglass, 04 Polyethylene Wother(explain) Dimensions: Scum thickness: 107_ Distance from top of scum to top of outlet tee or baffle:�i) Distance from bottom of scum to bonom of outlet tee or baffler Date of last pumping: A4 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,-etc.) (rwlaod 01/2s/77) Yap• 4 of 10 r , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: .75 Beldan Lane Centerville,Mass. owner: Henry Wilson Date of Inspection: /0/'J?1/98 TIGHT OR HOLDING TANKcya)e (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grader Material of construction:VA concrete metal vA Fiberglass,%�Polyethylene,*Aother(explain) Dimensions: Capacity: 'a gallons Design flow:_ y/1- gallons/day Alarm level:_Alarm in working order lVA Yes; AA No Date of previous pumping: A�/ Comments: (condition or inlet tee, condition of alarm and float switches, etc.) Tight nr holding tanks arP not nrPGPnt _ DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet inven:4_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or%out of box, etc.) Distribution box has one lateral;No evidence of solids oarrz nvnr- Nn PvidPn .P of 1eakaae into or out of the PUMP CHAMBER:�I le— (locj(c on site plan) Pumps in"working order: (Yes or No)_,Azg, Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Atimp ohAmhar i q not hrpgant z lr�vS�.0 01/JS/S7) ley• 7 of 10 • N . .� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 75 Beldan Lane Centerville,Mass. Owner: Henry Wilson Date or Inspection: 6190198 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: . leaching pits, number: leaching chambers, number: leaching galleries, number-.- leaching trenches, number,length: leaching fields, number, dimensions:_1 overflow cesspool, number: 6) Alternative system: o Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to bonev soi c to merii um fi na canrl_;mn c; rrnc of hydraulic failiire nr t nnrli ncj- all xrAgotat_rapi.s—porwa•l CESSPOOLS: &Avt2 (locate on site plan) Number and configuration: 0 Depth-(op of liquid to inlet invert: Depth of solids layer: Depth of scum layer: AJA Dimensions of cesspool: Materials of construction: ll Indication of groundwater: Jll inflow (cesspool must be pumped as pan of inspection) Cesspool c are nni-=recant Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesc;pc)nl c arp not =scant PRIVY: &VAV— (locate on site plan) Materials of construction: �l//� Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Priv32 is not pracpnt — (r•vis•d 0//2S/17) P690 I of 10 , 21 Su8SVRFACf SOYAGE OISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Piopenr Address: 75 Beldan Lane Centerville,Mass. O.:ner' Henry Wilson 041e of In(pat(ion. /0/0/98 SKFTC►i OF SfwAGE OISPOSAL SYSTEM: inclvdc tics to at least two permanent references landmarks or benchmarks loci It all wells within 100' (Locate where public water supplY comes into house) 3 ' SUBSURFACE SEWAGE SYSTEM INSPECTION FORM C SYSTEM INFOItt.; .PION (continued) Property Address: 75 Beldan Lane Centerville,Mass. Owner: Henry Wilson Date of Inspection:/O/PO/98 Depth to Groundwater pZA Feet Please indicate all the methods used to determine High Groundwater Elevation: f�/ Dbjseryation Obtained from Design Plans on record of Site (Abutting property bservation hole, baserwil-sump etc.) termine it from local conditions Check with local Board of health Check FEMA Maps bl/Check pumping records ,_(Check local excavators, installers Use USGS Data Describe in your own words how you established the.High Groun�.rerElevation. (&—uji be completed) Used Gahrety & Miller Model 12/16/94 , 'I.QOr 10 .y T1Tw rrtI'lT7—Ttr\Tfr�JIR'R1T+.IfrT'I1R..l1R1I1'.�ITlffrfTfftf\flT11Rn17iT.l�llfpf Tll TR'fTr�1T.iI�.•.T.1�•'� l 'TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I `� F.^•Tri�T••. ::\-T.IIT.�.TTT TT.wI'II.TTI T4TAl1f 71.