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0075 CAP'N CROSBY ROAD - Health
75 CAPT'N CROSBY LANE, CENTERVILLE A = UPC 12534 No.2-153LOR HASTINGS, MN No.=�01&7/ FEE C®MMONWF-AICTI 01 MAS C14USETTS � Board of Health, - MA. APPLICATION FOP DIS AL SYSTEM CONSTRUCTION P MIT Repair(,)for a Permit to Construct Repair Upgrade (( ) Abandon - ❑Complete System Individual Components Location Owner's Name ) !!!!f Map/Parcel# l� Address 1 Lot# Telephone# Installer's Name 7 �( v1 r 6 Designer's Name Address \ I ` ,. �,� Q Address Telephone# Telephone# Type of Building Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria( ) Other Fixtures Design Flow (min.re q ired) gpd Calculated design flow Design flow provided L gpd Plan: Date Z� Number of sheets 1 Revision Date Title Description of Soils) Soil ftaluator Form No. Name of Soil Evaluator f ' Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS �r The undersi d agrees to the a descri ed Individual Sewage Dis os System in accordance with the provisions of TITLE 5 and further agrees not to t6 sy tem. n oper ti Oftate ficate of C m fiance has been issued by the Board of Health. Signed 45 Inspections No / ( a � r' FEE�V COMMONWEALTH Of MASSACHUSETTS 4 Board of Health, - �, MA. - '� " APPLICATION FOR DISK SAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( Upgrade(: Midon( } - ❑Complete System ©Individual Components Location Owner's Name lMap/Parcel# i { q Address IF � ~T (6 Lot# Telephone# Installer's Name U (X Designer's Name Address Address Telephone# Teleph)ne# Type of Building Lot Size sq.ft. ; Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers( ),Cafeteria-( ) Other Fixtures i Design Flow (min.reg1ired) gpd Calculated design row---_� Design flow provided -22'-I 1 gpd Plait: Date 4 (. Number of sheets C Revision Date Title A- �i Description of Soil(s) t�,1 Soil Evaluator Form No. roe Name of Soil Evaluator Date of Evaluation 14 M.2#Z ' DES MPTION OF REPAIRS OR ALTERATIONS � a The undersigned agrees toAi�tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to pl th'e sys(em in operation un �CArtihcate of Comtliance has been issued by the Board of Health. Signed Da .v..a a 1. Inspections r' �oca coo ooa0000co';000000e000a, oc00000-,oa6Dncoe„0000,,.,_ , ,.:DCCGC.c0 ceer..c�.,..c-0 '_..UC CDC u^'� Jcoe:'o•:0000Co", -cc or,L"oc�:.er No. AY-)/R o ) , FEE C®MMON 1LT14 ®F SACHUSETTS Board of Health, WU , MA. �'' CERTIFICATE OF COMPLIANCE E Description of Work: Dylndiv>dual Component(s) ❑Complete System 4 The undersig Id1hereby certify that the Sewage Disposal System; Constructed ( ),Repaired (1��graded ( ),Abandoned ( ) by: �,4W UgE�1dY�l,. �� atY) has been installed in.accordance with the provi ion) f 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application s '`�o�- dated S� Approved Design Flow 713e'l (gpd) Installer / . A Designer: Inspector 1 .s..... -� Date: ��� The issuance of this permit shall not be construed as a guarantee that the system will function as designed. :a= Jo: . cn C:_CO" �'�:'J'rr Ct.'J JCC.�c.Zc. cc �Lji No. FEE_/ 00 CT� COMMONWEALTH OF M SSAC USETTS Board of Health, , MA. DISPOSAL SYSTEM C0 STRUCTI®N PF-RMIT Permissions iis/hereby `gran ,ted to; +Construct( ) Repair ) Upgrade( ) Abandon( ) an individual sewage disposal system at I�'1 low IV\!j C✓{—OrJ as described in the application for Disposal System Construction Permit Noe l �� dated An Provided: Construction shall be completed within three years of the date of this per i . Al,local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Charlestown,MA Date �`�� Board of Health Town of Barnstable Regulatory Services Richard V. SGali,Interim Director aaex�aasr�. 1� Public Health Division Thomas McKean,.Director 200 Main Street;flyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer 8c Designer Certt_if atioan Form Date: �� ZO 10 Sewage:Permit# 2 e� Assessor's I aplParcel [Resigner: Installer. p ' / i Address: �, Address: t On _was issued a permit to install a (date) (installer) septic system at 715 CAPS based on a design drawn by (address) M .�_. dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strap out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was construe __. _�liance with the terms of the I\A approval letters(if applicable) f Apt O A�,�s c7 UAVIU MASON n nsta er's vignature} '70 d A4i ;d (Desigrle s Signatu.re (Affix IDesag Tr s Stamp Here) PLEASE RETURN TO B ErABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CO SCE WILL NOT BE ISSUED UNTIL BOTH 'I S FORM AND-AS- RtJJLT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU, QA Scpti6Designcr Certification Form Rev 8-14-13.dor TOWN OF BARNSTABLE LOCATION N U L SEWAGE# ZLX ASSES OR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO 0)%fj4 C 1"m —SEPTIC TANK CAPACITY jOG2� LEACHING FACILITY:(typ^ (size)a?S��c NO.OF BEDROOMS, OWNER / 14,ueX PERMIT°DATE: 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 NO feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY w Town of Barnstable P# l Slr qb Department of Regulatory Services • enaxsrneU& ' Public Health Division Date {j r� 200 Main Street,Hyannis MA 02601 J Fe„i Date Scheduled Time / Fee Pd. -a } Soil Suitability Assessment for Sew-age Disposal �) �� V Performed By: {� W'1/ 0- )A�'tJ Witnessed By: _LOCATION & GENE INFORMA ION Location Address � Owner's Na...eu,#l''�✓ /vim ZaavB9 Address Assessor's Map/Parcel: f ��, Engineer's Name ^/ , NEW CONSTRUCTION REPAIR Telephone Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line. ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I { Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER LE--- Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ _ DEEP OBSERVATION HOLE LOG _ Hole# Depth from Soil Horizon Soil Texture Soil Color J�Soil Other ~ Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ~. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel IV Am r �-*4 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) a i Flood Insurance Rate May: Above 500 year flood boundary No_ Yes Within 500 year boundary No— Yes U.S. Postal Service" CERTIFIED o . ECEIPT Ln Domestic Mail • nly For delivery information,visit our website at www.usps.comO. M1 43 Certified Mail Fee Er $ Extra Services&Fees(check box,add tee as appropriate) ❑Return Receipt(hardcopy) $ rftostm�ark � ❑Return Receipt(electronic) $ �r C3 ,❑Certified Mail Restricted Delivery $ '` O ❑Adult Signature Required $ [-]Adult Signature Restricted Delivery$ J it L J O postage , m $ Total Pt r��Pst u, $ e�rTo SAWYER, RICHARD H & SHIRLEY K rq siee�a75 CAP'N CROSBY ROAD crry,sr CENTERVILLE, MA 02632 Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate •Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. ' USPS®-postmarked Certified Mail receipt to the •A record of delivery(including the recipient's retail associate. signature)that Is retained by the Postal Service' Restricted delivery service,which provides for a specified period, delivery to the addressee specified by name,or to the addressee's authorized agent. Important Reminders. Adult signature service,which requires the ;a •You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). ` or Priority Mails service. Adult signature restricted delivery service,which •Certified Mail service is notavailable for requires the signee to be at least 21 years of age International mail. and provides delivery to the addressee specified •Insurance coverage Is notavailable for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the •To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,It should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on. ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailplece,you may request Certified Mail item at a Post Office'for t the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion,-, of delivery(including the recipient's signature), of this label,affix it to the mailpiece,apply _ You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.t 7 electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return Recelpi;•attach PS Form 3811 to your mailpiece; IMPORTANT.Save this receipt for your records. PS Fom,3800,April 2015(Reverse)PSN 7530-02-000-9047 I COMPLETE • ■ Complete items 1,2,and 3. A. signature ■ Print your name and address on the reverse X ❑Agent so that we can return the card to you. 'a ❑Addressee ■ Attach this card to the back of the mailpiece, B. Received by tPrinted Nand, C. Date pf. fir or on the front if space permits. ✓ c,�CJ - - ---"�=�- ` —elivery address different from item 1? OYes ES,enter delivery address below: ❑ No II SAWYER, RICHARD H & SHIRLEY K 75.-CAP'N CROSBY ROAD CEITERVILLE, MA 02632 it I IIIIII IIII III I ii II II I I I Ilill I II I I I I IIII III _ 11 Ad. ice Type ❑Priority Mail Express® ❑Adult Signature ❑Registered MaiIT^+ ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted 9590 9402 1933 6123 1785 07 tertifled Mail® Delivery Certified Mail Restricted Delivery AFtetum Receipt for ❑Collect on Delivery Merchandise 2._AAicle Number_(fransfer from service label) 0 Collect on Delivery Restricted Delivery ❑Signature Confirmation"" I ❑Signature Confirmation 7 015, 1730 0 0 01 141987 7015 V(Restricted Delivery Restricted Delivery Ps Form 3811,July 2015 PSN 7530-02-000-9053 "Domestic Return Receipt 1 USPS TRACKING# I '•,, r:r".a-" First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9402 1 T31 3 1785 07 jUnited States •Sender:Please print your name,address,and ZIP+4®in this box• Postal Service - - --- - - -- ---- -- - ,� q Town of Barnstable Health Division � � I ' 200 Main Street I Hyannis, MA 