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Home My WebLink About0099 CAP'N LIJAH'S ROAD - Health 99 Cap'n Lijah's Road Centerville P A = 192 164 a u Fse/te 1521/3 ORA 100/6 P2 a Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 99 Cap'n Lijah's Road -Q, Property Address ] Jill Shuman -z Owner Owner's Name : information is °h# required for every Centerville ✓ Ma 02632 12/16/2017 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 A. General Information ,51w- 1a76"0 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12/16/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 'L 0)�Cd VS Commonwealth of Massachusetts _ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .y 99 Capin Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 99 Capin Lijah's Rd Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 3 Infiltrators. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N . ❑ ND (Explain below): t5ins-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 a 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. Cityrrown 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 Y day flow t5ins-3/13 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 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 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. t5ins•3113 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 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 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): 2 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 r Commonwealth of Massachusetts N - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (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 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: tank pumped for inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? size of tank Reason for pumping: routine 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)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 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owners Name information is required for every Centerville Ma 02632 12/16/2017 page. Cityr town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: , ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tank pumped at time of inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank was pumped at time of inspection and should be done again every 2 years for proper maintenance. Water level was even with outlet invert, tank was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 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 o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-bo was in good condition with water level even with outlet. 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: I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 Infiltrators ❑ 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.): s.a.s. consists of 3 infiltrators. Leaching facility was video inspected through vent and was found dry with no sign of past hydraulic overloading. 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 F y d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. Cityfrown 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.): i 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 ,•°'e 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is Centerville Ma 02632 12/16/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner owners Name information is Centerville Ma 02632 12/16/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i it C � t A A 8 ► � � 3 O a a 30 3I : 3 3o a(. j t t5ins-3113 Title 5 official Inspection Farm.Substaface Sawage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. 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 ,.' 99 Cap'n Lijah's Road Property Address Jill Shuman Owner Owner's Name information is required for every Centerville Ma 02632 12/16/2017 page. Citylfown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for �Digogal *pgtem Con!truction Permit Application for a Permit to Construct( )Repair(V )Upgrade( )Abandon( ) ❑Complete System I individual Components Location Address or Lot No. let �1 •_ Owner's Name,Address and Tel.No. Assessor's Map/Parcel 4C—pr!4 7-C✓vile Installer's Name,Address,and T 1.No. ® Designer's Name,Address and el.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building / C e No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /l9W? .6iX/Ip e Type of S.A.S. —7 a � s Description of Soil ll X 7 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is Boar. f H lth. Signed Date l Application Approved by Date Zf Application Disapproved for the following reasons '� Date Issued Permit No. .�.� , a _ pw 1�jZ No. / O 7 V , Fee —•.// THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Application for IDi!5po5al *pgtem Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) El Complete System M Individual Components Location Address or Lot No. n /�jy •¢/s Owner's Name,Address and Tel.No. Assessor's Map/Parcel v�.Ile cz Installer's Name,Address,and Tel.No. G Designer's Name,Address and del.No.�9 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building / C 8-,No. of Persons Showers( ) Cafeteria( ) Other Fixtures_ "r Design Flow gallonsper day. Calculated daily flow 330 gallons. Plan Date Number of sT ets Revision Date Title { Size of Septic Tank / ''DO 1il'%9IIY�e Type of S.A.S. Description of Soil .X 7 f Ir Z Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by his Boar If H lth:" Signed Date Application Approved by k Date li Application Disapproved for the following reasons r ,P Permit No. IV '�S Date Issued ————————————----———————————————— ---- --- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site S wage Disposal System Constructed( )Repaired (!