HomeMy WebLinkAbout0027 BROKEN DIKE WAY - Health 27 Broken Dike'Way_
Centerville '.
A =. 227 079
I
Omrford. , NO. 152 1/3 ORA
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Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 Broken Dike k� Dy
Via.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
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.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC
Company Name
raa P.O.Box 763
Company Address
Centerville Ma. 02632
'erom City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/06/2008
Inspector's Signature Date
✓ry
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"s'-ystem�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.
h�
This report only describes conditions at the time of inspection and under fhb conditions ofyuse
at that time.This inspection does not address how the system will perform I. the future u`�der
the same or different conditions of use. , r"
•27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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):
❑ broken pipe(s)are replaced
❑ obstruction is removed
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
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 thatprotects 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.
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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.
r
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 '/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.
27 Broken Dike Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All System's (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 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.
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
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
❑ Z 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?
® El available
as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
1
Residential Flow Conditions:
Number of bedrooms (design): 4 ,Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2006:98,000
9 ( Y 9 (gpd)): 2007:9,000
Sump pump? ❑ Yes ® No
Last date of occupancy: 3/06/2008
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:
Last date of occupancy/use: Date
Other(describe):
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
I .
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Capewide.Enterprises,LLC
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume.pumped: 1500 gallon
gallons
How was quantity pumped determined? Measured
Reason for pumping: Maintenance
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M a 27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 15"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No'evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: 16"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed b a Certificate of Compliance? attach a co of certificate ❑ Yes ❑ No
9 Y ------------py-------------- )
Dimensions: 1500 Gallon
Sludge depth: 0
Distance from top of sludge to bottom of outlet tee or baffle na
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle na
Distance from bottom of scum to bottom of outlet tee or baffle na
How were dimensions determined? Tank pumped clean
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth'& Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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):
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�M 27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level-above outlet invert No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No signs of leakage into or out
of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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: 1-1000 Gallon
❑ leaching chambers. number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
Vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line is 11"
below invert pipe.
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 27 Broken Dike Rd.
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town State Zip Code Date of Inspection
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.):
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.):
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Map' Page 1 of 2
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 27 Broken Dike Rd.
M
Property Address
Robert J. Mutrie
Owner Owner's Name
information is required for Centerville Ma. 02632 3/06/2008
every page. City/Town 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: Bottom of LP 8'
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:
USED:USGS Observation Well Data.USED:TechnicalBulletin 92-000-01 plate#2 annual ranges of
ground water elevations.
27 Broken Dike Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
THE COMMONWEALTH OF MASSACHUSETTS -
- BOARD OF HEALTH
.....................................OF.........................................................................................
Appliration for Disposal Works Cfonstrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-...:_... __ -.� ... ..... ;:... •.. ......7----------------------------------------- .
Address ? or Lot o.
`/JJ/J��a `Ow,n/ey �_(,, o / dress /
Installer Address T�
U Type of Building Size Lot.... .?�_d S_?F......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (�C)
P4 Other—Type of Building ............................ No. of persons--.......................... Showers (2,,) — Cafeteria- ( )
A4 Other fixtures ................................. .
W Design Flow..... ......._P..........gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity../Y lQgallons Length................ Width................ Diameter.....--......... Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.-.z .sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.3.2-9hrq. ft.
Z Other Distribution box (>0 Dosing tank ( )
'-' Percolation Test Resul Performed b �... -%. �___.�..��.._-._.... .. !
y--•• p�
Test Pit No. 1200-...minutes per inch Depth of Test Pit....l._�c....... Depth to ground water....! ..............
Test Pit No. 2_.a.'0_...minutes per inch Depth of Test Pit....:.....?......... Depth to ground water.--.- ITIf........
Description of Soil....... �_...._._. `........ .-Z-.__.._
vz...._.....c....... .--
W ................... ----•---••-••••--••-••-••••••••----------••••••-•-----------------••••--•-•---••--------------------•--------•-•-•......•..........................................................
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
...........................................••• ---•-------...............-----•---•-•---------------------.....-------------------------------------•---•......------.........
Agreement: T[--
The undersigned a e to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of AITIE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has a issued h.
Signe -_-----
Date
Application Approved By•_-•••• • • •••-• -•••-•. ...•...•��W
...... ••-•••••-� 1 -�---
Dat
Application Disapproved for t e following reasons:..............................................................................................................
•••-•...........................•.....•••............•••.............••••--...•-••--•-•....._.........••.••----••----•-•-•••••••••-•----••-••-•-••-•---••-•••••-••••••••••-••••••-----•--••-••••-•-•••--
Date
PermitNo......................................................... Issued.......................................................
Date
-------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................OF...........................................................................................
z
Appfira iun for Disposal Ends Tonstrurti att Errant
Application is hereby made for a Permit.to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: t
G� �- Loeasion-Addres � ....................... � .Y.. .... .i' ........
Owner.
-------•r - . .................................................
.---....- dr ........�..._.....s� q.
� Installer Address
d Type of Building Size Lot....---.-�./.-�-..........S feet
Dwelling—No. of Bedrooms........"`'�..............:....................Expansion Attic ( ) Garbage Grinder
Other—Type e of Building .............. No. of ersons_..__._..................... Showers
a YP g .............• P (Yf — Cafeteria ( )
a Design Flow_Ot.$.3�tures - _P:::::::-:gallons per person per day. Total daily flow....................................gallons.
W. �/ ICI
WSeptic Tank—Liquid capacity../.Sl allons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.--_--------------- Width.................... Total Length.................... Total leaching area-. sq. ft.
Seepage Pit No............:........ Diameter.................... Depth below inlet................... Total leaching area.--!.. - ':..sq. ft.
Z Other Distribution box Od Dosing tank ( )
m fed by----- _`_51.��... �.�.� Date..
� Percolation Test Result Perfor .._._. ...._.._
Test Pit No. l.�i .__ inutes;:per inch Depth of Test Pit.....:!_ ....... Depth to ground water........................
rz, Test Pit No. 2.__a..'..D_....minutes'per inch Depth of Test Pit....._...`1i-........ Depth to ground water......F'.Y.........
......................................................................................
0 Description.of Soil...... .QR±t�,. -�.&�Q{ -------
t
-----------•----------------• �'-.if �c'.....aca•r....e .�
................... .........•--......_.......---••........---------_...
..
U, Nature of Repairs or Alterations—Answer when applicable...............................................................................................
................................................... ------•----..._y.. ._.........-• . . ----•--•....-----•--............--••...........
Agreement:
The undersigned agyr!es/ttoo�install the aforedes bed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State,.Sanitar Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued by Kie boar ot health.
Signed....... -- �:�•------ 7 �y .... ...»....
Application Approved By.........
..2. . 1
Date
Application Disapproved for towing reasons---------------•-----------------•-•------..............----•---••---•----------------------•------------.----
..-•-•-••-••.............•-•-•••--•------•-----------.....---•••--•••-•-•......-•------........-•••-...»....---•••••---•-•--•-•--••-----••-••--•---...-------•-•--•-•--•••..........---...•••••--•--••-
t,. Date
PermitNo....................................................».... ;, Issued::_...............•••--...._........................»