02601 ill-ii1lifil;hpIliiiM11!p;i:' j: i Town of Barnstable Barnstable S�r � Regulatory Services Department edcaC j HAMSTABM ' 6 9 Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 7015 March 22, 2018 SAWYER, RICHARD H & SHIRLEY K 75 CAP'N CROSBY ROAD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 75 Cap'n Crosby Road, Centerville, MA was inspected on 03/09/2018 by Brett Hickey, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "FAILS" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thoma cKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\75 Cap'n Crosby Road Centerville.doc Town of Barnstable - • 31lV1115 AT S R '1 ,b$ Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA•02601 Office: 508-862-4644 Richard Scab,Director FAX: 508-790-6304 Thomas A McKmao,CHO Feb 6, 2007 Rev. 5111116 DEADLMS TO'REPAIR FAILED-SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An`Y'marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA - o Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe , o Backup of sewage into the house ue to an overloaded or clogged SAS or cesspool ONE 1 YEAR DEADLINE CRTTE $(Static liqui eve m. on box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality,analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q "Single-Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Tower. Code §360-20 h) OTHER Repair deadline: - Q:ISEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 page. City/Town State Zip Code Date of Inspection '`t' tea 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 # a filling out forms / $?3 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation � Company Name 374 Route 130 Company Address Sandwich Ma 02563 Citylrown State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-9-18 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Cap'n Crosby Road "M Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 75 Cap'n Crosby Road Property Address Richard Sawyer , Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 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 'h day flow t5ins•3113 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 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 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: 0 ® 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage-Disposal System Form - Not for Voluntary Assessments M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is Centerville Ma 02632 3-9-18 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016-91,000gallons 2017- 59,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 ;M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 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- last pumped 2 years ago 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 . 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: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3,feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 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 allons Dimensions: 1000g � Sludge depth: 8 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 �M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is Centerville Ma 02632 3-9-18 required for every page. City/Town 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" Scum thickness 4 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 12 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 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: NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 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 over 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-box was in poor condition at time of inspection. 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.): NA * 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Cap'n Crosby Road M Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: (1) 6'x4' ❑ 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.): Leaching was in hydraulic failure at time of inspection. The liquid level in the leach pit was over the inlet invert when inspected. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is Centerville Ma 02632 3-9-18 required for every page. CitylTown 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 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 Garage t 1 � � l37' / 36'1 42'6;,, / ! 