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HomeMy WebLinkAbout0017 CAP'N LIJAH'S ROAD - Health 17 Cap'n Lijah's Road Centerville P A = 192 157 FF No. 42101/3 ORA ESSELTE 10% 0 0 0 0 . -- f � Commonwealth of Massachusetts ro Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 ` a Property Address Gregory J. Cox Owner Owner's Name = � information is required for every Centerville MA 02632 May 22, 2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information S/# - /3 OL f D— on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr use the return Name of Inspector key. Eco-Tech Rapid Response Company Name 155 George Ryder Road South Company Address rem Chatham MA 02633-1621 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of.on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes tAOFMASs qcy ❑ Conditionally Passes ❑ -Fails _. ❑ Needs F r Ott 2tlo e Local Approving Authority ° COU A IOWR 0.1 28 May 22, 2018 Inspector's Signat - Fry INSpso Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f. ,. �k• r e r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required for every y 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 nofifound any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or th°eseptiank4(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 septicctaynk as approved by the Board of Health. f; A metal septic tank will pass inspection if it isastructi.rally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20'years,old s available. t_.�41 ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System`Page 2 of 17 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required for every Y page. City/Town State Zip Code `Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect.public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required for every Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: . ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or'less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 17 Capin Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is required for every Centerville MA 02632 May 22, 2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen,and nitrate nitrogen is equal.to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a ..design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 9 p t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required for every y page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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)] 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 gpd t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is required for every Centerville MA 02632 May 22, 2018 page. CityFrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use?. ❑ Yes ® No Water meter readings, if available last 2 ears usage (gpd)): 149 gpd 9 ( Y 9 Detail: 2016: 41,000 gallons 2017: 68,000 gallons I Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22 2018 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? El Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t in 6 s.doc-rev.6I16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required for every y page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 41+ years. Design plan for a new system was dated 11/3/1976 (file at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.):. No evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' x 5' x 6'-1000 gallon Sludge depth: 10 inches t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments °M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required for every y page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 inches Scum thickness 2 inches Distance from top of-scum to top of outlet tee or baffle 9 inches Distance from bottom of scum to bottom of outlet tee or baffle 13 inches How were dimensions determined? previous inspection report Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required for every y 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete - ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required.for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches - number,length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology:- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. A level of standing effluent was observed at a depth of 12 inches below the top of the peastone layer. 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 t Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22 2018 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is Centerville MA 02632 May 22, 2018 required for every y page. City(Fown State Zip-C-ode Date-of-Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:_ Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately LOCA §OoNSS -OF SEPTIC COMPONENTS -DISTANCES IN DECIMAL FEET A 8 THIS SKETCH I5 BEST VIEWED IN 1 22 18 COLOR FORMAT EX IS T§ G 2 25.5 23 D WEL LNG 3 31 28 OF 117 I A B NOT TO F_ 100E GALLON SCALE SEPTIC TANK I W 2 DISTRIBUTION BOX Cr Q LEACH j PIT Cr .. _ ��. C APW U JJAH'SS ROAD p F s 508 364-0894 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'•Page 15 of 17 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Capin Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is required for every Centerville MA 02632 May 22, 2018 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 20 feet above p p p Y groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 17 Cap'n Lijah's Road Assessor's Map: 192 Parcel: 157 Property Address Gregory J. Cox Owner Owner's Name information is required for every Centerville MA 02632 May 22, 2018 Rag e. C-ityT-T--own State-Zip-Code-Date-of-Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE - NOT TO SCALE I 9 1 /P 9 ltI 10 10 /II II r) ri PRECAST LEACH PIT z 0 N - BOTTOM OF LEACHING PIT LEACHING is ABOVE HIGH GROUNDWATER GROUNDWATER ELEVATION PER GIS MAPS t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M s 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7 2016 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information v. / on the computer, 1 { II&S 9 use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Rapid Response r� Company Name 155 George Ryder Road South Company Address Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes El Conditionally Passes El Fails ���®6MASs9 ❑ Needs r §X910a °N the Local Approving Authority o� D, COUG N WR N P-5— . 