Date �.I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- ..........................................OF.....................................................................................
Tertif rate of Tuntphatt r
b THISIS TO CERTIFY, That the In ivi .age Disposal System const ructed- ( Nor Repaired ( )
yL�.-.L.Y�:Q!?a.`. ............ --- -: .. .............................. .......... __....»
nn Installer { »�
fat...... Ip ?------ .... .. ...-..._...W.. ..... -1��'yt _`_ -......---... ................................................
has been installed in accordance with the provisio s of TITLE 5 of The State Sanitary.Code as`d'e'"scribed in the
application for Disposal Works Construction Permit No......................................... dated..............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.------... l:�D f.?��~,............................................ Inspector-- -•- - _ �� ....... ...
! ! 'C .
THE COMMONWEALTH OF MASSACHUSETTS P ;N -•t I,�r t 1�
BOARD OF HEALTH (
No.`.�-5.. ?. .... V"(.^j.............................OF........... ........................-----................ ................... Fix........................
s rn ttl nr , . Tunstrurttan, rr
Permission is hereby granted...._ ..!�..'......_. .'.ax. .`r�J F � ......... ........._..,.
to Construct ) or Re air �,. ) a ndi idual Sewa a Di osal Sstem
atNo....... ' - l? h�.` i4.. .:..__... ..............................................................
Street �.+
es'S--Cg
as shown on the application for Disposal Works Construction Permit No.............. ... ated._..--..........._........................
.................................. �...........s...............
- � B rd of ealth
......................
FORM 1255 A. M. SULKIN, INC., BOSTON
i ELLIS & THULIN, INC. LAND SURVEYORS 6� CIVIL ENGINEERS
478 ROUTE 6A-P.O. BOX 159 DAVID C.THULIN, PE
EAST SANDWICH, MASS. 02537 JOHN R.ELLIS, RLS
TELEPHONE (617) 888-2345
February 6 , 1986
Board of Health
Town of Barnstable
367 Main Street
Hyannis , Ma . 02601
re . 85-127 , Lot 7 , Broken Dike Way , Centerville
Gentlemmen :
Enclosed please find three copies of the Certified Plot Plan
for the ref . lot indicating as-built condition of the septic
system and location of the residence .
A table is included which demonstrates that the septic system.
was installed in substantial conformance with design set forth
in the Proposed Plot Plan .
All elevations were measured on the system components prior to
backfilling .
Ver, rul o ,
Ellis _& Thulin , Inc .
David C . Thulin , P.E
&,c c .
t Bayview Corporation, -Owner
tcE K Z 1
R
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bamE r-is is' -=-a a - i 34 F-';,AvvjEw c,=,aDoPA,jioLi
311-
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COLIF00A TO TI4ff Zo1.111.16 LAWS
,J,R MvSKM-SET LAja pQ,BY: -� E. OF BAP-6'JSTABLE, MASS.
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Q�oFTMEro�` TOWN OF BARNSTABLE
OFFICE OF
s seaSTAMAM t BOARD OF HEALTH
pp 1639.
no k' 367 MAIN STREET
HYANNIS, MASS. 02601
May 23, 1985
Mr. Joseph D. Iafrate
Bayview Corporation
P. O. Box 2048
Centerville, MA. 02632
Re: Variance for Lot 7, Broken Dike Way, Centerville
Dear Mr. Iafrate:
The variance granted Raymond J. Ratkowski on April 4, 1984, to construct an onsite
sewage disposal system on Lot 7, Broken Dike Way, Centerville, is extended to expire
May 1, 1986, with the following conditions:
(1) The septic system leaching pit must be installed in strict compliance with the
approved plan.
(2) All other requirements contained in the Town of Barnstable Health Regulations
and Title 5, of the State Environmental Code, must be strictly complied with.
(3) The designing engineer must be on site to supervise construction of the system
and certify in writing to the Board of Health that his design has been complied
with before the issuance of a certificate of compliance and an occupancy permit.
(4) You must receive approval from the Conservation Commission.
The Board reserves the right to deny any further variance time extensions. The variance
will not be renewed if the Board feels that installation of an on-site sewage disposal
system has the potential to adversely affect the environment.
V ell t ly yours,
Robert C i ds
Chairman
BOARD,OF HEALTH
TOWN OR BARNSTABLE
JMK/mm
cc: Conservation Commission
T.
TOWN OF BARNSTABLE
OFFICE OF
i Hesa9T rAM BOARD OF HEALTH
1639. �� 367 MAIN STREET
HYANNIS, MASS..02601
April 4, 1984
Mr. Raymond J. Ratkowski
c/o Bayview Corporation
Blantyre Avenue
Centerville, Ma. 02632
Re: Lot 7, Broken Dike Way, Centerville
Dear Mr. Ratkowski:
•fi
You are granted a variance to install a septic system leaching pit 90 feet
from wetlands and have the reserve area 85 feet from wetlands, in lieu of
the required 100 feet, at Lot 7, Broken Dike Way, Centerville,. with the fol-
lowing conditions:
(1) The septic system leaching pit must be installed in strict compliance
with the approved plan.
(2) All other requirements contained in the Town of Barnstable Health
Regulations and Title 5, of the State Environmental Code, must be
strictly complied with.
(3) The designing engineer must supervise construction of the system and
certify in writing to the Board of Health that his design has been
complied with before the issuance of a certificate of compliance and
an occupancy permit.
The variance expires May 1, 1985.
Ve r y yours,
R ert L. C i ds, Chairman , .
Ann Jane Ishbaugh
.�. ..a--In 2 tN1, 17.
H. F. Inge, M. Gt�/
BOARD OF HEALTH U
TOWN OF BARNSTABLE
JMK/mm
/ � f
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME i ADDRESS
t / � ea c led
' R U I L D E R OR OWNER
DATE PERMIT ISSUED - ._ j _ ram
DATE COMPLIANCE ISSUED a _ fu ��
1�
Fe rts$—
�Ir
04/Z � �s
tHE Town of Barnstable
�p Tpk
Regulatory Services
BMM
,,STAB Thomas F. Geiler,Director
aTE1639. Public Health .Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
J
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.
May 23, 1985
Lair. Joseph D. Iafrate
Bayview Corporation
P. O. Box 2048
Centerville, MA. 02632
Re: Variance for Lot 7, Broken Dike Way, Centerville
Dear Mr. Iafrate:
The variance granted Raymond J. Ratkowski on April 4, 1984, to construct an onsite
sewage disposal system on Lot 7, Broken Dike Way, Centerville, is extended to expire
May 1, 1986, with the following conditions-
(1) The septic system leaching pit must be installed in strict compliance with the
approved plan.
(2) All other requirements contained in the Town of Barnstable Health Regulations
and Title 5, of the State Environmental Code, must be strictly complied with.
(3) The designing; engineer must be on site to supervise construction of the system
and certify in writing to the Board of Health that his design has been complied
with before the issuance of a certificate of compliance and an occupancy permit.
(4) You rnust receive approval from the Conservation Commission.
The Board reserves the right to deny any further variance time extensions. The variance
will not be renewed if the Board feels that installation of an on-site selvage disposal
system has the potential to adversely affect the environment.
