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HomeMy WebLinkAbout0038 CAP'N JAC'S ROAD - Health 38 Captain Jac's Way Centerville A= 194-053-W00 o w i SMEAD �e� No.2-153LOR UPC 12M s+..daom • Yad.�n 11� QFMSR I�i�N11i1NNIRtW Commonwealth of Massachusetts /9/ 053-TOO O Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o" F _I 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is Owner's Name required for every page. Centerville MA 02632 August 22,2019 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. A. Inspector Information 61* Az/1/3 1. Inspector: Nicholas Geneseo Name of Inspector Wind River Environmental Company Name 46 Lizotte Drive Suite 1000 Company Address Marlborough MA 01752 City/Town State Zip Code (973)830-6126 SI 13988 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: Q Passes ❑ Conditionally Passes ❑ Needs Further Evaluation by the Local Approving Authority ❑ Fails t August 22,2019 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 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. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 1 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection C. Inspection summary Inspection Summary:Complete 1,2,3,or 5 and all of 4 and 6. 1)System Passes: Q 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 system is working as designed at the time of this inspection.All covers are within 2"of grade. 2)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.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 20 is Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) 2)System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3)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. a.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: t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 3 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) ❑ 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 b.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. c. Other: 4)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Q Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Q Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 4 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is Owner's Name required for every page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) 4) System Failure Criteria Applicable to All Systems:(cont.) Yes No ❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Q Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped:_ ❑ z Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Q 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000gpd-10,000gpd. ❑ Q 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. 5)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 CA. 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 t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 5 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CM 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No Q ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ Q Were any of the system components pumped out in the previous two weeks? Q ❑ Has the system received normal flows in the previous two week period? ❑ Q Have large volumes of water been introduced to the system recently or as part of this inspection? R1 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Z ❑ Was the facility or dwelling inspected for signs of sewage back up? Q ❑ Was the site inspected for signs of break out? Q ❑ Were all system components,excluding the SAS, located on site? Q ❑ 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? Q ❑ 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: Q ❑ Existing information. For example,a plan at the Board of Health. ❑ Q 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)] t5ins.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 20 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information 1. 