1 3 June 7, 2016 Inspector's Sig ure 1STE Date SINITAR\PN The system insp 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 t11 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 the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �b� _ Vs Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 17,Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the,se'ptic-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 septictaik as approved by the Board of Health. *A metal septic tank will pass inspection if it is+structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than,20 years old is available. ❑ Y ❑ N ❑ ND (Explain below)` f t,. tw t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel.157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7 2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA. 02632 June 7, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and�the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7 2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence 4 of ammonia nitrogen and nitrate nitrogen is,equal to or less than 5 ppm, provided that no other'failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? , ,> _ ..a<_ ❑ Yes Z No Water meter readings, if available last 2 ears usage 164 gpd 9 ( y 9 (gpd)) Detail: 2014: 57,000 gallons 2015: 63,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: k Source of information: Owners Was system pumped as part-of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool - ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Age: 40 years. Design plan for new construction was dated 11/3/76 (Plan in Town files). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting-, evidence of leakage, etc.):o, Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ .Yes ❑ No Dimensions: 8.5 x 5 x 6-1000 gallon Sludge depth: 6 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts v v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal -,❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: - Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required):. If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology:- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the stone layer. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. Cityrrown . State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is required for every Centerville MA 02632 June 7, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately LOoCQ §OoNSS —OF SEPTIC COMPONENTS —DISTANCES IN DECIMAL FEET A 8 THIS SKETCH IS BEST VIEWED IN 1 22 18 COLOR FORMAT rWEL §NG 2 25.5 23 §NIC� 3 3i 28 7 A B NOT TO F_ -110 SE GALLON SCALE SEPTIC TANK 1 w 2 DISTRIBUTION BOXUj Uj L EA CH 3 PIT Q 3 0 1995�\ CAPuN U�IJAH"SS ROAD 508 364-0894 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owner's Name information is Centerville MA 02632 June 7 2016 required for 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: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: -- - - Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Cap'n Lijah's Road-Assessor's Map 192 Parcel 157 Property Address Cape Cod Homes LLC Owner Owners Name information is required for every Centerville MA 02632 June 7 2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE — NOT TO SCALE PRECAST LEACH PIT g O N BOTTOM OF LEACHING PIT LEACHING IS ABOVE HIGH GROUNDWATER GROUNDWATER ELEVATION PER GIS MAPS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUS,ETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 1, JgrT ( ? DEPARTMENT OF ENVIRONMENTAL PROTECTIOtlNt V Fri TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 17 Captain Liiah's Road �1�R F Centerville,MA 02632 OARCEL Owner's Name: Mary Alvezi 2� Owner's Address: P.O. Box 521 `. .,. Centerville.MA 02632 Date of Inspection: September 30, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: October 6, 2004 The system inspector sha\suba 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 ****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 1 M Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Captain Liiah's Road Centerville,MA Owner: Mary Alvezi Date of Inspection: September 30, 2004 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: 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 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Captain Liiah's Road Centerville, MA Owner: Mary Alvezi Date of Inspection: September 30, 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 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: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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: 17 Captain Lijah's Road Centerville, MA Owner: Mary Alvezi Date of Inspection: September 30, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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. ✓ 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 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 System: 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: 17 Captain Liiah's Road Centerville, MA Owner: Mary Alvezi Date of Inspection: September 30, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ 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: Yes No ✓ _ 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 CNM 15.302(3)(b)]. M 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 Captain Liiah's Road Centerville, MA Owner: Mary Alvezi Date of Inspection: September 30, 2004 FLOW CONDITIONS RESIDENTIAL 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: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgf(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: Pumped 2 years ago-per 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 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: Installed 12117176-per as built card 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: 17 Captain Liiah's Road Centerville, MA Owner: Mary Alvezi Date of Inspection: September 30, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 30" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Baffles were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. 