Very truly yours,
io rt L. Childs
Chairman
BOARD OF HEALTH
TOWN OF BARNSTABLE
JM1K/mm
cc: Conservation Commission
May 9, 1985
Mr. Joseph D. lafrate, President
Bayview Corporation
P. U. Box 2048
Centerville, MA. 02632
Dear Mr. lafrate:
We are in receipt of your recent letter requesting an extension to a variance
granted to Mr. Raymond J. Ratkowski on April 4, 1984.
We are enclosing our variance request form. Please return this form to
us with the fee of $25.00 and submit at least five days prior to our next
Board meeting which will be hiay 21, 1985, at 4:30 P.14. in the Board of
Health office.
Very truly yours,
John M. Kelly
Director of Public Health
JUK/mm
I
Bayview
Corp.
P.O. Box 2048, Centerville, MA 02632 Tel. 775-7637
May 8, 1985
Town of Barnstable
Board of Health
Hyannis , Mass .
Re : Lot 7 Broken Dike Way , Centerville
Dear Members of the Board:
In preparation of obtaining a foundation permit to-
day, I discovered that the variance for the septic system
obtained from you last year, for this lot has expired as
of May 1 , 1985.
The Barnstable Conservation Commission has approved
the foundation plan for thid lot, and the Building Inspec-
tor the house plans , and there are no changes to be made
to the septic system as presented to tou earlier.
I would like at this time to request an extension
of the variance granted previously, or advice as to how
it may be obtained , so that I may acquiue a building
permit. Thank you very much for your cooperation in this
matter.
6 Of / % Yours truly ;
tili�
Joseph D. Iafrate , Pres .
Enclosure
1
No.
g DATE 1-- 03
*THE E
TOWN OF BARNSTABLE FEE
yp t0
OFFICE OF
B�iS
MAIL
L BOARD OF HEALTH
367 MAIN STREET
HYANNIS, MASS. 02601
VARIANCE REQUEST FORM
All variance requests must be submitted five (5) days prior to the scheduled Board of
Health meeting.
NAME OF APPLICANT Joseph D. Iafrate , Pres . Bayview Corp TEL. NO. 775-7637
ADDRESS OF APPLICANT P 0-Box 2048 Centerville , Mass-. 02632
NAME OF OWNER OF PROPERTY Joseph D. I afrate
SUBDIVISION NAME River, s End. DATE APPROVED 1,9- 1 Qom_
Lot 7, Broken Dike Way , Centerville
LOCATION OF REQUEST
VARIANCE FROM REGULATION (List regulation)
Please see attached- -
VARIANCE- REQUESTED (Specific request) :R le ase see attached - -
f.
REASON FOR VARIANCE (May attach letter if .more. space needed) .
-t�re,_i-r�U'
PLANS- Two copies of plan must be submitted clearly outlining variance requested.
VARIANCE APPROVED
NOT APPROVED
REASON FOR DISAPPROVAL
Robert L. . Childs, Chairman
Ann Jane Eshbaugh
t Grover C.M.. Farrish, M. D.
BOARD OF HEALTH
TOWN OF BARNSTABLE i
f
��p�oFTHETo``� TOWN OF BARNSTABLE
OFFICE OF
. BSSasTmm
+00 "639 BOARD OF HEALTH
�aYAYk� 367 MAIN STREET
HYANNIS, MASS. 02601
May 9, 1985
Mr. Joseph D: Iafrate, President
Bayview Corporation
P. O. Box 2048
Centerville, MA. 02632
Dear Mr. Iafrate:
We are in receipt of your recent letter requesting an extension to a variance
granted to Mr. Raymond J. Ratkowski on April 4, 1984.
We are enclosing our variance request form. Please return this form to
us with the fee of $25.00 and submit at least five days prior to our next
Board meeting which will be May 21, 1985, at 4:30 P.M. in the Board of
Health office.
Very truly yours,
tihn M. Kelly
rector of Public ealth
JMK/mm
tr.r
�T
TOWN OF BARNSTABLE
OFFICE OF
t
Bas
NAM T BOARD OF HEALTH
1U ` 367 MAIN STREET
HYANNIS. MASS..02601
April 4, 1984
r
Mr. Raymond J. Ratkowski
c/o Bayview Corporation
Blantyre Avenue
Centerville, Ma. 02632
Re: Lot 7, Broken Dike Way, Centerville
Dear Mr. Ratkowski:
You are granted a variance to install a septic system leaching pit 90 feet
from wetlands and have the reserve area 85 feet from wetlands, in lieu of
the required 100 feet, at Lot 7, Broken Dike Way, Centerville, with the fol-
lowing conditions:
(1) The septic system leaching pit must be installed in strict compliance
with the approved plan.
(2) All other requirements contained in the Town of Barnstable Health
Regulations and Title 5, of the State Environmental Code, must be
strictly complied with.
(3) The designing' engineer must supervise construction of the system and
certify in writing to the Board of Health that his design has been
complied with before the issuance of a certificate of compliance and
an occupancy permit.
The variance expires May 1, 1985.
Ve r y yours,
R ert L. Child's, Chairman
QAA — S'
Ann Jane Ashbaugh
H. F. Inge, M. GkAol'
BOARD OF HEALTH U
TOWN OF BARNSTABLE
JMK/mm
i
Ab
April 4, 1984
Mr. Raymond J. Ratkowski
C/o Bayview Corporation
Blantyre Avenue
Centerville, Ma. 02632
Re: Lot 7, Broken Dike Way, Centerville
Dear Mr. Ratkowski:
You are granted a variance to install a septic system leaching pit 90 feet
from wetlands and have the reserve area 85 feet from wetlands, in lieu of
the required 100 feet, at Lot 7, Broken Dike Way, Centerville, with the fol-
lowing conditions:
(1) The septic system leaching pit must be installed in strict compliance
with the approved plan.
(2) All other requirements contained in the Town of Barnstable Health
Regulations and Title 5, of the State Environmental Code, must be
strictly complied with.
(3) The designing engineer must supervise construction of the system and
certify in writing to the Board of Health that his design has been
complied with before the issuance of a certificate of compliance and
an occupancy permit.
The variance May expires 1 1985
P Y � .
Ver truly yours, ,; r• "
Robert L. Childs, Chairman
Ann [Ja e-7E-shbaugh
r'T" /
H. F. Inge, M. D.
BOARD OF HEALTH
TOWN OF BARNSTABLE
JMK/mm
1
NO. .. / 9'
DATE �?-o?7-9-/
FEE
' TOWN OF BARNSTABLE
F TN E
OFFICE OF
i BARI MM
NAM BOARD OF. HEALTH
367 MAIN STREET
° cr�t'' HYANNIS, MASS. 02601
VARIANCE REQUEST FORM
All variance requests must be submitted five (5) days .prior to the _scheduled Board of
Health meeting.