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): 340 GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes Q No Does residence have a water treatment unit? ❑ Yes Q No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes Q No information in this report.) Laundry system inspected? ❑ Yes Q No Seasonaluse? ❑ Yes Q No Water meter readings,if available(last 2 years usage(gpd)): 222 GPD Detail: Usage:21,600 cu.ft.X 7.5=162,000 gallons/730 days=221.91 4 222 GPD.See attached Customer Statement provided by C-O-MM Water Department. Sump pump? ❑ Yes Q No Last date of occupancy: Current Date t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day d P Y(gP ) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes,discharges to Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): General Information 3• Pumping Records: Source of information: Wind River Environmental last pumped on 4/16/19,see attached. Was system pumped as part of the inspection? ❑ Yes Q No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is Owner's Name required for every page. Centerville MA 02632 August 22,2019 City/Town State Zip Code .Date of Inspection D. System Information (cont.) 4. Type of System: Q Septic tank,distribution box, ❑ 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): Approximate age of all components,date installed(if known)and source of information: Septic Tank: 1985. Soil Absorption System:2005. Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints,venting,evidence of leakage,etc.): No leakage or obstructions were observed in the line.The flush came through clear. t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 0 Page 9 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is Owner's Name required for every page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8' x 5' X 5' Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The liquid level is at the outlet invert and both tees are intact.The tank appears to be in good condition with no leaks. Both covers are on risers to 2"below grade. Recommend pumping on an annual basis. t5ins.doc rev.7/26/2018 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System*Page 10 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is Owners Name required for every page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): B. 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 t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is Owners Name required for every page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): The distribution box is on a riser to 6"below grade.The box is watertight.There are four outlets taking equal flow with very little carryover. t5ins.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 12 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: Q leaching fields number,dimensions: 1 @ 20'x 40' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 13 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(Cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): There is no breakout or ponding in the field and the vegetation is normal.The soil Is dry sand and there are no signs of hydraulic failure at the time of this inspection. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 14 of 20 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 15 of 20 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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: Q hand-sketch in the area below ❑ drawing attached separately {{3 Ca?'NTCLcsR l� �3 A SIR R6.�' 300, ° �i t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 0 Page 16 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Q Check Slope Q Surface water Q Check cellar Q Shallow wells Estimated depth to high ground water: 8'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Q Checked with local Board of Health-explain: Reviewed Soil Logs on file for 46 Cap'n Jac's Road ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The soil logs on file for 46 Cap'n Jac's Road from 10/11/2007 show no water encountered at 8'. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 17 of 20 -� Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Q A. Inspection information:Complete all fields in this section. Q B.Certification:Signed&Dated and 1,2,3,or 4 checked Q C. Inspection Summary: 1,2,3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed Q D.System Information: For 8:Tight/Holding Tank-Pumping contract attached For 15: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 16: Explanation of estimated depth to high groundwater included t5ins.doc rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection Water Records C-0-MM WAITR DEPT CUSTOMER STATEMEW�r ACCT NO 8.037 19 CHFUSTOPOULOS,ARI,5 58 CAPTJAC'S RD CEN Consumption.Histary PAU, REM 063W19 W 34 1 IJI.5 W 19 517 76 06-!101118 44[ 31 I2.E147 4W 75 06130VI7 lil 26 12 L 16 30.0 67 063 0,1 16 242 24 12)�It 1.115 il$ 73 t5ins.doc rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 19 of 20 .� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G 38 Cap'n Jac's Road Property Address Owner Aris Christotoulos information is required for every Owner's Name page. Centerville MA 02632 August 22,2019 City/Town State Zip Code Date of Inspection Pumping Record Work Order 0217071040 Cwt#21664SS4 ClrstamerSk me-2019 Tarr_s.2sao Scab Comments Tech Comments 04/1612e13 MM 1500 CAL,. Li¢Yar TSrr. 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Dkp0sat Volume: payment Oetat: Waste Code:cuapraptic logo_Dooa max 11,11,2004 1r4,no24 Sales Rep: CSR: Rick cr liaa—:aaaaipt Truck Tecf ddam€e-tb carpaatar On Stie t 06.47 AN P 0 ffiazdrer,t Tech Hotes€ Syota raparotiog Hies, Moxmal,aatar leva1_ Modsrat2 top colldo_%cavy bottom almcx�a. �6:'a baSE'1am am in:tatt- mash l.iraa elaar- 130.ri3.tar ingseamant as tl1a tams: exrtant.tank.caa n®outrittza vita a.ziltor.. : - Boost amsiti�wa.' Customer riot:oil ske 87[iS a Fitiva,.1n talllrsg a.^lltsr. Cavarlsl :viva.. '2900 gallaxa.tank - - .... cummierswawre ENVt[t0N MENTAL t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 20 of 20 Town of Barnstable P# 3 (0 4 ' Department of Regulatory Services F Public Health Division Date d�u` -7 20 f�- rEo �� 200 Main Street,Hyannis MA 02601 Date Scheduled_MA U.�� �y4 F 10 1 Z Time'l Fee Pd. Lo S Soil Suitability Assessment for Sewage .Disposal Performed B : `l°I.V 1 A 0• ( o t/oo hwv o ' y Witnessed By: Dvh QeS VYlgl-oi,, S �OCATION& GENERAL INFORMATION LOC r) Owner's Name D°IN�la T �dQ o ddress 5` -7 r�2 s6 1� h eel: 7�`f �' �j 3 _Too Engineer's Name 1)u 0 1 64 14we kvr NEW CONSTRUCTION REPAIR Telephone# ✓�T V a"� Land Use: key 1 4 e i4/cl , Slopes(`16) O Surface Stones n D.h.•e Distances from: Open Water Body-( 8 ft Possible Wet Area (tot R Drinking Water Well 1 ft Drainage Way 7 ft Property Line I ® T ft Other, ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) lu UN a T P I . Lz431 • � E Parent material(geologic) rU�` Ltl V+ Depth to Bedrock Depth to Groundwater. Standing Water in Hole: �"G WE Weeping from Plt Face Estimated Seasonal High.Groundwater ZO +E �L DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: mo 4-te 5 Depth Observed standing in obs.hole: In. Depth to soil mottles: In. n P l Depth to weeping from side of obs.hole: In, Groundwater Adjustment f. Index Well# Reading Date: Index Well level Adj.factor— Adj.Groundwater level,, PERCOLATION TEST Date 511+1 t Z nwe l t Observation ,L t Hole# ( Time at 4" ?(A —_ 10 yl:. Depth of Perc 1 Time At 6" t t h ' Star[Pre-soak Time @ �C 66 Time(9"-0) End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) + Original: Public Health Division Observdtior Hole Data To Be Corripleted on Back-------- �+ 1 e• t ***If.percolation test is to be conducted within 100' of wetland,you must first notify the• .,Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# i _ Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. onsi ten_y.%'Gravel) d - o Pit l A Cog ts C D-y R '2-11 `�Z. SIln/ [0 YJz �Jolt� �Ni�Ib�P 1-61- t3r6 RQ-4 ' end . GD YP- S�4- �,)OvtE Lsvo e DEEP OBSERVATION HOLE LOG Hole# I- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure„Stones,Boulders. Consistency.%Gravel) 2c -30 s6 '136 C bid Soh�( �(� R Sl4 t LOo S e DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stmeture,Stones,Boulders. Co i to c Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stories',Boulders. Cositn e Flood Insurance Rate Map: Above 500 year flood boundary No— Yes .