394/ \ � 33' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I' Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 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: No GW @ 14' 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: 11-12-84 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: Plan on file with BOH. f Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 75 Cap'n Crosby Road Property Address Richard Sawyer Owner Owner's Name information is required for every Centerville Ma 02632 3-9-18 page. City/Town 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 y� CP�RtAJ �&I� 1 TOWN OF BARNSTfABBLE LOCATION � I C SEWAGEC# VILLAGE �� Nt��sl ASSESSOR'S MAP1& OT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) / 0 0 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 byca r��T f AAAa� ,031 0 o V IL go �! r �'� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION I Property Address: 75 CAPT'N CROSBY LANE CENTERVILLE 1 9�y I Name of Owner SYLVIA VELLANTE Address of Owner: 16 POLLARD DR.MILLIS MA.02064 Date of Inspection: 6/9/99 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) `5 J U N 2 3 1999 Company Name: nla I%OF Mailing Address: n/aIHp� Telephone Number: n/a E, ti CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Ev lu on By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:6/10/99 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6/9/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water.level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced nta The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6/9/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6/9/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 76 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6/9199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6/9199 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):I Total DESIGN flow: = Number of current residents:ft Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):,CES Water meter readings,if available(last two year's usage(gpd): Wa Sump Pump(yes or no): NQ Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n/A Last date of occupancy: Wa OTHER: (Describe) 114 Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: UNDETERMINED System pumped as part of inspection:(yes or no):NO If yes,volume pumped nt& gallons Reason for pumping: n/a TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 20 YEARS OLD_ Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6/9/99 BUILDING SEWER: (Locate on site plan) Depth below grade: EC Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: Wa Comments: (condition of joints,venting,evidence of leakage,etc.) Wa SEPTIC TANK: X (locate on site plan) Depth below grade: JE Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) LVA If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nLa Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: Z Distance from top of sludge to bottom of outlet tee or baffle: IL Scum thickness: 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: 17" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) oLa Dimensions: nta Scum thickness: WA Distance from top of scum to top of outlet tee or baffle:iVA Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) D1a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6/9/99 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) , (locate on site plan) Depth below grade: n(a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) Itla Dimensions: nta Capacity: Wa gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:_n(a. Alarm in working order:Yes—No—: NO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6l9/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: j3& leaching galleries,number: ji& leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n& Name of Technology: j3& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION HAS BEEN 3/4 FULL. CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. nla Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6/9/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a I t A4 a� Ag a 7y RC 3 4® 3-?q 01) FA ►� gC 39 gp 94 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION('continued) Property Address: 76 CAPT'N CROSBY LANE CENTERVILLE Owner: SYLVIA VELLANTE Date of Inspection:6/9/99 NRCS Report name: nLa Soil Type: nLa Typical depth to groundwater: WA USGS Date website visited: nLa Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 AW THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH plication is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Installer Address Type of Building Size Lot.j Z Other Distribution box (Y sing Percolation Test Results Performed by.......;� Test Pit No. I-----Z------minutes per inch Depth of Test Pit------ ...... Depth to ground water.—Al/ ........ ---'--'--- '------'----'------'------''—'--------- Agrccnzcuz: The undersigned agrees to install theaforedescribe6 Individual Sewage Disposal System in accordance with the provisions of'JZ'L lZj 5 of the State Code The o6 igoedfo to place the system in operation until a Certificate of Compliance has been � ;Jfet�by the '�o=;h -~ne Application Approved Dv................==������-�'^o ----_-------------� ________.