NAME OF APPLICANT BA-ev40-W GoQPoQATno►.1 TELEPHONE NO. -1-1 I - 14S9
ADDRESS OF APPLICANT R,LAWT'.(QE AjE,,Qe Ce64TEiLv►rL.L-E o�1.e.32
NAME. OF OWNER OF PROPERT I!ows,G I
LOCATION OF REQUEST LcT '"1 P_oreru �t r�E w�`r ,_�a=uTEQv ► I-L-C
VARIANCE IfROM REGULATION (List regulation) LEi+<--H PIT ee-.F- F-- ►COS FM
VARIANCE REQUESTED (Specific request) Ta p~T
�D�E W E}ftP►'�� � I C� vtr2 1�.rz.E � "la Gcxs3T2�cT �E 2✓E A�-�A t F Q.EQ�►ego
$S Fi A N�G•E of WE-" ^U-0 ( l5 v�Q�/k�SLE - vAQ►h�CC PQE.t tdvsW �QRr.,Z'ED
E�tP►�� 02 •0l 8S )
REASON FOR VARIANCE (May attach letter if more space needed) 04-A of l� !T
A,-jM(CA-bL.c- Foe. Le1kcr+,d?- FAcILtn DUE- To scr IL 2�v�u�na�►s o�s0 cuE�ft,�o�
.PLANS - Two copies of plan must be submitted clearly outlining variance requested.
VARIANCE APPROVED
NOT APPROVED
REASON FOR DISAPPROVAL
Rob L. Childs, Chairmat
Ann Jane Eshbaugh
H. F. Inge, M. D.
BOARD OF HEALTH
TOWN OF BARNSTABLE
GRA-OE Sr,-bT'S� 400A'no�JS A,�D Cc�ouQ�uv -
°SITE PIA�b, Lr�cA no�J : Ge,j-mk jL-La, MASS. / J� -nbALVjenA jj) —
'. FoQ. RA�fMouD �. 2.AT KOW sCl f3�( � � I
P3A-M bE
I 14 51. lEO6E wenA,Zs
�-re R Pip !S DE
n�,e hE�IK PLAt4
o �A �
Le �' P Q i v Ai E
/100-7
44K14�eJ+c+l.teD�ro0. owi.rEft ate
14 10 A= 19- 13
w
•�ILTEST `0
+4 4
LOT / n^
/ / `DQAiu,46E. EAS�ffMELIT
0K OF
loe
VJ
4 �/
— S�RR�RtA�
i �.
OF
n Icry'w I DT}4
P�v 1 ou5 F,L I N 6 : S E 3 eo 4 s� �� F. S .FS c=,
IL 19 15"L
P spa ti� ao sugiv
Vp
ts
7 N
—— — — €� L'csT PL.4w
EX ISn WL/= ELEVATIG�.J �c�rlrcu2-
e� Cou-roc�r2 � ^ _
D EL�/A"nC11J �91 L oT -7 - An La J D I L.E: K�
'Ls aS�q
APPDc./t=D: b=ARD (= = 4eAL-n-1 C E=-L1TE Kam/ 1 L L E�
MATE A6EnI7' � .LE I = ' DA"[t:- 3 2Co 84
CLI�Lrr, f3�vv I.� I waE EBy nR�nFY T144-'THe P2cR--SeD
LL.1S sv�EYIN ►-� bEa u� : 84-03 BUILDIU6 Showw o►J I'WIS PLAaJ
COuFoQMS TO 7l 4E 1cQ W6 LAWS
4q Mars E�' LAu>= D2.BY: -� OF BAP-WSTABLE, MASS.
C�Ulr(cL/IL1L�� MASS., 021032 /
G14. t-i 3 16,84
SWEET /QF�r QED LAuD 5Lj!b✓E\/oA
VOTE IF:- Ern-aV— Ti-1E —_a PT IC T/4�14- OIL -
--- LEAC--"IW6, PIT At12.e mcDRa T1•4A,•-_I I t- r-seuJw
10 FT, WWI .. —_ � � G PA-DE , A 24't,I A A/1i=TAP- R
SHA" 2:5E "T -ro GRAD7= ( DPrvI=WAYS
ca_Ic Q Esr✓ / 4 P./c P t PC- , R 1 Rs A u l=xTa A H EAvn( Dore CA-t I QCk! coves R
r=L= 18. o /�ca��RSi\ `/8 pc-P- FT. I
1: / ) 1
\ � \ �2-/oMW, fauG2Erm;
GaAp=- GiFFA"-SAuD
uSI=D w..1 1'sAcKFa L-,
/ \\ 2 8
L IC?J�D L�VEI_- . . . . � •� .
'V LAYER of
t per, P"pE i 15 00 wAs+4E-=D fir=
mIu. PI7 4 GAL. o o o a e o ° °e
/4 PEP- FT. �Rt'lG TAIL FIST. e ° e f' , ,
° � e BOX Q °° o B ° a of I °
W PSH E D STa<11=
• � � o e o o • � � o
1-75.9 x• 2.5 = 439. 8 ca/D ° ° ° e e • o e e 1 _ PQEcAtsT SEEPn�S1=
I-JVEQT 1=LLt/�TIo1-JS 1 53.9 x I•o = 1 53.9 G,1D ° ° o ° ° ° 6 1 — PIT oR F vAL.
QT AT BLiILDI /L 1=T. Dvrc.ADA--rr---e 593.-7 L/D to Rr. D/AM.
1.J LET St=PrI G TAu 13.o FT• 5�3-� F-r. D 1 AM• _ C (--gas TA 2 cX ATIou1
Der LET SE PTI G TA+_I'F. A. 8 FT. D I z—.P.
111L�T DIsTQIPxmau Bob 1/L. (� FT• S�rlo►� of nnAx GRauuD wAT>=0. T4,�7-- 1=L
-T DrS pjBLrjcxj L2 FT S�wAGE D1SPoS,AL S�(ST1=M
I u LET LEA�1 wb PI-r I IL 2 FT.
PIT
(� DI/�te►:►�Io�, A 4.8 Fr.
DE516 r l G�I TE iL-1 A ---cA, ' I/4 I o
D l M I=N51 a—J 8 4- FT.
�LJ M P. r2 o f PEDQcwxnS 3 D 1 M E u 51 C=xj C 4 FT.
Gr�R�A�>= Drst�L uutT YE 5 �t L LOCH
T(=Y rA L ESri AAATED Flaw .130 6Al-. 1DA-! 7E5-r tjs l So i L T6T N!
I.lu M BE R of LC-A41,{.16 P I'S I •E L= 15.9 1=L - 8. o T� of S�►L SST' Na� I I
St DE LEASH lu6 PIE P- PIT 115.9 `�. F`I'. o, 2, LpAM a LcAAA A(. ��,L-1��R'�(Z�D !'S`� �gySI�E 5✓PJFY CclP /61r-Foeo
p,�T7?nM LEFKa-11tab PC-:R-AT 153.9 �_q. FT. CEPn=LA-na./ 2A?r-- 1.1O 1 I F=sS nn u / ucr-I
Z-a-rA L L�A�"("d= A aQ e A 3 29.8 SG=. FT. PE RmI�aT o� . RATE ti� 2 TH A N nn I u/ 1 UGH
319.E �W. �T �L 8' IV1IvM
Q�5�V7= L�AKN 11..16 A�A � .
MAD sc �uD
�- t/L' E FL
L.T OF
1,A
OF
c s.co moo, c, r C E—== LB
EL -
c A� ;' WATU--G-.