�)Upgraded( ) Abandoned( )by o/ L¢' / 2 De 1 � at 907 � .4 /a G',eIA�l ► has been constructed)n acc rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. ? -S O dated Z Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Q _ t,✓' - � Inspector --------------------------------------- No. ?F—TY6 '/K7 Fee -0, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ]Dizpozal *p6te!/�T' Conotruction Permit Permission is hereby granted to Construct( )Repai ( pg de( )Abandon( ) System located at 9 C4 • ✓`r /' Y le-co 1-y-lill1le and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. 'O Provided: Construction m st bee completed within three years of the date of t ' ermit. Date: � �% / d Approved b -�' 10/9197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) d1'f L°l hereby certify that the application for disposal works construction permit signed by me dated 011915� concerning the property located at '15 meets all of the following criteria: /There are no wetlands located within 100 feet of the proposed leaching facility Y ere are no private wells within 1-40 feet of the proposed septic system There is no increase in flow and/or change in use proposed V ere are no variances requested or needed. If the proposed leaching facility will be located within :50 feet of any wetlands, the bottom of the proposed leaching facility will t14.[he located less than fourteen (1ul feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map► %®C� B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.art 1019/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A -DISPOSAL WORKS CONSTRUCTION PERMIT.(WITHOUT ENGINEERED PLANS) I hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at meets all of the following criteria: . There are no wetlands located within 100 fee:of he proposed leaching facility . There are no private wells within 1:0 feet of the proposed septic system There is no increase in How and/or change in use proposed . There are no variances requested or needed. . If the proposed leachine facifry wiil:e locared•within:50 feet of any wetlands.the bonom of:he proposed leaching faciiiry will am be located'ess than fourteen(,i-1 feet above the maximum adiusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. nap) B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan. this plan should be submitted]. aF health War.pert 1 TOWN OF BARNSTABLE I'( „ATION —t 1 CAP �.._��.L��S SEWAGE # Vti,LAGE � �1�� ASSESSOR'S MAP & LOT a �� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACELrrY: (type,) 3- /h 1',�tiA�orJ (size) /I X arl X a h NO.OF BEDROOMS 3 BUILDER OR OWNER 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 leaching facility) Feet Furnished by 1011 J Fol� r C � j FrOA A A O � 8 3 � as a� a 30 3i c 3 TOWN OF BARNSTABLE •LUC,ATION �9 �/� ®�� s ', SEWAGE # �,VILLAGE 1`�ry��/Zr' ASSESSOR'S MAP & LOT J?Z k6l INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY two, Ca� LEACHING FACILITY: (type)-2 112.o,4q (size) NO. OF BEDROOMS. .� BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: " _ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet vate Water Supply Well and Leaching Facility (If any wells exist on-site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist ) within 300 feet of leaching facility) Feet Furnished by z;� +`� �q� �_ �,'`� 3�, �5 G �, Fyn` . 3� .,. � �^ rr p,�f W �6 10 30 E E-; TOWN[OF BARNSTABLE LOCATION �r �iP ��/!1'f�4 SEWAGE # VILLAGE Ge-e 1`��y1�i �" ASSESSOR'S MAP & LOT TZ�6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY -CGC GaL LEACHING FACILITY: (type)-2W2,g4o (size) // 9 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility s�` Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �� Feet Edge of Wetland and Leaching Facility(If any wetlands exist ) within 300 feet of leaching facility) "' /�/�� Feet Furnished by COMMONWEALTH OF MASSACHUSETTS JOViN GIF BARNS TAB EXECUTIVE OFFICE OF ENVIRONMENTAL WFAIRS DEPARTMENT OF ENVIRrOF4f9Pn�UA } fCiffiECTION DiVISION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 99 Captain Liiahs Road I-I 9� Centerville, MA 02632 Y Owner's Name: Kevin Fucillo �.._ Owner's Address: Date of Inspection: April 1. 2005 �0 1 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Ostervft 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 Fu her Evaluation by the Local Approving Authority Fails Inspector's Signature: % Date: April3. 2005 The system inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector.and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT F R VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL YSTEM INSPECTION FORM PART A CERTIFICATIO (continued) Property Address: 99 Captain Liiahs Road Centerville, MA Owner: Kevin Fucillo Date of Inspection: April 1. 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS comple a 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 evaluate I 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,z s 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 6ank(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 he Board of Health. *A metal septic tank will pass inspection if it is structurally sound,no 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.x. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or reph ced 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 99 Captain Lahs Road Centerville, MA Owner: Kevin Fucillo Date of Inspection: April 1. 2005 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: 99 Captain Liiahs Road Centerville, MA Owner: Kevin Fucillo Date of Inspection: April 1. 