✓_-_ Within 500 year boundary No Yes.: r Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? _— If not,what is the depth of naturally occurring pervious material? Certification y cR�s I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consist the required training,expertise and experience described in 310 CMR 15.017. ��SN oF' syc DAVID yo Signature Datt; MAY ISM �^ ?_0 Z. COUGHANOWR `� y �O /CENSER Q Q:1S.EMOPERCFORM.DOC /� eVALUP�O Town of Barnstable Barnstable Op SHE Tp� Regulatory Services Department All-AmeficaCitV i MRNS'I'ABLE, •MASS. public Health Division m 9Q Op 039- �9 'Eb"A0`� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7011 0470 0001 4525 6812 May 11, 2012 David Holt Today Real Estate 1533 Falmouth Rd/Rte 28 Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system located at, 38 Cap'n Jac's Road, West Barnstable,MA,was last inspected on 4/13/2012 by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails"under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • System is in hydraulic failure. You are ordered to repair or replace the septic system within sixty (6) days from the date you receive this notification. Failure to repair/replace the septic system with in the deadline period will result in future enforcement action. 4homas ER O E OA OF HEALTH McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\TOB Itr L `' � ��dli r�� (� 70w� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Cap'n Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is —Centepi.We �5{ I�I MA 02632 4-13-12 page. City/Town State Zip Code Date of Inspection a� -rb0 Inspection resuL—' mu be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General iniormation 1. Inspector. Shawn Mcelroy Name of Inspector Upper Cape Septic Services 1.v111(Oily ivdiiic 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-5(1R-dQS_f19n5 1;I1Q71 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 ajr�aintenan� of ark site sewage disposal systems. I am a DEP approved system inspector pursuan_t�Sectio"5.34dof Title 5(310 CMR 15.000).The system: `{ ' _. ❑ Passes ❑ Conditionally Passes ®;;Fails- I �f ya ❑ Needs Further Ev luation by the Local Approving Authority10 CIO 4-16-12 r1i nspector's Sign ture 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 nas a aesigin iiow of iu,uiiu gFitj 0-1 gieaiel, situ uie sysieiil uvvilei shall 5uiiiifit We 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 nerform in the future under the same or different conditions of use. ....,J ...... ....,..... ....... ,. .., --....,...,..,.;.yam..,.t....- ..y_.... �' �. .. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Cap'n Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is r.Pf1tp.M11h- MA 02632 4-13-12 reclined,f::P evciy page. Cityfrown 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 descrit)ed 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 neefd to be replaced or repaired. The system, upon completion of the replacement or repair, as aipproved 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) i s 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 Ceirtificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy:stem•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Cap'n Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is rPrtlllrari Mr pyPrry Centerville MA 02632 4-13-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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): I-I -n-b fjo-4inn romnvoA 1-1 v 1-1 Ki n t\Ir1 /Gynhin KoInIAA: 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 Bass 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 ❑ Cesspooi or privy is within 50 feet of a bordering vegetated wet and or a Bait marsh toins•'i"ii'iu Titie o ii 66i inspection Forfn:Subsurface sewage uisposai System•rage s of'i1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 38 Cap n Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-13-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public water Supplier, if any!) determines that the system is functioning in a manner that protects the public Health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a poublic water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a priwate 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 nitrolgen 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 