71_1J5 5c,e.�-11►1� I►.IG.
29874 C � /L=1 AAUc►=c ET L.4A E, ¢s.rrE2VI t iE, MASS:
t``.�gTE��vO� �1STEQ` O WATER
N� SUiN�y a�lrrtllmu� [� J2ouu0 wA-rEQ a EI_ -
p H I/= 4 C-=QavkaD wA 71`Q. Conn 0s
' Permit Number:_ -fir . Date:
Completed by
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location:- g�C>t=ts �l 0:—_ Wh�f C ,rr� t t�.c Lot No. -7
Owner: Address: WA
Contractor:. f YYIeW CC)0., -Ilot•.I Address: p.p, 6C% 2048, CC- Ep-*ltu� OIf,
Notes: &•C,; 6 f)oF !ilUCTA 0w.o.A rcf b;r n(.'(n•
C2) W Sr Gam CO"AA.FLc-ISa sE 5. 604- of Z5• b'L
STEP 1 Measure depth to water table g p
to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . It/it /8l
date
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
a�w•1�
A) Appropriate index well . . . . . . . . . . . .
B) Water-level range zone . . . . . . . . C
STEP 3 Using monthly report"Current
Water Resources Conditions" �
determine current depth to • 1
water level for index well . . . . .. ►2/81
mo yr
STEP 4 Using Table of Water-level
Adjustments for index well
STEP 2A , current depth to
water level for index well
(STEP 3) , and water-level
zone (STEP 2B) determine 3 •L
water-level adjustment . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
STEP 5 Estimate depth to high water
by subtracting the water- ;
level adjustment (STEP 4)
from measured depth to water 4.4
level at site (STEP 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
�"F k"Anc>u F9onM IVIS. GAF�Q��Ll = r �OiT G.L• D. 4z E. D.G . Gl• IO• B4
e- Pe-L- ri.-E EL = O•O
�Qcv..fl c..A•�£ Vc� ® t,..rT� ��As: EL = 'S.V
�yviEw Cap•P.
of• io. gQ
,r
M
January 200 1982
Mr. James Crowell 1
Agent for Raymond. J. Ratkowski
Bayside Survey Corporation
89 Willow Street `
Yarmouthport,* Ma.0267$
Dear Mr i CrovolI t
Youtare granted a variance to have .the reserve sewage 'leaching
urea 80 feet .from the wetlands in lieu of- the required 100 feet
on Lot 7, Broken Dike Way,, Centerville*:'
All other requirements'. contained in the'.Town 'of Bamstable
Health` Regulations and'Title 5, of the State Environmental Codes
must be complied with.
The septic system must be installed in strict compliance with e.
the approved plan. The designing engineer must supervise con
struction and certify, in writing, that. his design, has bey.
complied with prior to :the issuanco of a. certificate of com
pliance"and an occupancy permit..
It would.,be. appreciated if: future plans 'sub®itte$ ieted t2�e
scale.
This variance .expiree. February 1, 19830'
Very truly .you ;
-� REMIVED :
&MMMLA
COMMMn�
Childs, Cha rmanCowie*
Ann Jane E baugh
H. F. Inge,'M. . D. ,
BOARD OF HEALTH
TOw'N OP BARNSTABLE
JMK/mm
cc: Conservation Commission
NO.
DATE
FEE
TOWN OF BARNSTABLE
OFFICE-OF
= BAHISTAHL S '
r►Na BOARD OF.HEALTH
°o i679• `e� 367 MAIN STREET
'�o►t�Y�' HYANNIS, MASS. 02601
VARIANCE:REQUEST FORM
All variance requests must be -submitted five (5) days prior to the scheduled Board of
Health meeting.
NAME OF. APPLICANT aA,lvtEvA/ GoJ?Pc�P.AT�o� TELEPHONE NO. '1-1 I - 1459
ADDRESS OF APPLICANT I_AWT-QE ACE ►wu1= Ce-►-+Tl=a-vt -Le o�1-(-32
NAME OF OWNER OF PROPERTY 2 A-emc>"D , 4T Y.oW S 4 1
LOCATION OF REQUEST LcT -1 c-►-1Tl=Qy t t_i._C
VARIANCE FROM REGULATION (List regulation) UEA--H Prr QsEQe ►e0' FM 'Jertt*-+0
VARIANCE REQUESTED (Specific request) Ta c®,.,sTQvcT LEA{-rh"C- ptT
i=fl�E r� � to' vsefZ t o.►rz C- Ta ccxss-rQucT R.esE e� Af-SA t F aE-C ►- e-D
gs' FA A. a cF wETt L r I C ( ts' v�2�A-uz-r-- - v t aZ-E PPe1J tayst q Q A#--'rF-
E�cPt2Efl o2 •ct• 93 ) .
REASON FOR VARIANCE (May attach letter if more space needed) Ariz--A, of 1oT
A'\4ML'A-6LC- Foe. PACtLiTr DuE 'z) ScrOAeIL 2l:v Ttot.►s O Et.E��t,�o�
PLANS - Two copies of plan must be submitted clearly outlining variance requested.
VARIANCE APPROVED
NOT APPROVED
REASON FOR DISAPPROVAL
Rob L. Childs, Chairmalw
Ann Jane Eshbaugh
H. F. Inge, M. D.
BOARD .OF HEALTH
TOWN OF BARNSTABLE
s
G QA O E -S rJoTS T L.GcAnoN 5 Aw D
°S+TE PLAW LaCAT1OLJ ; Gr--Q-mQ.JILLE, JAASS. j J, jn0ALWETLAmjD
3A�5,DE SuQJE�coQP. , 1/AP�noL�Tr+-PoQT, 1. X __ /
1 14 82." - ! E-t6e weT>_A,.&us
-r r -�Q hele PLn E
A�
T•8en• /
j3 Q EL: 13.98 M•S.L.
�A,;
n I LE Leo' PQ,vA
� (vAR�A*+�Qg��,Pr�)Q_3S.00 � /I DRo+b� pQ,,,E;wn-! t0 c.r3. �='LO•�
to 8 I�S.oCo A= 19.-13
LOT
10 � L /
V- � y, ` '/�/ / / MAIWAc,E EAS�ffN F-QT'
x
OF
ca
/STE.�
of
�L�D 2�..1ti5 A � 9 Y/� �o�>= ILG ��►� .
Rp Imo' wIbT" i� W
PP�VIOUS. F+LINC� : SC 3 804 '��, F. 5 .f3. /Lo sm
(RAT s Ic I ) a I 'Ls • 19 5,L
° 4 s at.- 2 . r3. - I o o�ar�P o4`
i P spa
7Ap on .
sXrsnQG ELEVA-now cc TcuR-. oQ. Vol
9 PAD PLr-T PLAN!
D EL�1/ATIdJ eL CL�u'TocV2 4� LoT -7 - BV�K��I D+Lra D,-,4D
25 Po4
COTE A6EN7' `aC'A I R: I = 4c=>' DA'T'E% 3 2Cc 84
GLI raUT BY eaEP--n FY TWAT THE Pkc)R$
'EELL1S JOg jjS 84-a3 BUlLDIU6 Sflowu cJ "T>-4IS PLAaJ
COUFo2MS TO T41= 2o►JIN6 LAWS
2�t MUSK ET LAu>= DR.BY: -� IQ� pF B,AawsTABLE, MASS•
M �' 5. K.