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: 17 Captain Liiah's Road Centerville,MA Owner: Mary Alvezi Date of Inspection: September 30, 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: Qallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. 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: 17 Captain Liiah's Road Centerville, MA Owner: Mary Alvezi Date of Inspection: September 30, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gal.) 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.): The leach pit had 6"of water on the bottom. The scum line was approximately Pup from the bottom There did not appear to be any signs offailure. The bottom to grade was 9. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 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: 17 Captain Lijah's Road Centerville, MA Owner: MaryAlvezi Date of Inspection: September 30, 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 feet. Locate where public water supply enters the building. �► fir• -t- Q A r as tg a a ash �3 3 3� aS 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: 17 Captain Lijah's Road Centerville. AM Owner: Mary Alvezi Date of Inspection: September 30, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to determine the 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: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps the maps were showing approximately 25'+/ to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 � 1 THE COMMONWEALTH OF MASSACHUSETTS -----_.,,BOARD OF HEALTH _--------------OF............ ��'J ..................... Appliratinn -for Dinpnttl Works Tonntrnrtinn Puniit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System a Location-Address ✓ or Lot No. ................... ...••--- ........ •--------------------------•--......--•---•-----------....._.._................................... -Owner Address Installer Address Type of Building Size Lot_. ,,e, lf� --Sq. feet Dwelling—No. of Bedrooms............................................Expansion fjttic s� Garbage Grinder k,�,p a Other—Type of Building ............................ No. of persons........ .................... Showers ( ) — Cafeteria ( ) Q' Other fi es --------------•---•-•-----•----- W Design Flow.............................---------------gallons per person per day. Total daily flow................�_�_._..�........._.....gallons. WSeptic Tank—Liquid capacity./��gallons Length------ Width................ Diameter................ Depth.----.-__. --- x Disposal Trench—No- ____________________ Width-------------------- Total Length.................... Total leaching area--------------.-----sq. ft. Seepage Pit No...... /--------- D' eter__fr�_6-__.__ Depth below inlet.................... Total leaching area._._.__.-______-sq. ft. Z Other Distribution box ( 4T Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.................... (Xq Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water__.._._____-___.____.. - W -----------------------------•----•----•----•--------------------------•--•------•-•--------.---------------------•------------•-•-•-•-•-•- ...............­ 0 Description of Soil.-----------------------. ..--------------------------- ---•------------------------.._..--------------------------------------------- -------------------------------- x ---------------------• � � =Z.r-------------S�=C J� - U --- r�� ------------------------------------------------------------------------------------------------------------------------------------------ --------------17-0-4-V -- ............---- V Nature of Repairs or Alterations—Answer when applicable..------------------------------------------------___------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------- Agreement: The undersigned agrees to install the-aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned fur not to place the system in operation until a Certificate of Compliance has been issu y the boar of ealth7.7es Signed -- --_-- ..... -----� � �'G .. -------- rate ApplicationApproved BY .......................................................... ------------ Date Application Disapproved for th ollowing reasons----------------------------------------------------------------------------------------------------------------- -•---------------------•.•---•-••----•-------•-------------•--••----------•••--------•-•-•-••-•--...._..... ----------------- Date "14Z Permit No.--- f ....... Issued......................... .._._. ••-----•-------------------•-----•--•----• Date i N(�.............___/'_-- FEim............................... THE COMMONWEALTH OF MASSACHUSETTS ,,,-BOARD OF HEALTH `� .. -- .OF............".........ii../�-cJ Appliration -for Bhipoiittl Works Tonstrurtion Vrrntit Application is hereby made for a Permit to Construct ( ')'or Repair ( ) an Individual Sewage Disposal' System at Location-Add or or Lot No. ................... i�Gl jell_ �g' 'OWner Address -------- Installer Address UType of Building Size Lot__._ ? __Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion tic Garbage Grinder (�'G aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixt es ------------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow..................