�IT7'��t•tr'{tTR\RRA►-TR�1QA7<ATfRAI�Tt�'fR� t�.Il •.TrT'1`+" ..�..A .-TYPE OR PRINT CI.EARL1'- PROPERTY INSPECTED STREET ADDRESS _75 Beldan Lane Cent erv; 1 1 A M---=sc - ASSESSORS MAP, BLOCK AND PARCEL # _ / 9 /J �� D 7 OWNER' s NAME Henry Wilson o PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & won Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 1 775 - 3338 FAX (508 1 790 - 1 578 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and complete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: __-'zSys teui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public liealLh or the environment as defined in 310 CMR 16 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection whictl I have con acted has found that the system fails to Protect the j-)ublic health and the environment in accordance with Title 5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date Onb copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF HEALTII. * If the inspection FAILED, the owner orlhoperator shall upgrade - the within o'ne year of the date of the inspection, unless allowed orrequiredm otherwise as provided in 3.10 CMR 16 . 305 . partd .doc No. ........ Fps... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH G✓ ..............OF.. 1� ,� ----------•----..............._...... Appliration for Disposal Works Tonstrnrtion Prrutit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System t: � _ '' vv �� ....... n .... ........................ _. -- - -•--------.- Location-Addres Lot No. .... , ��. ...,, :_.. :..................... ................................. Ownez Address Installer Address Type of Building Size Lot.5 i.74�_.._._Sq. feet Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .------••----------------------••------------- W Design Flow...........3.3_.2...................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid ca.pacity4?AO..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.a��_....sq. ft. Z Other Distribution box ( ) Dosing tankA( W Percolation Test Results Performed by........... ��.. �!, .!°:___ !�/�......................... Date_.K _.. .......................... Test Pit No. I ICY------minutes per inch Depth of Test Pit./.�._1..._.. Depth to ground water.,l�Q✓`'v.....__-. (s, Test Pit No. 27MA^ .2-minutes per inch Depth of Test Pit.................... Depth to ground water.elmayl/a pG ...--•--•------------------------------ ------------------- ---------------------------•--•---------••---• •. O - Description of Soil--- �.-..r�......, � .9`f...........••�-.'-. ----- lf�.l,!?. _._ ��A, " F_ /.�,�._-'-....fAwl.1,P:fi��--------------------------------- U -•-- f} -- W UNature 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 iI:'Lis 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by the bo of health. �j ed CjR - ?.. .. D. to Application.Approved BY .._.. j, s Date Application Disapproved for the following reasons:............................................................................................. .................. ..........................................................---------------•----..........---------...-•----•-••........................................................................................ Date PermitNo......................................................... Issued_ 1.. -- - Date .,i L 4 . .. w THE COMMONWEALTH OF MASSACHUSETTS BOARDOF HEALTH ....--.......!....r✓..................OF..FI�i.."' :...:... ............................................... Appliraativan for Dispoii al Works Tomitrnr#inn rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................__ ___................. ............................................... ::....--.•--------------------•-----------------------....--•----•------------.........•--......