G�uTEQv1►..LE., ASS., o2b32. (�yY• -4 _.l
3 26.84 L
SUEET I of 3 naTF-- lQErpIS'TERED LAUD 50aJE`ina
20 RT. M 164, LcSTE i F E ITH a2 T.-I E. '5E PT I V-
oGL
LFAG t•- i w b P►T Aar-- MoRB Tn-I A" f 2" (3e1=�W
10 f-T, .MIW . _ GRhflE , A 24-DIAku=-r1=2 GATE CGSP-
/� �-1ALL e3 E R4LC �r4T � GQAD� ( DQrl./i=WAYS
C�c Qa-r� / 4" . P t PE- o QFca��I Q� ALj swrP-A HEAVY D�CA�r I Qa! ca/1=R
M 11.1. PITcI-1�
FT. )
A
GRAB cov�R- A�SA►JD/ i — US>=D I" f?1�GKFi L
/- _
LA`!--R-OF
IS t PIPE- 150o An
R
mIN. PITc4-1 GAL. FIST. a t o e e e o e o•
t/4" PEJ0- Fr. TA"IL
♦, nX
v ° 1 e 5/4"
° ° 1 ' Ct=P I-I ' ' WP6HED SroLl�
e
• � I I e e o p . � e e
(�75.9 x L,5 = 4��. 8 U/D ° ° e p p e e ° o p p + _e_ PRECftST 5EEPAba
t LJ�/E QT 1=�- /ATfO1JS 153.9 x 1. O 153.9 C•=/D PlT aQ
Ip)�/ERT AT BLAL0i"C= 13./L F=T. F1' DiAM.
FT• 5�3-I FT. D I A M. C t�g� TA J �AT(:>-I)
�r"L�T SE PrIG TA+JL' 12. 8 FT. plsp, = .0 v/D
I Solo
I u L'ET D I I f3�tnot-► Bob 11. (� FT• S�,C r I�t-I o F=
nn A x G 9-CLJ W D wATE 0- 7,4BLT-- I=.L =
cx-rn-a-r D`��1 (3ox 12. 4 FT• Sz-:wAGa D ISPcvsAL SYSTEM
►t l LET LaA,:fH, 16 PIT I2. 2 FT.
L_EAc►4106 PIT
DES16tJ GRITI=iLrA �cAL= 1. I/a" I ' o Dlanel.,�te� A 4.8 pr.
B4- _ F-=1".
w1uMR2 of PD�c�xn5 3 D I M Eu Slo&j C 4.Cp FT.
6,4RBAG>= L1SLuuIT. YEStL LOG '`��tL 7l-=15T
TEAL ESn Ail ATED F-Low - 0 6A1.. /DA-( So I L TEST N= t So I L TeST ►J 2'L
1JUMBS7P- cF LI=A44tii6 PrtS I EL= 15.9 ML . 8. o C>A7T--- of L--T1=ST 1bc l 1 I` s I
SIDE If=-A---Htub PEP- AIT 1-15.9 . Fr. Ld,A+ a LoAn+ ac R1='SvLrS� I2. b r: `( BA`ItE S,jPyti Fo CoPP /CwFQD
@aT-toM I E (�A,--H 1 w6 Q-AT 155,9 FT. C�ZeoLA no•r P-_ATE I.]* I L>=55 m r u /I ue-"
TOTAL A-P-Z:-A 329.8 SCE. FT. Q/1�1uM P--P,=LaTto+ RATE �je iL lT-IA-N M Iu / Iuc.-+
R 75E=P-V1= LeACN(IJ6 AAA 31.9.8 S5�. fT. 2 8' ec.CCsnC-2�= 2.
IVIt=-t gc sAuD
/L- I/L' c:z:=thP-SE T
• `� 4 e I U D t �2R ® wrfL (-oT -1
OF
EL= o.o
Al -+I
H WATfC
� P► ► IS Sc�i�-ll►.1� I�IG.
2W4 C �� 451 MV5►CE.cSE=r LAI.iE, rE2VILLE, NIASE
F
0
a
O ISTE I.l 0 6 Qo��1 a D WATER��c� I�D 11
�8T>E ,gyp ❑ cl.Ircl.tr: PIAq�f�li=w�oRP D�4'i� . 3 /L(-.e>q.
SURV� uffA kw C3- G 2ovuD wA-ra=R.to EL• 3•Ce
84
Permit Number:_ Date:
Completed by' :
HIGH GROUND-WATER LEVEL COMPUTATION..
Site Location: �►hl Lot No. �7
Owner: CIA Address:--
Contractor: r AYYtew CCWNOPA-1_1CtJ Address: p.6, &OX W48, CC—NTF;4LoE 0111ZI2
Notes: C�+r i i i vv �c �1r� Qw.•o.AkrriE b7t 0(.in. A2 (2ATYnwS%r_t -
Ct P LSr Gam Cau nn Fi Lc-tS'- 5E 5. 804- of Z5 �2 C P-� l)
STEP l Measure depth to water table . g p
to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . /81
date
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
A�w•1�
A) Appropriate index well . . . . . . . . . . . .
B) Water-level range zone C
STEP 3 Using monthly report"Current
Water Resources Condit-ions" �e
determine current depth to • 1
water level for index well . . . . .. !'L/81
mo yr
STEP 4 Using Table of Water-level
Adjustments for index well
STEP 2A , current depth to .
water level for index well
(STEP 3) , and water-level 444
zone (STEP 2B) determine 3 •�
water-level adJustment . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
STEP 5 Estinate depth to high water
0
by subtracting the water- ;
level adjustment (STEP 4)
from measured depth to water 4.4
level at site (STEP 1)
,►,l Fc:1"A-nC>U . FPOM /l/IS. 6 A i3 K��LI E Lt=i G.L P. eL E• D.G •4 c l• l O B 4
GKcuuD wP�Ti'Q. Di={- 'r�ST t•1o�-E El. = a•o
��owD c.�A-re4. Pe£ ® �� C�tys: EL = 3•(�
�y�IEw �P-P•
0110• SA
7r�C�ET 3 c� 3
3 '
.—�- A.
January 20,.. 1982 y
Hr. James Crowell
Agent for Raymond. J. Ratkowski
Bayside Survey Corporation ti
89 Willow Street `
Yarn►outhport Ma.0267$ `
2
:Dear Mr Crovoll=
You are granted a variance .to have the reserve, sevage leaching
area 80 feet from the wetlands in lieu of- the required 100 feet
on Lot 70 Broken Dike Way, Centerville.
All other .requirements`•contained .in the .Town' "of Barnstable
Health` Regulations and'Title 5, of the State Environmental Code,
must be complied with.
:The septic system must:be installed in strict compliance
the approved plan. The designing engineer. m"t -supervise cony
struction and certify, in writing, that his 'design: haa'beea';;
complied with prior to :the issuanco of a certificate of com-
• plianceland an occupancy permit,,
It would.:ba� appre edciated if future plans: submittlisted the
scale.