--s:.. ........... gallons. WSeptic Tank—Liquid capacitv-,l�d'>gallons Length................ Width---------....... Diameter_....--------- Depth....----_-.----- x Disposal Trench—No-____________________ Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No-___--_-/--------- D�meter---f-!�%----- Depth below inlet____________________ Total leaching area.-...__-__--__-_sq. ft. Z Other Distribution box ( W Dosing tank ( ) aPercolation Test Results Performed by___________________________________________________________........................................................... Date-------------------------.-------------- a Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water....-_._.-.---.--.-._._- �11 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water._.-. --__-----.._-.__. P4 ----•-----------------------•-----•---.......•-••-••....•••••••---••. ....................................................................................... GDescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ U •--------------------- W -------------- ---------- --------------------------------------------------------------------------------------------------------------------------------'-------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----••-•---------------•---•-----------------------•-------•--------•----------------------_----------------••-•--------•--------•----•--•----•-••••----•-•-••••---------- ---------•------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further-agrees not to place the system in 11 operation until a Certificate of Compliance has been issued`by the board of health. Signed.......� " =-- ....... '_ ✓�•f/�6'l��G' Date Application Approved By--•--------/ 1---'-.. ---•----•-•-•--•-•--•-•--•----•-----•....................o..----•-•.. Date Application Disapproved for the following reasons------------------------------------------------•_-_----_-----------------------------•------------•-•----------- ---•--•-•••••----•----------------------------------?-------•-•--•-------------------------•----------------------------------------- ----------•-----•----------------------------••-----•---------- PermitNo...... - -------------------------------- Issued------------------------------------•--•--Hate-•---•- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �~ .............................. ........OF......... .... I .. _................................................. �rrtifirair of f�ompliatta THIS IS TO CERTIFY, That the_Individual Sewage Disposal System constructed (,,,.) o�Repaired ( ) /.. c!7c.i_ C J ...by....... 4 = a.. - -- Installer s _________________________________ ___.__---.--___-______--.________-____---______--__--_--___-__-_--_______-___________-___________ has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated......./!-..!' __....__............................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. , DATE-.._ i" = " a�--le"•1 ------•-- Inspector__��---�� � -.-:- =v----------------------------------- 42 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......... FEE........................ �i��la,�ttl ork� �nn�trttrtioat �rrntit Permission is hereby granted----------- ._.____ = C -•------.-..-••-------------•------------ .--..----•---....-•----------------.._-..--------........_------•-_.. to Construct ( ,,)'�-or'Repair�( ) an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit No----- .f_ ...... Dated-------_- �:: 7-- --------•...-•-•-•--•................................••--------••-----------•--•---------•---•.._.__...-- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TOWN OF BARNSTABLE OFFICE OF i BAHHSTABL g i MAO& BOAR® OF HEALTH �Ov013 9 'a�9m 397 MAIN STREET HYANNIS, MASS. 02601 To : Building Inspector From: Health Department Subject: Test hole and Percolation Test A examination of the soil 4 (Lot) ( dr as) ( Vil age) .was made on .2 and found to be (date) suitable for sub-surface sewaget at site of test hole. Building Permit will not be approved or sewage permit . issued until Health Department receives two copies of plan showing building, sewage systems and all other details listed in Board of Health instructions to sewage applicants. This approval does. not constitute a final decision r concerning the installation of a sewage system. All State and local Health regulations apply to final approval. (S'gn " lure) 6/20/75 TOWN OF BARNSTABLE LU--' TION +� C� 1, L1SAh�S SEWAGE # VILLAGE Cpn^i Zr ASSESSOR'S MAP & LOT 2- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I Club LEACHING FACILITY: (type) 10'^ 4 X 6 (size) I OW NO.OF BEDROOMS r, III.DER OR OWNER Mq r� VLZ.J PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leacking facility). Feet Furnished by T"I SM-010A r - - ' 1. A �3 7011 � as cg a a asp a� 3 3i a8 r � LCiCAT10N 4l No SEWAGE PERMIT NO.. VI!/LLAG f�, - I INSTALLER'S NAME & ADDRESS B UtLDE R OR OWNER DATE PERMIT ISSUED HATE COMPLIANCE ISSUED / _ f7 7 1_. ,`Z2� '�' �� �;� .� �� r i ��`` S L �.�G� � �. �-; �� ��� � � L.O7- 3 . rr- 11 � -r 2 /6;O$¢d 19tt-I: n • Q \ aTtNa 1a�cpv�ga � ��' •Q / fA . Fovaawhana �It Lt/.?$ �€ Q'/ L •e 1 me bl'JA4 C7�At/CL 4 LF-4cH � J M//V/MUIL4 20. 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P"i- • I G I STEEL - .. 20000 H- /O LOA D/A/G L3 y C. e— S/-/O,2—T /A/C. �����0 , /4 7-O,ey L.IA/E ;� , q ,��/VEWAY NOT 7'O BE LOCATED IsCR..arc, �y • O✓E.2 SYSTEM UNLE-55 N- 20 MLI RAYMp*rD S• V, 01ES/GA/ L Oa E)IAJG /S USED. .z CE /z-r�,P-v 7WA�r 70'A46 EX/,57"/A/G No, 27,E / Qn✓ .L C?C,qT/OA.) /S C OTZ- �¢ ,� r 1S7k W�Ti�/ Tl1E_ [3t✓!G 7/nJG S�TC��CK TZE- L � ,AJ7 C 'F- T.Y T!4 Gc>i�1� Q, `r`-- /5 A TA E . I>,4 TE NE.AL 77/ A0,E V7 2::,A T' /1 A PX;'�eO 1/4 Z-