HomeMy WebLinkAbout0065 BIRCHILL ROAD - Health 01
65 Birchill Road
Centerville P
A = 189 063
No. 4210 1/3 ORA
loft JAL dIl 100ow
.. _ __ _
YOU WISH TO OPEN A BUSINESS? ,
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by 1M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and Iget the Business Certificate that is
required by law.
DATE: f/ Fill in lease:
r s8 x a' s APPLICANT'S YOUR NAME/S: . {'" - YIJ�� 'r Vl / 1,E�/V
BUSINESS YOUR HPME ADDRESS:
c
n h sxz;; TELEPHONE # Home Telephone NumberAa
NAME OF CORPORATION. C:
NAME OF NEW BUSINESS, -t-�: f L TYPE.OF BUSINESS- Gl�
IS THIS A HOME OCCUPATIONS YES NO
ADDRESS OF BUSINESS; " !/ / MAP/PARCEL NUMBER /: `�/�� .
Assessing);
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of -
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200;Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the approp'riate`permits and licenses required to legally operate your business in this town.
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1. BUILDING COM1.%Aut
S OFFI �!.ND REGULATIONS. FAILURE TO
This individuforme o rmi requiremen that pertain to this type of business. 1 MAY RESULT IN FINES.
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2. BOARD OF HEALTH
This individual hQs bee anf s ned o e r it re uirements that pertain to this type of business. MUST :,OMPLY WITH ALL
US WTFRIAI S REr!t_1J T;')»,
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY) I J
This individual has been informed of the licensing requirements that pertain to this type of business.
I
Authorized Signature**
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COMMENTS:
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Date: I Z.1 / -7,v I
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE
i
NAME OF BUSINESS: 11,&th1L_-'
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: al lz-e� TOTAL AMOUNT:
TELEPHONE NUMBER•
CONTACT PERSON: _
nv-
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: Jn ! ,�`� a&4Ab 6_
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout ' Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
k(_919 / Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
p Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
-- (including chloroform, formaldehyde,—
Paint -
✓ Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS App' ant's Signature Staff's Initial tllr
I
1) R_.
may' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
..'Y 65 Birchill Road C
Property Address
Countrywide Home Loans I I v✓
Owner c/o Century 21-Cape Sails
information is 133 Route 6A LA-1 �o
required for every
page. owner's Name
Sandwich MA 02563 1/4/2008
Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Peter T. McEntee PE, SI
use the return Name of Inspector �a
key.
Engineering Works f
ICI Company Name x "�
12 West Crossfield Road
Company Address j
Forestdale MA c 102644�,
Cityrrown State .4 Zip Code
(508)477-5313 SI 1480
Telephone Number License Number c.,3
w
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. 1 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
Pz'AX 1/4/2008
Ins or's ignature 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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner c%Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owner's Name
Sandwich MA 02563 1/4/2008
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:
New covers must installed over cesspools to provide complete cover over the cesspool openings.
Note: Future maintenance should include pumping of the primary cesspool every 2-4 years.
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
co, 2 I �
i
Commonwealth of Massachusetts
Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
owner cto Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owners Name
Sandwich MA 02563 1/4/2008
Cityrrown State Zip Code Date of Inspection
❑ broken pipe(s)are replaced
❑ obstruction is removed
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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
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:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner c/o.Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owner's Name
Sandwich MA 02563 1/4/2008
City/Town State Zip Code Date of Inspection
❑ 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.
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cunt.):
❑ 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
Commonwealth of Massachusetts
Title 5 Officia-1 Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner clo Century 21-Cape Sails
information is 133 Route 6A
required for every
page. owner's Name
Sandwich MA 02563 1/4/2008
Cityrrown State Zip Code Date of Inspection
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to.a surface water supply.
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ ® 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 colifortn bacteria indicates agent 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
Commonwealth of Massachusetts
ugTitle 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Birchill Road
Property Address
Countrywide Home Loans
Owner c/o Century 21-Cape Sails
information is 133 Route 6A
required for every
page. owner's Name
Sandwich MA 02563 1/4/2008
CitylTown State Zip Code Date of Inspection
❑ ❑ 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.
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ Z 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?
® 7 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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner clo Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owner's Name
Sandwich MA 02563 1/4/2008
Cityrrown State Zip Code Date of Inspection
❑ ❑ 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
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)):
n/a
Sump pump? ❑ Yes ® No
7/07(approx.)