This variance expires February I 1983.
Very truly .you
1lp
. Childs, Cha Haan
/- .09 ,
Ann Jai!j aug
H. F. Inge,'M. D.
HOARD OF HEALTH
TOWN OF BARNSTABLE .
JMK/mm
cc: Conservation Commission✓
January 20, 1982
Mr. James Crowell
Agent for Raymond J. Ratkowski
Bayside Survey Corporation
89 Willow Street
Yarmouthport, Ma.02675
Dear Mr. Crowell :
You are granted a variance to have the reserve sewage leaching
area 80 feet from the wetlands in lieu of the required 100 feet
on Lot 7, Broken Dike Way, Centerville.
All other requirements contained in the Town. of Barnstable
Health Regulations and Title 5, of the State Environmental Code,
must be complied with.
The septic system must be installed in. strict compliance with
the approved plan. The designing engineer must supervise con-
struction and certify, in writing, that his design has been
complied with prior to the issuance of a certificate of com-
pliance and an occupancy permit.
It would be appreciated if future plans submitted listed the
scale.
This variance expires February 1, 1983.
vVery truly you , �!
4
. Childs, Chairman
Ann Jane baugh
H. F. Inge, 'M. D.
BOARD OF HEALTH
TOWN OF BARNSTABLE
JMK/mm
cc: Conservation Commission
atri o t
u�
Published on Cape Cod since 1830
A community newspaper published every Thursday at
24 Pleasant St.,Hyannis,Mass.Tel.771-1427
7�
1830 1982
}
TEL. 853-2620
� S t SvnL)C/ 06� .
CROWELL & TAYLOR CORPORATION
Land Development & Engineering
89 WILLOW STREET
YARMOUTHPORT, MASS. 02675
CIF �n- -�
Iso-VI- s'L�-r
J7 ftEaC(5y lW -QUOST A U/-6,\,t -4t\jc6 FYI Gy si
• 1 E-A uE /-�-r� } 5 �- v�.r� c�� COT
&n& I )t& WAY
rz, .
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Wlillam F.Wald
clower+or Trudy Core
Arpeo Paul Cellucel S---ry
U.Governor David B. Struhs
. CamnMeriorwr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
7 CERTIFICATION /I
Property Address:- d [ Zc O Ke,'l `V`��'�C� KJ Eby/ E i! l� ddee•s of Owneriir�o I�C'�•G�4t.c/l .St y t
Date of Ins 6 i �L'► h ,
Name of Inspector. �l t. I( / : (If different)
�aV:cL J :, �; ^ ` R
Company Name,Address and Teleppone Number. �v- 5 M�
VO e.-h tt- SA,
CERTIFICATION STATEMENT Pt"5 k`I-1`� '�'� c d_,C,
I certify that I have personallyins SO�� " �� S
petted the sewage disposal t system at this address ankat the information reported below is true, accurate
and complete as of the time of inspection. The.inspection was performed based 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 Approving Authority
_ Fails
Inspector's Signatu .0- —
\���..f''"'``"—t 1 Date: lvZ
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY.
Check A, B, C, or D:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as de
Any failure criteria not evaluated are indicated below. fined in 310 CMR 15.303.
B1 SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired The system, upon completion of the replacement or repair, passes
inspection.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined', explain why not)
The septic tank is metal, cracked, structurally unsound, shown substantial infiltration or enfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)5WJ049 • Telephone(617)292-5W
w
`J Pnnied on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address- V10 Kt,,� �.)K L' �0
Owner. v�o '►1 e,I O G ►O✓1 •� J V 4 L C..
Date of Inspection:
B)SYSTEM CONDITIONALLY PASSES (continued)
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):
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:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT
The system has a septic.tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The evstem has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is leis than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for ooliform 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
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: V�� �J c��c'.� /.(— Lo A�_1
Owner. Dvf v^+ 2Ll VC-.4 kk opt, SWt/+c_
Date of Inspection:
zk—
D) SYSTEM FAILS:
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 correct the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS 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 1/2 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 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.
— 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
ooliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design now of 10,000 gpd or greater(Large System)and the system is a a
health and safety and the environment because one or more of the following conditions exist: significant threat to public,
— 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)
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 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:-'. 1 ZV`O K{c�---�
Owner. �J v, �.'%
Date of Inspection: r��t ' ,
Check if the following have been done:
(Pumping information was requested of the owner, occupant, and Board of Health.
_None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
All system components, excluding 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 bates 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 existing information or
approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
1�Co c-C_ ��<—A -Ir- t S dV d+ r 4&4 V V" 0 A. L
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7�,ro .W N y
Owner. rv?r- Z
Date of Inspection:
RFSroENTIAi- FLOW CONDITIONS
Design flow:_-L-jQ_galons
Number of bedrooms::_
Number of current residents: O
Garbage grinder(yes or no): Q.,S
Laundry connected to system or no): . 5
Seasonal use(,yes or no): Jl p
Water meter readings, if available:
Last date of occupancy: 0✓L ^p-_.,—.%
COMMERCLAL/INDUSTRIA--
Type of establishment:
Design flow:_gRUons/day
Grease trap present: (,yea 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:
OTHER (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
A"0✓L t—
System pumped as part of inspection: (yea or no)1lJo
If yes, volume pumped: gallons
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)
Other(explain)
APPROXIMATE AGE of all components, date installed(if known) and source of information: V
Sewage odors detected when arriving at the site: (yea or no) V40
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �., sp K e.--� ��� k( •��{
Owner.
Date of Inspection:
SEPTIC TANlr:_Z,
(locate on site plan)
Depth below grade: !a -
Material of construction:_2Sooncrete_metal_FRP—other(explain)
Dimensions:!4O Jbk J >I I U )Too
Shulge depth: � -
Distance from top of sludge to bottom of outlet tee or baffle:3-,
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle: Of
Distance from bottom of scum to bottom of outlet tee or baffle: `f
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.)
GREASE TRAP._
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP_other(e:plain)
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle*, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Address: 02 cU✓c; c.n )j t\_ w A
Owner. � �c.`G4�4�'lCi-� S `vj.,c�
Date of Inspection:
TIGHT OR HOLDING TANK_
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(e:plain)
Dimensions:
Capacity:- gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX_X
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal dence of solids carryover, evidence of leakage into or out of box, etc.)
,
PUMP CHAMBER_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc,)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
-7 ? SYSTEM INFORMATION(continued)
Property Address: l u rr� K�n,.� �y kL 1�l�y
Owner. 2t.�pGl�� io-1 Surl���C�
Date of Inspection: Ja4
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:Oil t.