__________ Date Application Disapproved for the following reasons:................................................................................................................ ---------------------------'---------------'----------'---'--------------------''---------------'---- q Date Permit No.....................................j------------------ Iaooed-'-_-l'1 ��-.....-__--- - No...................Ct FEE............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 3272- t .,� . .............OF....... .� y ..........._... Appliraiion fur Disposal Works Tons rnrtinn Famit Application is hereby made for a Permit to Construct V) or Repair ( ) an Individual Sewage Disposal Yi +A System t'-•----- ._ �. o oea'� ls - - 4l/7'jfY. `. ,f. l ............ Owner Address Installer ' Address d Type of Building- „.' „erg Size Lot-4---1 .....Sq. feet U Dwelling—No. of •B,edrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers- ( ) — Cafeteria ( ) Q' Other fixtures .:............................... ----•-------------------'-----•-------------------------------•--- ---------•-------------- ._.............. 00 W Design Flow........ ...... gallons per person per day. Total daily flow.......r3.310..........................gallons. WSeptic Tank—Liquid capacit4voo.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 areaF _sq. ft. Z Other Distribution box (*A Dosing t nk ( ) aPercolation Test Results Performed by._..: 5-- i•. .................... Datej _,1y -------- a Test Pit No. I.....4t......minutes per inch Depth of Test Pit..... . :...... Depth to ground water---�'.6........ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... ........................ • --- •-•-• ......................................................... �'�Description of Soil �t. . . 4.4 4uw . --------------------------------------------------------------------------------------•--------------------------------------------------------------------•-------•------•-----------------------•---- 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign •- - ------ -----------•--------- -------Da.e......... � Dat Application Approved BY ... -----------. w l� = = Da te Application Disapproved for the following reasons----------------------•-•------••----•------------------•----................................................... .................••......--••-•--•-•-•-•-•--•----••---••----••-•-•••••••--•••••--•-••-----•••-•..._.......-•--•---•--------•---•-•--•---•-••-•---•--------• ............................. Dale Permit No._•••. ------------......... Issued....----13 - -�--- Date ------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tpx#ifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by--------------------------------------------------------------------------------------------- ------......--------...------------------------------------------......._...--•-•-•--•-•------- Installer at.....................................................................-.................................................................... _ . has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._�.`}.`:.. ._9-J.......... dated-__.--11..-__' THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONST ED AS A GUARANTEE THAT THE SYSTEM WILL FUNC ON SAT SFACTORY. DATE..................... .. - ----.�................ Inspector-------------- . . ------ ---- ----•-•-•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH • t ...........................................OF..................................................................................... 1) No......................... FEE.-••--•.f.......... Permission is hereby granted -•------------------------- .................... to Construct ( ) or;Repair (-, -?nevWual Se r Di sal Sy ft atNo -------------------................ Street as shown on the application for Disposal Works Construction Permit ......... Dated-----------------------` ............... `} "> F,- ••-----------------•---------------- - - ------------------•-�------•------------ /� 2� y Board p f Health DATE ........................................ . '"°� -•------------------ FORM 1255 A. M, SULKIN, INC., BOSTON ^ 5'►�` - �.'�� v71�7�„tea.- � +S4 t .+( r ti+{ �+ �i jw"`..":J ay.�',w.'T'1 . - 3 ,of `.n f= .' v�'• ...+v ��f'M��r"! r .t � R s i I f' 4 58•r saS 441 3/4 • I � � I 1 NI 47.e Y T.S. r�Y �� F4✓�d t,�.. f7 �' Fu }µ. $EWAGEE OES16N ` Pl: ' OCATION SCALE �. . . DATE64-564/�,�W. PLAN REFERENCE . `. :'. . . .. . . .:. . LAND SURVEYOR CIVIL ENGINEER PETITIONER ���N of of THOMAS � �, ���P THO. 90 Et K , MOWS E. KELLEY o eY ' o. ENGINEEP.- SURVEYOR Y �260 0 346 LONG POND DRIVE .09 ^� 0 SURV SOUTH YARMOUTH, MASS. v�i _ 02664 SS��NAL Ea SHEET �2° Or .2 SHEETS 4 TOP OF FOUNDATION a � . CONCRETE ._COVER', ' CONCRETE COVERS r 4 n _ Tarr ems► n e 4' CAST IRON 12"MAX. 12"MAX. " r OR SCHEDULE 40 4"SCHEDULE 40 .P.V.C.