Last date of occupancy: 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.):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner c/o Century 21-Cape Sails
information is 133 Route 6A
required for every
page Owner's Name
Sandwich MA 02563 1/4/2008
Cityrrown State Zip Code Date of Inspection
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:
Last date of occupancy/use: Date
Other(describe):
D. System Information (cont.)
General Information
Pumping Records:
Source of information: not obtained
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)
f�a o I (D
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y< 65 Birchill Road
Property Address
Countrywide Home Loans
Owner c%Century 21-Cape Sails
information is 133 Route 6A
required for every
page. owner's Name
Sandwich MA 02563 1/4/2008
Citylrown State Zip Code Date of Inspection
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
42 years+/-, House built in 1965
Were sewage odors detected when arriving at the site? ❑ Yes ® No
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1
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.):
Pipes are intact and functional. They are in FAIR condition.
Septic Tank(locate on site plan):
Depth below grade: 6"(primary cesspool is treated as
a septic tank in this case.
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ®other(explain)
concrete block cesspool
If tank is metal, list age: years
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner c/o Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owner's Name
Sandwich MA 02563 1/4/2008
City/town State Zip Code Date of Inspection
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 6'diam, 6'effective depth
Sludge depth: 1.5'
Distance from top of sludge to bottom of outlet tee or baffle
4'
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
How were dimensions determined? measuring rod
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.):
The cover over the primary cesspool was cracked and needs replacement. Liquid level in cesspool
was 4'deep. Structure appears sound. Piping and Outlet Tee are functional and in fair condition.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide.Home Loans
Owner c/o Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owner's Name
Sandwich MA 02563 1/4/2008
CitylTown State Zip Code Date of Inspection
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.):
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):
D. System Information (coat.)
Tight or Holding Tank(cunt.)
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
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner c/o Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owner's Name
Sandwich MA 02563 1/4/2008
Cityrrown state Zip Code Date of Inspection
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
D. System Information (cunt.)
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:
Type:
❑ leaching pits number:
❑ leaching chambers number:
Commonwealth of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner c/o Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owner's Name
Sandwich MA 02563 1/4/2008
Cityrrown state Zip Code Date of Inspection
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number:
1
❑ 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.):
Overflow cesspool (SAS) had 6"of standing effluent. Effective depth below pipe is 6'. No evidence of
hydraulic failure was observed. There was a mild ring at 32"indicating the probable high water level
during normal flow conditions. Larger cover is needed to cover entire opening of cesspool.
D. System Information (cont.)
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.):
cax Is cp I b
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner c/o Century 21-Cape Sails
information is 133 Route 6A
required for every
page Owner's Name
Sandwich MA 02563 1/4/2008
City/Town State Zip Code Date of Inspection
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.):
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
�a� �� eF 1(0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner c/o Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owner's Name
Sandwich MA 02563 1/4/2008
Citylrown State Zip Code Date of Inspection
WATER SVC.
BACK OF HOUSE
:� •S 6�'6 518
OVERFLOW PRIMARY
CESSPOOL CESSPOOL.
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 30feet
Please indicate all methods used to determine the high ground water elevation:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Birchill Road
Property Address
Countrywide Home Loans
Owner c/o Century 21-Cape Sails
information is 133 Route 6A
required for every
page. Owner's Name
Sandwich MA 02563 1/4/2008
Cityrrown state Zip Code Date of Inspection
❑ 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: x
See comment below re. GIS info.
You must describe how you established the high ground water elevation:
Town GIS Database has site at EL=50 and groundwater at EL=20. Also, this engineer performed a
soil evaluation on a site in the vicinity on12/27/05 Ref#11198 with no groundwater observed at 1 ft.
Town of Barnstable
OF THE 1p�
yP� Regulatory Services
sUrsrnsc E Thomas F. Geiler, Director
ArE1639.D3�p Public Health .Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
r,
OAP
ECOJECH PARc4a 0 3
Environmental
www.eco-tech.us LOT
4
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000)
TITLE 5
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 65 Birch Hill Road(aka Birchill Road)
Centerville
Owner's Name: Enenar&Elizabeth Bolin
Owner's Address: 65 Birch Hill Road
Centerville,MA 02648
CD
Date of Inspection: April 13, 2004
-o
Name of Inspector: (Please Print) David D. Coughanowr,R.S. N
Company Name: Eco-Tech Environmental <FP1 CD
Address: 43 Triangle Circle o >
Sandwich,MA 02563 x -�
Telephone Number: (508)364-0894 W
co
CERTIFICATION STATEMENT: i m
I certify that I have personally inspected the sewage disposal system at this address and that the inforriation 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:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature ' /44 0, 6� kS Date: �t'P f� � �� 200
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
NOTES AND COMMENTS
Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10, 2004
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
A] System Passes:
Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR
5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no, or not determined(Y,N,or ND). in the_for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not),is structurally
unsound,exhibits substantial infiltration or exfiltration,or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout or high static water level 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 Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced.