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
eats: (note condition of soil, signs Of
hydraulic failure, level of ponding, Condit' n o vege tion,etc.l
9 .Alin:n 1 -� c 7 ,i
o r
CESSPOOLS:_
(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(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
(revised 11/03/95) 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9-1 `3 Mi k w Dy k4 LA-)-'k.�
Owner.Date of Inspection:
SENMR OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
�5
Ouj
,J
DEPTH TO GROUNDWATER
Depth to vwndwater. 1 X"_feet
Of determination or approximation: y S 'f o WL/i l 1_ `
L -. i ["i
I
(revised 11/03/95)
9
r
t Page of
Commonwealth of Massachusetts `
Executive Office of Environmental Affairs a°
e
Department of
Environmental Protection ii 19 ,
' 1 '96
WlUlam F.Weld
Governor
Trudy Coxe
S:!',y,EOEA
David B. Struhs
Comminioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION 1
�rO key 7 D 1 �AG�I'I S TR T _
Property Address: �� •� ��1Ad ress of Owner:&e Q r e � ��� v p In Q.�
Date of Inspection: 46C �� /f � (If different) 97 k-m U k WC.-4
Name of Inspector: Kevin H. Powell Cl-_f1i eal Ile
Powell Construction Company 7 �J a(�
Company Name, Address and Telephone Number: 3�
1495 Ocean Street
Marshfield,Ma 02050 617-837-6633
CERTIFICATION STATEMENT
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-sites wage disposal systems. The system:
Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ FaLiltInspector's Signature: �1 Date:
Kevin H. Powell J `
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authoritN.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] 7Any
M PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street a Boston,Massachusetts 02106 a FAX(617)556-1049 a TWephoee(617)M-5500
�ieT Primed on ttactoded Paper
Page A of
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: a. / 171D k� h
Owner: —,-!TO G-PG y j e
Date of Inspection: a- 1,57 (qs
8]SYSTEM CONDITIONALLY PASSES (continued)
_ 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):
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:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The cvstem has a septic tank ano soli absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil.absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D] SYSTEM FAILS:
1 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 correct
the failure.
_ Backup of sewage into facility or system component due to an overloaded or dogged 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.
(revised 8/15/95) 2
f
r� 1Page 3 of
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFIJ/CATION//,(continued)
Property Address:
Owner. 6&or ?P
Date of Inspection: /.�/1s—A5—
D] SYSTEM FAILS(continued):
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 1/2 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 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.
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. 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:
The following criteria apply to large systems in addition to the criteria above:
The design floe,- of system is 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:
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)
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 8/15/95) 3
Page / of
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: / /3-ro
Owner: 6�eo✓ -e
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
t/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
durin that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
he facility or dwelling was inspected for signs of sewage back-up.
he system does not receive non-sanitary or industrial waste flow
he site was inspected for signs of breakout.
system components, excluding the Soil Absorption System, have been located on the site.
he 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 existing information or
approximated by non-intrusive methods.
he facility o-,%nc' lard occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
Y,
Page � of
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR_M
PART C
SYSTEM INFORMATION ,
Property Address: ro P h
/ d
Owner: &t,p r of t -70 YI f s
Date of Inspection: `.;L/�S—/��
FLOW CONDITIONS
RESIDENTIAL- 4lo
Design flow:��itallons �9�%9/'� A �QS/� ` s
Number of bedrooms:-yjO
Number of current residents:
Garbage grinder (yes or no): c. eS
Laundry connected to system yes or no): LIe-S
Seasonal use (yes or no): a c�_ ���yf,�f
Water meter readings, if available: ��r�O /J J��� /
Last date of occupancy: retie n
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 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION /a,
PUMPING RECOR 5 an sours of informal1n:a /�O017� �O J �7S Pr oc.5/7
K
System pumped as part of inspection: (yes or now Wt s R"f rrt 00E0 p n Abc k t91i
If yes, volume pumped. gallons iDke,r +e ow rteY
Reason for pumping:
TYPE O 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)
Other(explain)
APPROXIMATE AGE of all components, date in lled (if known) and source of information: (sr►1a//�l/IC-e ( r��t/�QT�
eel
Sewage odors detected when arriving at the site: (yes or no)&:5
(revised 8/15/951 S
Page 60 of I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 6 eo r5 e Uo o-e
Owner: AtP-17 vnnl
Date of Inspection: /d//S/�S'_
SEPTIC TANK:_/.-40
(locate on site plan)
Depth below grade: /
Material of construction: Aconcrete _metal _FRP—other(explain)
4Z of
Dimensions: O
r
Sludge depth: it
Distance from top of slud$� to bottom of outlet tee or baffle: 3oZ
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: �S j[
Comments: ,�p�'�j � �E h 1 !'!r,.� S'f ou!G� ��4L'� T��e CO U e!"•�
(recommendation for pumping, condition of inlet and outlet tees or baffles, pth of liquid I vel ' relation too let invert, ictural
integrity, evidence�lof I akage, etc.) !/ .'S -fit O �G /7 /F n Grp /
,S P o ve
!� Pd L
GREASE TRAP: `UNL�
(locate on site a
Depth below grade:
Material of construction: _concrete _,metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom n` <rU^ 1- r)0110n! Ot 011!le! iee Or 132111r
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.)
(revised 8/IS/95) 6
r Page '7 of---L/
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ,)? 131101 e A7 " /
Owner: 45eo/Z 7 e 0, n eS'
Date of Inspection: 14
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:Comments: / s
?o e�
(note ii level ano istribution a�js/-ir/ c! !,<1
al, e\ide ce of so cajjr)o% r, evi ence of le kage into or out of o3 etch
�'d 0 Lo o , �P IS T'�'r �u�d .007CS�acc�(�' O uI �
L,4)-cl c rai e!2 us P�7G/,p c
e L,*-►-V t I e e 1
-q-z, e- \ti '�o c�cD C 6 nc9 V ion , n e of l/ yr /pe'G /'V/0��
A&
PUMP CHAMBER: 10 A/6�:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 6/15/95) 7
Page of I ' '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SY'SSTTEM INFORMATION (continued)
Property Address: d 7 T�
Owner: G 'eU� e ', G ✓1-PS
Date of Inspection:
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:��1
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comm n s: (note ndition of soil, of hydraulic ailure, level of ponding, cond' ion pf v tation,etc.) r�
dv w'r3 L�1'4QcC� G S Ctin C� 11� 1-a►:�cA�C
co P ]cc CP i 1 S 7 r o F -P C-0 '
CESSPOOLS: _
(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 ground�%ater.
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) B
I
{� 1 Page of
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Prope Address: rd/C /� 1CP
Owner: G?'e c e-i-e Sr,Y1 f 5
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
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DEPTH TO GROUNDWATER
Depth to groundwater: 473feet o r Ice-
method of determination or approximation: B
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In the certification state the inspector is certifying that the conditions
existing at the time of the inspection are accurately presented in the inspection
report. The inspector is not certifying that the system is adequate for the
current use of the system nor for the future use of the system.
This inspection is not a warranty that the system if functioning properly, or
appears to be functioning properly, will continue to do so.
The septic system inspector, Kevin H. Powell , is representing the interest of
the Commonwealth of Massachusett on this inspection. If any party who has an
interest in this septic system being inspected and does not fully understand the
contents of the septic system inspection form should seek professional consultation
from a Professional Engineer,Registered Sanitarian or Certified Tittle V system
inspector to protect his or her interest in this septic system.
C,4�a'-Oj
Kevin H. Powell
Certified Tittle V System Inspector
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THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Kevin H. Powell
Has satisfied the q q Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21 A of the
General Laws. Issued by The Department of Environmental Protection.
February 27, 1995
Acting Director of the ' -ion of Water Pol1ution Control
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