2005 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: 99 Captain Liiahs Road Centerville, MA Owner: Kevin Fucillo Date of Inspection: April 1, 2005 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 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 99 Captain Liiahs Road Centerville, MA Owner: Kevin Fucillo Date of Inspection: April 1, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: n/a Does residence have a garbage grinder(yes or no): n/a 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/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable 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 on 8125198-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 j Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 99 Captain Liiahs Road Centerville, MA Owner: Kevin Fucillo Date of Inspection: April 1. 2005 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: 12" 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 izal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: S" 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: Measuriniz 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.): Cement tees 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: 99 Captain Liiahs Road Centerville, MA Owner: Kevin Fucillo Date of Inspection: April 1, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): 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:. 99 Captain LUahs Road Centerville, MA Owner: Kevin Fucillo Date of Inspection: April 1, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 infiltrators-II'x 29'x 2' (per as built card) 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 infiltrators were clean. There did not appear to be any signs offailure. 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 r Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 99 Captain Ldahs Road Centerville, AM Owner: Kevin Fucillo Date of Inspection: Apri11. 2005 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. C B rrrpnT A 6 O I aa6 a� 3 0 a 30 3 i a. c 3 30 a cp 10 P r Page 11 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 99 Cgptain Liiahs Road Centerville, MA Owner: Kevin Fucillo Date of Inspection: Apri11, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- 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: topogrgphic.and water contours naps 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 and water contours snaps, the snaps were showing approximately 30'+/-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 No. ..�.......!...... Fss....s..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH n...............OF....... �� .. . .c�h�L ................................. Appliration for Uioposal Works Tanstrnrtion Errant Application is hereby made for a Permit to Construct ( for Repair ( ) an Individual Sewage Disposal System at: Location Address or Lot No. Owner AdcVL rr Installer Address �"O O d Type of Building Size Lot..\........................Sq. feet V Dwelling—No. of Bedrooms..........2.............................Expansion Attic (0)O Garbage Grinder (00 '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -----•---------------------------------•-•--•----- -- W Design Flow............... \.5...................gallons per person per day. Total daily flow............ ..................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width-______-_-__-- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `" Percolation Test Results Performed by..... .. ^ d'__. ...................... DateA.................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Test Pit No. 2................minutes per inch Depth of Test Phi :..._ Depth to ground water........................ a •---••----------------- --------•---...........•--------------•--•...........--- .•---•--•---......................................................... O Description of Soil.......Q'--�--.---�-�a►.rn....................................... x ------------ -- v ...................................... - ------- ---------- ------ C�............................................................................ W UNature of Repairs or Alterations—Answer when applicable----------------------------------11)-_-...-_---__--_-______---__-___-__---___--:----------_-. --------•-----------------------------•••-•----•-•-••-•-•-••---••-••••-•••---••-•-•-....----------•-----•----•-•---------•-•----•---•••------•-----------••--------•-•-•---•----------•--..........----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'L U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. gned Application Approved •••--•. ••••-•-•-----••••••......•------------•-•--•.........-•--••--•----•----•-•-•.•----- 5----� -- -------------- Da Application Disapproved o t following reasons: --------------•--------------------------------------------------------------------......................... ---------------------•-----------.............--••-•-•-•------•--••--••---------•---------......-----...._......_..............-•---------------•----•-•---•------------ ............................... Date PermitNo........................................................ Issued........................................................ Date �`�'y/♦ ISM T'`� .. Ir`J C V r •%q• '�,. No...................•--: Fss... .........<.•__---•-_.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ApptirFa#ion for Uiopoiial Workii Tiami rurtion ramit Application is hereby made for a Permit to Construct ( ,ey or Repair ( ) an Individual Sewage Disposal System at: ..0,�'wy. ......... 'c E......................... ........ _ ..._._A....---.._..------------.............----------........----......--- �t Location-Address ` or Lot No. �.1(Vne_- - ..-�-.......�.M.:�----------------------•-- 1�.—:- r�-- ��- � \cam .........