(ONLY) P.V.C. PIPE PIPE - MINIMUM LEACH ' PITCH_ "PER. PITCH PER.FT PIT CIRCULAR PRECAST �NVT LEACHING o a o EL... /rSD.. INVERT INVERT o W a PIT a SEPTIC TANK DIST. o INVERT EL..3$-�.i. . BOX EL 37./ Q INVERT p F- .. / INNER ,' w 0- GAL. .. 3/4 TO I t/2 EL37 2� o r EL33•, WASHED /f �+ STONE 10' MINJMUM� /Z — •—W DIA. ;o' •D 20' MINIMUM PROFILE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE $OIL LOG .-� WITNESSED BY DATE TIME. .2.-.30.P. . �!��� .J7-WXS0t3Z BOARD OF HEALTH ' , TEST HOLE I TEST HOLE 2 ENGINEER DESIGN DATA ' 61le4464. NUMBER OF BEDROOMS 3` r TOTAL ESTIMATED FLOW * a GALLONS/DAY r` $� BOTTOM LEACHING AREA .�-�+r ���� . SID.FT. /PIT SIDE LEACHING AREA . . .9 SQ.FT_./:PIT ' GLrAY GARBAGE DISPOSAL . .(50% AREA, INCREASE) JJ3� TOTAL LEACHING AREA .��e5�4 007. .. SQ:FT_ AA'1 4 r-r PERCOLATION RATE . MIN/INCH LEACHING AREA PER PERCOLATION RATE 7,&.FT L No.WATER ENCOUNTERED NUMBER OF LEACHING PITS .44 :.. �+ APPROVED BOARD OF HEALTH DATE . . . . . . .• . . . . . . . CIVIL ENGINEER AGENT OR INSPECTOR fi. a OF Xf4 PETITIONER �/ 02� THO C�/ri�sGGaS K THOMAIS E. KELL•EY ¢ 260 ENGINEER— SURVEYOR tSTEQ���``' 346 LONG POND DRIVE t' SJONAI SOUTH YARMOUTH;_MASS.' 02664 f t. F f. a 72- ` 0CATI N AGE PERMIT NO. v I L L APr c �tc�se r INST� LL NAB ADYNESS , � A d UILDE R OR OVINE DATE PERMIT ISSUED DATE COMPLIANCE ISSUED s- ool �i ich��cA Saw-lPC TOWN OF BARNSTABLE Cot Cm�� 2012 PEAR -7 PM 3' 45 s 1X t4 DIVISION m' cor\4;ovoos(,;dte lrn� P.Q a.-v - r a la Xs _o 5 0 o M J I so A a is - rco a L. a1.7)cta P.T._R:nn 3oX�� 3oxc�o i�U� ',�c,o 756 o 3o ��2�c�o P�-r. Ancho.-gd•}. CQmen}�i�_pe�Mc er--j yX��P.T. Qos4W jp`oQeronc.,5 5-- ASSESSORS MAP. TEST HOLE i LOGS PARCEL: r �i 1) The installation shall com,2 with Title V and `Town of W I oard of SOIL EVALUATOR: JII] IJ�I C y "` ; I FLOOD ZONE: G g [lealth Re ulations. � _ laT� lG �L.L WITNESS.> 2) The installer shall verify the location of utilities,sewer inverts and septic REFERENCE D Z DATE O2JL Z-5 Z6/8 components prior to installation and setting base eleva(ions. 1 PERCOLATION RATE t ZX41 :J , ; ; 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.]'lie first �" ! / L , o >F2 .� �_� �'.. two feet out of the d-box to the leaching shall be level. HIV I � `/ ,( / _ 4) This plan is not to be utilized for property line deternunalron nor an other q , �. - — —__ purpose other than the proposed system installation. 11 L9 /M A ) septic L° 5 All se components must meet Title V specifications. ` D / / , p 6) Parking shall,not be constructed over 1110 septic components. 7) The property is bounded by property corners and property lines. 2 `yl .yp 8) The property owner shall review design considerations to approve of total I G design.flow and number of bedrooms to be considered for design. Receipt LOCATION MAP G', �.� ;, /� '—plc ? g p 7 of payment for the plan and installation based on the plan shall be deemed I 1 a ,5+42 l 4 G ' i approval of the design flow by the owner; $v 9) The existing leaching or cesspools shall be pumped and filled with material 1►')ED /►�, ,� per Title V abandonment procedures. Those within the proposed SAS shall 8w ►2.� 1 be removed along with contaminated soil and replaced with clean sand per ` y 7 - Title V specs. I 10)System components to be 10 feet from water line. Sewer lines crossing the Flo Ax 4" � g i water line shall be sleeved with 4 inch SCI140 PVC with ends grouted if L ' applicable. The proposed SAS is being installed below the water r g r service i line. The line is to be sleeved as aforementioned and maintained in place. SEPTIC SYSTEM ` D E S I GN 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure sueh. FLOW EST I MAT t ! 12)The installer is to take caution 1n excavation around the gas line if such exists. j I BEDROOMS AT��� GAL/DAY/BEDROOM -G GAL/DAY 13)Tne installer shall verify the location, quantity and elevation of the sewer i i i. i lines exiting the dwelling"rior to the installation.L; SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting Title V requirements. I cYOGAL/DAY ,x 2 DAYS - GAL I ,.✓ USE /DCOGAi:LON SEPTIC TANK , CS01L ABSORPTION SYSTEM . VII SIDE AREA: Z� 'Z. , J04_1 BOTTOM ,AREA: L 2 0 i �,� MAsori` y7 I v No..106 � • --� / � '?Nt IL SEPTIC SYSTEM SECTION 1 b �d o , '� ' ...... � 6 10 r Y yr Z ,,tit ,,< ......- -•---... ,�.,..,. ,,.,..�„ � --� to' ; i ► .� . : 19641ate. Y�► ZZ l 9eD b 0 73 :.. 1rQbO I GAL p� T SEPT 1 C TANK � x " -- - i ; y + 3 Z5 x 12., �. mac_--�,__w ..���_a i, _ � - i t SITE ' AND SEWAGE PLAN - LOCAT I ON 11.• I I PREPARED FOR : CAQ-DmqL_ 1 6M IT o SCALE: I: DAV I D BeMASON R� DATEA 17,10160 DBC ENVIRONMENTAL DESIGNS I L DATE HEALTH AGENT ZI EAST SANDWICH , MA ( 5a81 . n�3- 2I7T : ,