distributor, box above uutiei te)an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available vollume is less than day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts n� Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Capin Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-13-12 page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24 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.): Good condition. Septic Tank(locate on site plan): 18" Depth below grade: 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 gal Sludge depth: 12" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Capin Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-13-12 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 20" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structu ral integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 um in P P 9 Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sysllem•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Cap'n Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for eve ry Centerville MA 02632 4-13-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No L65ms1110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 38 Cap'n Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-13-12 page. City1rown 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 cairryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and stain lines above inlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Pqo Alarms in working order: ❑ Yes ❑ Pqo Comments (note condition of pump chamber, condition of pumps and appurtenances, etc:.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sysltem-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Capin Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-13-12 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit has signs of hydrolic failure with stain lines above inlet invert. 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-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 38 Cap'n Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-13-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sysltem•Page 14 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form BSubsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 38 Capin Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-13-12 page. City1rown 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 nn �"-1`c3Y1 !7 -r —a�r6���� 33`6 L'o o 0 14 -rr- 3a, d--F- q.36 .. D� t5ins-11/10 Title 6 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 38 Cap'n Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-13-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 - Title 6 Official Inspection Form:Subsurface Sewage Disposal Systtem•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form a.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Cap'n Jacs Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 4-13-12 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 S?A-L ,�- V'-gp A% ��Y- u,53 -fD o cv.'11t 4: l 1N-OS-3 —WOO No. Fee THE COMMONW LTH OF MASSACHUSETTS Entered in computer: Yes ��� UBLIC HEALTH DIVISION -TO N OF BARNSTABLE, MASSACHUSETTS w• application for Disp 6pstem Construction VPrmit Application for a Permit to Construct( ) Repair Upgrade ) Abandon( ) ❑Complete System individual Components ati Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's ame Address and Te l/.4 Designer's Name,Addre s,and Te No. ale W�� o�� n� � c� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �-- Design Flow(min.required) � gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 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 Certificate of Compliance has been issued by this Board of Health. Si e o'1° Date Application Approved by Date /2 Application Disapproved by Date for the following reasons Permit No. 2 /a — /SS' Date Issued �— - '—* `q`*C0.'ryt^"'x.`,.1"'.-.. ,..•w-^yes... », .. ►r, v 3 D a S PP��{`� g, ` 19.W_ S ` 1 JyR� fly,.� �.