------- r) - Owner .Address ......:....................... a _-¢'r'__..... ..1.. .��..`t..t..'...`.'......---•----4- .�.---'..................... ..•----••4==-CJ.(..Y'1_ ..�_.Gn. \-c. \C-- Installer Address UType of Building Size Lot_ -�.------�________Sq. feet I—. Dwelling—No. of Bedrooms____.______.............................Expansion Attic (�.� Garbage Grinder C� Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Design F .\_•----------------•----_-_ allons er person per da Total dail flow-_--------- - Other fixtures __________________________ _ W g g P P P Y Y ;~ -----•-•-----•--•--gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth......... x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area_-______..____._____sq. ft. Seepage Pit No--------------------- Diameter____._._____________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by..... ........................ .._:a ________________ Date-�'_ .' Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ raq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---••----•-•••--------------•••••-•-••••--•-•••-•••-•-•------••--••--•-......---•---•.........•----•........................................................ 0 Description of Soil.......�=��------=.., L. ..af.0-----•-•-•---------------•-•--------------- -- W ) UNature of Repairs or Alterations—Answer when applicable................................................................................................ -•---------------------------------------------------------•-------•--------------------•---.......-------------------------------•---•----------------•--------------------------------------........_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si n .. �-'. a- APplicationApprov -s ---••-_• •------••••••-------•------••-•--•----•----••----•-•--•...............• a -�, ate Application Disappro f the following reasons--------------------------------------------------------•----------------------------...-•--•----•-•-....••-••••- ........:..-•--•-••........................•-•-•----••-•-•--•-----•••-••-•----••-....---.._._..------••---------•-----•.._.._---•-•---••-•-••--•-•---------•--•-••--••--•---•••--•-----•-•-•-•-•--•-••-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i ......... .............OF........ - .. -'b. . . %rrtffirate of Tonapfianrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed (� or Repaired ( ) bY------. - n ---..... y�= -----------------------------------------------------�----p----�---.......1....-------\----............__...__..........---------------- a t ! ! Ins(�llea ,�.JG.I/9\ t 1 j 1 \ at------- 0 .......H-•••••••• :==- --------• ` 4 has been installed in accordance with the provisions of F r f The State Sanitary as described in the application for Disposal Works Construction Permit N � _........._......... dated^___;................................... THE ISSUA CE F THIS CERTIFICATE SHALT. NOT BE CONSTRUED A GUARANTEE THAT THE SYSTEM IL U ON SATISFACTORY. �' �� DATE...---•-- ------- ----------------------------------------------- Inspector------ - -------------...----------------.......--------•----------•-----•--•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF...._......- ..................................................... Y. ............... . N ....... _•-•--- Diopostal Work.5 Tonotrurtion anti Permission is hereby granted.....�t =1' ...........Z-W._: ........ •--------------------------------------------------- to Construct ( LJ"'orRepair ( ) an Individual Sewage Disposal System at No.......\�'0--�.......... j---------•.. ._r, -------- "•.•`=K^ 1 L� li........................i i �. --••-•••-••-•••••-•.............. Street as shown on the application for Disposal Works Construction Pee ..................... Dated.......................................... Board of Health DATE................................................................................. FORM 1255 A. M. SULKIN, INC., BOSTON - oA 1 t...�f �•L,�a f' t to � 3i.�_-33 .. � - . - -- • . , .� ;..i.T., ., ` � i t I a'��" " 1 dc { S cf'Tt G T A�.I IL••�.d >< •(�O �I•�'��1� . i I I ..' ��. � � '�jp.�ti.� -..L �.^.►,ib�� : i. i S�VISPOSAL PI'� V$� Ct�l� LiI 1/ 5 V�+.•. I. I _ � I •r« , � 11.a� P . � �;'__ " :-TOT ,'-. �E.al 6•►•� °-. . .' : •'� .._ 1 ,.• � .•' ) � ss �`n s'Z, . ' :1: 4�^;*'r'"{ IZA-rL• l I W 4 A-W OQ LXA II ... .. s 1 ,• �. .. I rf :. "s r I .. .. t ' .., .. i ! ..1. 1,, ►r.44�- `i � -,./��f^^t 1 I Lf t. p 1 is �•.; __ I_• t { i 4yj WIh_i�F1�1_ i/��w I r -•� � C. i ,.. �. - � -j c ,F,i„ '' 1 o -1'+fiAll I .f �,•1 ?.. i '� I- �! 1( ��-r .�iw ` 1�.`..._ 1 ;i •t.;�{ .r.i ;�. �^15 •• I� �C> Nu.,299, .� 1 14 OP F6jD Q t ksp 77XM7rjoZrn X- DP4 =LKYYT " r/ tUd. PtT t' �_,. '� ice._ _ I •• �:�: iil i -. - ; - : : : ' ` ' I CISX T t F t E D Ol-oT PL-A N 4jo • Sae�t..c�s .` ! . . ...: ' . . . 5Gh L6 4,1`� o A. o'VJ �°`i'6� �1° 1 U So� ! p I C ECT I FI{ ' T"AT ' b4i-- Ff�l 11� r1(j 1�} ►-1Fi2E.o t,..l "C.Otic P�-Y S W t TH T4L�. ��DELI�•1� .. F••-�::'\\T_ ` (� C.. t , A+JD SVTBAGK REQvlefi,AA �1TJ5 OF T�_t�; • •TUw�.{ o F �'j��j�(�(x.A`!_1D i l S• }..>G� ,. . I ` I Zm SiL .Lt/4A�' L_oG.4T W l•t-�lI c.l . 'C►-IE �Laos ?LAI Q. • } �DA-t-�- 4► 1�1� �d . ;� � �4.ic..• ;. i •T"14, ?LAW (4 • UOT 845ED OU W lwlveJMI_J4T 0STC.RV0 t C_ M�S`a•T"G- OFFICT$ -5WOULD UOT $E UieX> APPI._IGAWT �AI�AEs, i TH To 'D eY t+Qjtl t tJ E toT L-I W SV. —, LOCAT ON l� SEWAGE PERMIT N0. qq VILLAGE 1NSTA L L E NAME & DDRESS Olt BUILDER OR OWNER DA T E PERMIT ISSUED DATE COMPLIANCE ISSUED L �4 OTC A T 10 N � � L!,�'h�4'A G E� R M I T NO. VILLAGE I N S T A LLER'S NAME i ADDRESS t -p /�-d 5 cr B U I L D E R OR110 OWNER I/ c:7 DATE PERMIT ISSUED OAT E COMPLIANCE ISSUED �� a 7 o % 0 r 5