ND explain
The system required pumping more than 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
ND explain
2
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10, 2004
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 and 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
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 by a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form
3) OTHER
3
Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10, 2004
D)System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
I have determined that one or more of the following failure conditions exist as described 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 correct the failure.
yes no
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high groundwater elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form)
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore, the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E)Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10, 2004
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
Y _ Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the last two weeks?
N Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of this inspection?
n/a _ Were as built plans of the system obtained and examined?(If they were not available as N/A)
Y _ Was the facility or dwelling inspected for signs of sewage back-up?
Y _ Was the site inspected for signs of breakout?
including
Y _ Were all system components,exelti the SAS. located on site?
_ N Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for
the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum.?
Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper
maintenance of subsurface disposal systems?
For information on the proper maintenance of subsurface disposal systems please go to:
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
N Existing information. For example,Plan at the Board of Health.
Y _ 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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept.
Number of current residents 0
Does the residence have a garbage grinder(yes or no): no.
Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required)
Laundry system inspected (yes or no): n/a
Seasonal use(yes or no): no
Water meter readings,if available(last two year's usage(gpd): 49 gpd
Sump Pump(yes or no): no
Last date of occupancy: March 2004
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203):: gpd
Basis of design flow(seats/persons/sqft/etc.):
Grease trap present: (yes or no)_
Industrial waste holding tank present: (yes or no):
Non-sanitary waste discharged to the Title 5 system: (yes or no).
Water meter readings,if available:
Last date of occupancy/use:_
OTHER: (Describe):
GENERAL INFORMATION
PUMPING RECORDS
Source of information: System not pumped in recent past(Owner)
Was system pumped as part of the inspection: (yes or no) No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM:
Septic tank,distribution box, soil absorption system
X Single cesspool
X Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternate technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
System is assumed to have been installed in 1965 at time of dwelling's construction.
Were sewage odors detected when arriving at the site:(yes or no) no
6
Page 7 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10, 2004
BUILDING SEWER_(Locate on site plan)
Depth below grade: 1 ft
Material of construction: X cast iron _40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting,evidence of leakage, etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling
SEPTIC TANK:none (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of
certificate)
Dimensions:
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 dimensions were determined: Probe to top of tank
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
GREASE TRAP: none (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:_
Date of last pumping:
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10, 2004
TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal _fiberglass_polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: _gallons/day
Alarm present(yes or no):_
Alarm level: _ Alarm in working order(yes or no):_
pumping:Date of last
Comments:(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: none (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.)
PUMP CHAMBER: none (locate on site plan)
Pumps in working order: (yes or no)
Alarms in working order: (yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10, 2004
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required)
If SAS not located, explain why:
Type:
_leaching pits,number
_leaching chambers,number
_leaching galleries,number
_leaching trenches,number,length
leaching fields,number,dimensions
X overflow cesspool, number 1
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
Soils above overflow cesspool appeared unsaturated. No evidence of surface ponding,breakout,lush vegetation, or
other evidence of hydraulic failure was observed. This component was dry.
CESSPOOLS: 1 Primary (cesspool must be pumped at time of inspection)(locate on site plan)
Number and configuration: 2 total—1 primary and one overflow described above
Depth-top of liquid to inlet invert: 36 in
Depth of solids layer: 12 in
Depth of scum layer: 0
Dimensions of cesspool: approximately 6 ft diameter x 6 ft deep
Materials of construction: concrete block
Indication of groundwater inflow(yes or no): no
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Soils above overflow cesspool appeared unsaturated.No evidence of surface ponding,breakout,lush vegetation,or
other evidence of hydraulic failure was observed. Primary cesspool was dry.
NOTE ON BLOCK CESSPOOLS: DO NOT DRIVE VEHICLES OR OPERATE MACHINERY OVER OR
IN THE VICINITY OF CESSPOOLS
PRIVY:none (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100'(Locate where public water supply enters the building)
LOCATIONS
PRIMARY OVERFLOW A B
PIT PIT 1 21 f t 67 IF t
2 29fr 51ft
B A
EXISTING
DWELLING
# 65
W
Z
J
W
W
H
G
3
I
BIRCH HILL ROAD NOT TO SCALE
10
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 Birch Hill Road
Centerville
Owner: Engnar&Elizabeth Bolin
Date of Inspection: April 10,2004
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to ground water: 20+ feet
Please indicate(check)all methods used to determine high ground water elevation:
Obtained from system design plans on record-If checked. date of design plan reviewed
Observed Site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of health-explain:
Checked local excavators,installers-attach documentation)
X Accessed USGS database
You must describe how you established the high ground water elevation.
Comparison of USGS Topography maps and surface water elevation shows site to be over 35 feet above nearby
Fish Hatchery.
11