_. / Location Address / f /' or Lot No. ....._.............._._.................. .... ........._............................................................... /O•wner //'� (- Address ....................... z Installer Address � .I t_G d Type of Building �s Size Lo "`'-_.__--_ :S.......Sq: feet U Dwelling—No. of Bedrooms................_5............... .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ......... No. of persons............................ Showers — Cafeteria Otherfixtures }r...........................................................................................:...--................................. Design Flow........... .. .. ...................gallons per person per day. Total daily flow............................ _... :__._.__.gallons. W Septic Tank—Liquid'capacityf�«..gallons Length................ Width.................Diameter............. . ......._........ x Disposal Trench—No..................... Vidth.................... Total Length.................... T 7—Depth otal leaching area............No--------------------- Diameter.................... ft. Z Other Distribution box ( ) Dosing tank '~ Percolation Test Results Performed by...............G�l rrs/�rf..._ N�Jn!:__._......._..._�Date.._6 � �d Test Pit No. Ik ......minutes per inch Depth of Test Pit.__rrf.5...... Depth to ground water.A-s�-`........ f f=, Test Pit No. 27Z.Zlx.2"minutes per inch Depth of Test Pit................. Depth to ground water.&:L0a.Af!. ---------=--------- •......--•.....................•-----------.............--.--•-- 0 Description of Soil.... _.... ?!f1�j `r �I�l '' '-.r"' !fry �'lln/.V t'.r7`' ............. ----------------.....-•---••---•----•----•-------•--------- W UNature 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. .........� .....................D... .......... _ D Application Approved BY-------- '-- --------------------•- ----> 'e' t N----------- Date Application Disapproved for the following reasons:______________________________________________________________________________________________________________ ................................-........................................................................._ Date PermitNo......................................................... Issued....................................................... ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH e-, .............. . f� ................................ CInrtifirtt#e of TOmpliFanrr THIS IS�TO CERVY, That the Individual Sewage Disposal System constructed O or Repaired ( ) bya�.flr c+' ..�?. ...1.............................•---------...----------------------•-........--------------------•-•-........------.......-•-•--...............---- J Installer,. at............. -;� = ram/,� ;✓ rfry C� %>, ",.._._..._...... ... .......................................................... ...........................-........ ---- has been installed in accordance with the provisions of TI T LF `' of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.................J.�y............... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE ` �� Inspector.... . -------- --- --------- 7--------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF..... rn. ....� I ../. _` Oer ,y No.........................y FEE ..."'".... .. .............. �io�oo�al orko �onstra�tion lerani# Permission is hereby granted..s_j. e�..........:'f -.--------------------------•--••--------•---•--••-••-•---------•.......•.----• to Construct (-'`) or Repair („) an Individua�ewage Disposal System ! a at No-----------------`'- -...'%'rr�� ......................... -----....-•--•--•--••--------------.......-----.---•--......•. ......•.......... Street . e as shown on the application for Disposal Works Construction Permit No..................... D�tted........................k................. - �r ........