� � � = 19y� OS3 -WOO '` No. I �J�J f o Fee 0 U r. THE COMMONW4LTH OF MASSACHUSETTS Entered in computer: Yes ��� Ile ,PUBLIC HEALTH DIVISION - TO�N OF BARNSTABLE, MASSACHUSETTS; ���" ftplication for Wpm a 6 stem Construction Permit f, 1 Application for a Permit to Construct( ) Repair Upgrade ) Abandon( ) ❑Complete System KIndividual Components I pcati Address or Lot No. Owner's Name,Address,and Tel.No. r f/ ze��6;2 010-1012-NIX Assessor's Map/Parcel laIll Installer's ame Address,and T��To. // D6� Designer's Name,Addres ,and Tel No 6? IM Type of Building: Dwelling No.of Bedrooms Lot Size sq.8. Garbage Grinder( ) Other Type of Building S No.of Persons Showers( ) Cafeteria( ) Other Fixtures �--- Design Flow(min.required) gpd Design flow provided �S] gpd Plan Date Number of sheets Revision Date Title T Size of Septic Tank Type of S.A.S. Description of Soil 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 Certificate of Compliance has been issued by this Board of Health. z Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. J 1 — 1S' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Urtificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by / at J as been constructed in accordance with the provisions of Title 5 and the fo�is sal System Construction Permit No.2-0 I? tY dated InstallerT Designer #bedrooms ? Approved design floc, 33 0 gpd The issuance oft s p rmit shall not be construed as a guarantee that the system ill ctio as desA ned. Date Inspector .. --------------------------------------------------------------------------------------------------------------------------------------- No. � D ( � �,5��� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal —6pstPUt Dnstructiott hermit Permission is hereby granted to Construct( ) Repair( l Up7 ( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mup be completed within three years of the date of this permit. Date Approved by ]p Np� C.VI I�Q.� r ( 1y-©.�3'��OU P ,t. ��n W.-60rn. TO N OF BARNSTABLE" �d 1° q-OS3-U✓0� LOCATION SEWAG #oLV�� VILLAGE — ASSESSOR' MAP ����� INSTALLER'S NAME&PHONE NO. W SEPTIC.TANK CAPACITY®D® X, LEACHING FACILITY.(type) �!5 (size) NO.OF,BEDROOMS OWNER 0U."Okeol .: PERMIT DATE: COMPLIANCE DATE: Separation Distance etween e: 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 f cility) Feet FURNISHED BY Qq /41 ly �- 0,0 Town of Barnstable °q 4 rqy, Regulatory Services ti Thomas F. Geiler,Director MA&& Public Health Division �EDMP�A Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 � 7 Date: Sewage i42_4 Assessor's Map/Pareel l L G> f Installer& Designer Certification Form Designer: Co vg�4h0w r Installer: < < Address: �3 Tv,iap0e_ (fir Address: ndwiG�I �� 0)-�'� i On was issued a permit to install a (date) (installer) septic system at 3 e5P4 h ae4e S [.A based on a design drawn by (address) bNuiG( D. 6v H yyowY k�dated YW4V � '0. Z. (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. Stripout (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 Re ulations. Plan revision or certified as-built by designer to follow. Stripout (if reg2�rqs e ected and the soils were found satisfactory. sq �o DAVI D yGm o D. a COUGHANOWR N nstaller's Signat No. 1093 ST LOA ,,,,G` S SgNITAR%PN (Designer's Signature) (Affix Designe 's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:\office forms\designercertification form.doc LEGEND EXISTING 1000 GAL SEPTIC TANK® eJC 3?9 e / • EXISTING // L O T 19 . LEACH PIT GARBAGE GRINDER / 1 TEST IS NOT ALLOWED bb {ice AREA e 15162 off �0 1 D-BOX ❑ PIT ® WITH THIS DESIGN. �pb/ ASSR MAP 194 PCL 53T I / 1 TREE �@-M 12-P // EXISTING MINIMAL 115/ I CONTOUR GRADING BENCH H MARK 40---. PROPOSED �/ 1 l-40 PAINT SPOT ON 1 / BRICK STEP CORNER * I / t ELEVATION = 116.25 M BARNSTABLE GIS DATUM 1 �' 114. � VENT PIPE I QOzO A z BSORPTION o O 1 c \\\/� YSTEM `. O 11 L�—� I TP2 Oft Q � 1 \ 2 SOIL REMOVAL AREA 1 1 o 113 Q� \ REMOVE ALL FILL AND OTHER UNSUITABLE SOILS I o 114 DOWN TO THE 'C' MEDIUM SAND STRATUM AND REPLACE 1 m N' - WITH CLEAN MEDIUM SAND o•IPER TITLE 5 � PLAN VARIANCE REQUESTED SCALE: 1 1 n = 20 f L MAY BE GRANTED IMMEDIATELY BY HEALTH AGENT OR HEALTH INSPECTOR. 310 CMR 15.221(7) - COMPONENT THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM DEPTH TO FINISH GRADE. 36 in DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING MAX REQUIRED - VARIANCE TO PLACEMENT OF ADDITIONS. SHEDS. FENCES OR SWIMMING POOLS. OWNER 60 in OF COVER REQUESTED. SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED'LAND SURVEYOR. TOR OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE SCH. 40 PVC VENT EL =116.69 +- 6 in OF FINAL GRADE AND TO PITCH AT I/8 in/ft MIN '. PIPE 115.0 ©-B® S INSPECTION 0�� USE H-20 MAX PORT 110.01000 GALLON 109.60 Mini =__= ==__= La _ _EXISTINGTANK 111.95 - -===-=-_ - _ EXISTING EXISTING STONE ONE SOL rA,BSSORPT�ON in � USE A-20 TE SEE DETAIL.ON BACK v- RATED 109.77 BASE 109.51 UNITS SYS T E -SEE DETAIL p EXISTING 28 ft 4-11 f t ON BACK 108.92 NO GROUNDWATER `nBELO MID CAPE NIGH N/AY MOTTLING OBSERVED _ Q3.25 RTE 6 - �,SNOFMgsS �S"OFMgs c �Cj -T�s�,� SEWAGE DISPOSAL ROAD 5ERV'`E ��' q SYSTEM PLAN cy � off° DADVID GNP oho DAD. a EST. -TO SERVE EXISTING DWELLING 4' )AC'S COUGHANOWR y CAP'N pOAD COUGHANOWR FEDERAL NATIONAL No. 1093 aao MORTGAGE ASSOCIATION Q LOCUS �FG/STE��O `�O 410E'NSE10 q- �G 1995 �� OWNER(S) OF RECORD IN NOr sqN a�PN FVA uP ONM�� 38 CAP'N JAC'S ROAD TO WEST BARNSTABLE, MA i SCALE , 43 TRIANGLE CIRCLE PROPERTY ADDRESS WEST BARNSTABLE, MA InA�� G I SANDWICH MA 02563 1A C DATE: MAY 16, 2012 LOCUS MA P 508 364-0894 PG.1/2 1 JOB* ETE-3613 SULK TEST LOG DESMN CALCULATMNS DATE OF TEST: MAY 14, 2012 DESIGN FLOW: 3 BEDROOMS X U0 GPD = 330 GPD SOIL EVALUATOR: DAVID D. COUGHANOWR, LSE-461 WITNESSED BY: DONALD DESMARAIS, HEALTH DEPT. SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS PERC NUMBER: 13643 USE EXISTING 1000 GALLON SEPTIC TANK IF IN NO GROUNDWATER ENCOUNTERED SOUND STRUCTURAL CONDITION. IF NOT, INSTALL TEST PIT 1 PERC AT 76 in NEW 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) LESS THAN 5 MIN/INCH IN C SOILS DISTRIBUTION BOX: USE 3 INLET 5 OUTLET D-BOX. ELEVATION DEPTH SOIL USDA SOIL SOIL COLD SOIL OTHER SOIL ABSORBTION SYSTEM: (FEET) (INCHES) HORIZOI I TEXTURE (MUNSELL) MOTTLIN 114.75 INSTALL 20 ADS ARC 36 BIODIFFUSERS 0-50 FILL 20 UNITS x 5.0 ft / UNIT = 100 L.F. 100.0 L.F. x 4.80 S.F./L.F = 480.0 S.F. 50-58 A SANDY LOAM 10 YR 2/1 NONE FRIABLE 480.0 S.F x .74 G.P.D. / S.F. = 355.2 GPD 58-82 B LOAMY SAND 10 YR 4/4 NONE FRIABLE USE 20 ARC 36 BIODIFFUSERS AS CONFIGURED BELOW 107.92 - Vt = 355.2 GPD ) 330 GPD REQUIRED 82-138 C MEDIUM SAND 10 YR 5/4 NONE LOOSE REFER TO DEP APPROVAL LETTER TRANSMITTAL 103.25 * W000052 FOR CERTIFICATION OF ADANCED NO GROUNDWATER ENCOUNTERED DRAINAGE SYSTEMS BIODIFFUSER SYSTEMS. TEST PIT 2 LESS THAN 5 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLD SOIL OTHER D§STUI "§ WT§0§V O�"}� NOT U4E8b (INCHES) HORIZO TEXTURE (MUNSELL) MOTTLING3 INLET 5 0EOUTLET DISTRIBUTION BOX SCALEY PRECAST H-20 RATED 0-26 FILL WITH SPLASH BAFFLE OR EQUIVALENT. 26-30 A LOAMY SAND 10 YR 3/2 NONE FRIABLE DISTRIBUTION BOX TO BE 30-50 B LOAMY SAND 10 YR 5/6 NONE FRIABLE PLACED ON A STABLE COMPACTED BASE ONTO � USE 110.68 WHICH b in OF STONE 50-136 C MEDIUM SAND 10 YR 5/4 NONE LOOSE HAVE BEEN PLACED TO H-20 103.52 REDUCE SETTLING. RATED UNITS LINES EXITING D-BOX TO O RUN LEVEL FOR 2 FEET O BEFORE PITCHING DOWN TO LEACHING FACILITY. 1 o0000o GALLONSEPT§C� TA nNK INSTALL RISER TO WITHIN � � O O b in OF FINAL GRADE DIMENSIONS AND DETAIL NO T TO b in MINIMUM SUMP USE EXISTING UNIT SCALE 12 in MINIMUM INTERIOR DIMENSION SEPTIC TANK IS TO BE PUMPED DRY AT TIME OF INSTALLATION AND IS TO L LS A C UUV G GQ L L ER U BE EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL NEW PVC OUTLET CONSTRUCTION DETAIL TEE EQUIPPED WITH A GAS BAFFLE. USE ADS ARC 36 BIODIFFUSERS I In GRAVEL FREE INSTALLATION - USE DEP TAPER APPROVED INSTALLATION PROCEDURES. INSPECTION P 25.0 ft OR c C O INSTALL O 0 TWO AND C .,,, SHOW ON +' 4- AS BUILT U-) CARD 8 ft-6 ;� O INLET OUTLET 20 UNITS TOTAL - 5.0 ft PER UNIT COVER COVER CROSS SECTION VIEW �3 IN DROP FLOW LINE --> RESTORE VEGETATIVE COVER FROM 10 in 14 TO BUILDING D-BOX BACKFILL WITH CLEAN PERC �^ SAND TO TOP OF CHAMBERS 48 in LIQUID GAS USE LEVEL BAFFLE H-20 RATED 13 in IFF UNIT S DEPTH SEPARATION OF INLET AND OUTLET TEES EXISTING SHALL BE NO LESS THAN LIQUID DEPTH 2.875 SUITABLE CROSS SECTION VIEW MATERIAL EFFECTIVE WIDTH = 5 x 2.875' - 14.375' USE 