-------------------•-----•----..._ /�, . of Health DATE.......,. Gt-------------------••-------•----••-•--•---. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS t LOCATION SEWAGE PERMIT NO. V I L L A G E (�q (pal . V _ 1 1J `J\A��►'" INSTA LLER'S NAME i ADDRESS Ole � s B UIIDE R OR OWNER e5x DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �_ � � �� b a� � LOCATION SEWAGE PERMIT NO• VILLAGE INSTALLER'S NAME i ADDRESS I U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r ` a� ,�y ^.., �� -�G 1 ` - TOWN OF BARNSTABLE 1 LGC`16.1`ION /c' 1,;?eZa e el L A419e SEWAGE # VILLAGE C elil V`« a ASSESSOR'S MAP&LOT G_�) 607 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 14 G d LEACHING FACILITY: (type) (size) NO.OF BEDROOMS '3 r BUILDER OR OWNER PERMUDATE: COMPLIANCE DATE:_ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �'/�,44 A C Owl/eelff S'®, rR . 1 % \ --4� "s ' 0 ,, y�•y s h or l t , � f P �} `V It 30 N t 4 o? j20BERT, t F� BUNIKIS ( S { ^t No.22162,0 c „ � •y..,�;.� .09 GI6T�� l is X,/ 'i �_� �o0isT BoX. ,r# ,�•r �FlSS:ONAL- � G!F.9Ci�./Ii/ 24 MIN 31 CIN �Altv x r ' '$•kr L E{�E N U 1 r, a °'lf e 4 4 •<«" a V EXISTl,NGtSPOT ELEVATION 0x0 CERTIFIED PLAT PL' AN EXISTING; CONTOUR — p tf NiSHEV 3 SPOT ELE,VA T'f.ON O'0{ F ��N;SHED' `CONTOUR ..:., p'. : • L.�� f---- CAN / �C(�/ ' rk ; IN gzr , t�PPROVE O BOARD OF HEALTH . �j .\ )) A Is r .` t, `", a f DATE 'S AGENT SCALE GATE A �"d > iEL�DRFQGE%�`ENG/NEERING CO. INC _ ..: ; CLIENT I CERTIFY THAT THE PROPOSED TfiRE[ 'REGISTERED JOB N0. � G� BUILDING SHOWN ON THIS 'PL AN s'tg kCL1%Il. .' LAND �'/ CONFORMS -TO THE ION'NG- LAWS ENGINEER �. SURVEYOR DR. BY 'f ,-,_ .4 OF BARNST BLEB MAS xs ti "til yfs MMl.ti• •1r ••, 7 CH 8Y !'� � f',,.J I-_ � �V V {f -• y i tI M.:ASiS HYAWS, YIA� T_l �" 1/ : SHEE OF DAhE AEG , LAND SURVEYQR ;k ;¢ SEPTIC rAgN,,,< OR -- --; :. i4CN/NG P/7- AREM , /2"BELojVq 2.0 01A M ET.�R CONCh' =7- CO!/E'R SjlALL &4E O ?OUGAyT TO 6 • 'CONCRL'TE 4"P{�C P/PE IAA OE.6A1v .EXTRA COI/ERS M/N. P/TCN h'EAVy CAST /?ON COVFR zI L3E C/SE.0 IB PEAQ FT. /F./N AR/VEloVA y Al I -i 2' MiN. CONC,E'E•TE -•:'� GRADE CC) 1-E,4 .a:� .•.. . . CLEAN .SANG " 45ACA-)—I L L CAST 2*LAYER i. G 2 M/N. P/TCN l GAL. . I • • • • e • • 1 r '6 0 D D v a e o o� QF '/8'-3/B.. SEPTIC TANK Ir{/A SH17-0 $TYJNE eOX o V � I1 � H • r • • • � • bno • v •EFFECTI 3VE' r� " 4 �DEPTH o o WA5,yEO STONE Imo:'::.'-o. 1 r • • • ♦ • • r 1: o e a• c a 1 • 1�• e s • • i 1� p pap -- PREG95T SE.EP.4GE !N(/eRT ELE1/AT/DNS LPL, �S, q ff p r r ■- • • • . • 1 1 e o P/T OR EQU/V INXERT AT BlJILDING Z `� �_ FT ( FT INLET SEPT/C TANK FT. U/,4M. C(51=E T,�IBULAT)OAV) OUTLET SEPTIC T.aNK J/• FT. ---� /NiF7"D/57R,1.3UT/ON DOX FT. GROUND /tl,[�TER TABLE OUTLETD/STR/BUT/UN BOX �/. 3 F7 SECTION 4F /NL6r LEACH/NG P,47- s/ o /cT .S'E;VAGE O/S/POSAI- SY.STE/Yl LEA CHI/VG P/T 7- 54/1-AT/DN DES/G!V CRITERIA SCALE �./ IA- o" U/ME/VS/oN A 3 FT, D/".ENS/a -FT. NUMBER OF BEDROO/ys 3 D/MENS/ON C— -7': /N' GAReAGED/SPOSA.L UN/r SO/L LOG TOTAL ES7/M.4TE0 FLOH/ 330 GA1-.1A9AY " SOIL TEST */ SOIL 7ES7-*2 SD/L TEST NUMBER OF .EALHtNG: ELEY,__ - S/DE L,�`ACH/NG PEK P/T ��$!" ,SQ FT � r /C DATE OF SO/L TEST 6O TTOM LE�1 G N/NG PER P/T 7 s4. FT r 9 RESULTS I4//THE SSED BY '� TOTAL LEACH//YG AREA FT 2 /L f'L`ZCOL ATN RATE � /O e- -5 M/N1//NGH �O SQ Sq. FT FLERCOL A'r1oN RATE AL-2 MIN.�INCH RESERI�E GEACN/NG AREA_2'6 � f cv :r s c C�aPCE�I%�3 2i Ems. /may' �o ROSER11 "� �`g L-D j- ' /��LD�t/ ��4 /!/E. n aunixi C oA-•/zs� c-�/r/7 e�Z.to sr`a��` ELORED6E ENG/N.E�R/A/G CO,% �N.A Li� ' Y �j,. 4. > ;^5 y' ..C«';Y's1' 'Y r.,a 7/f._.' cT"_ r MA%N STMA//V s NO01TOUNP Y,W,47,&, ENCOU/VTERLO HYANN/� + MtiSS GRO UA/O kV�T'4,P'AT SO• YARMOUTNr MASS ri JOB-NO 0 SMEET.ZaOF, Z! +� ...e ` Y,. �,'•'s i�or:��:,._Yw t'a".i.� 4z-.°:J-- ,4x..4 r" �ti-.y _ ,k,-•.: �,-.. '�•� - ( .. _ _. ..