5 ROWS OF 4-ARC-36 ADS BIODIFFUSER UNITS-NO STONE NOTES 1) INSTALLER JO ,OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 2) ALL COM;RONENTS INSTALLED YS.HALL MEET :THE MINIMUM REQUIREMENTS SEWAGE DISPOSAL SYSTEM PLAN OF MASSACHUSETTS _TITLE,5 SEPTIC CODE (310 CMR 15). PAGE 2 OF 2 3) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING'FOR'SYSTEM. ' FEDERAL NATIONAL 4) PIPES EXITING D=BOX TO'.RUN LEVEL FOR 2 FEET BEFORE PITCHING DOWN, OF MORTGAGE ASSOCIATION 5) EC IXTURES-TECHENMENTA $VAR LIANCESLAND BIANNUAL PUMP NGRECOMMENDS THEALLATION OF THE SEPTIC LOW TANK.OW 38 CAPON �AC'S ROAD 6) SYSTEM PARKOR DRRIIVE.DESIGNED TO VEHIIICLES OVER WITHSTAND SYSTEM VEHICULAR LOADING. DO NOT WEST B A R N S T A B L E. MA 7) SEPTIC TANKS TO BE INSTALLED +LEVEL AND TRUE TO GRADE ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH MAY 16, 2012 ETE-3613 SIX INCHES OF CRUSHED' STONE HAS BEEN -PLACED TO MINIMIZE UNEVEN SETTLING. ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -How ow 3(� .. �l t�.'1-------------OF.........B. ........_.......__ Appliration for 3lispos al Works Tonstrnr#inn Vernat Application is hereby made for a Permit to Construct ( *-<or Repair ( ) an Individual Sewage Disposal System at: TAC l$ ..��_ ....it ..._��......�/1�•..�\��...-•-- .....�-o..... .� -{ -- �®.'�a�. --�..---- Locatio Addres or er ddress °® s,.----------•------------------- �l u . _s..�. ......................................... Installer Address Type of Building Size Lot___1J 1_��-^____Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ((1� Garbage Grinder q aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -----••••-•••••••••••--••••-• • - w Design Flow______________0� __________________..gallons per person per day. Total daily flow..__._.__.n_�__ ._._______.___gallons. WSeptic Tank—Liquid capacitylqq9gallons 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 ( ) Dosin nk ( ) '-' Percolation Test Results Performed by.._ .....l._ �- _.__.____ Date___.N_:_ J�..-CY_ _.__.. 14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_______________________. 1% Test Pit No. 2........._......minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-•••-••••---- - ---- --•-•--•••••-•-....--• ......•--......--••-------•-----•----••---....•-•......................................................... O Description of Soil----•�'. "�" .�1!-r? - �'---=------- --------- �., �?----13 - yam ----•-------- 4�-�. _ 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 iITLZ 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. n •-• --�•••••--•••••-••••-•. � � ---•---••- --- ---- ---- - ApplicationApproved By-•••••• •-••-'. •----....••••••--••-•-•••••---•-••-•-•---•--.......................... ---��Q -- - ------•----•---•-- ate Application Disapproved for th ollo ng reasons---------------•-----....---•------------------------------------•---------------•------••---••-••••••-•--------- .......................................----•----------------...-------•------------...---•-•-------...--••••-••••••••••••-•-•---••----•••••-•---••••----•••-------•----- ............................ Date PermitNo......................................................... Issued.............. •- ace Fim . ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --------5 01.1)/1..............O F........1..a h Applirtttinn for Dhipaiitt1 Works Tonstrnrfilart Prrmit Application is hereby made for a Permit to Construct ( ✓f'or Repair ( ) an Individual Sewage Disposal System at: .... a......C U:� ........ �--©.k------_�.1... ................ Location-Address - •o, �. me-2... 1 - .�... . ,'�' ---------------------------- -----....'..`-_....'.. r-�. ........................................... ' '( ,n�er�., t_ ddress _..._....__. ` .,F,. -�u f 5. ��:"�. : ..................... ............. Installer Address Type of Building5 A`O�'..Sq. feet Size Lot-•-`---•-•--------------- Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic n � Garbage Grinde"13) 04 Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) 04 Other fixtures -------------------------------- - W Design Flow.............V�o.........©�_`�_..gallons per person per day. Total daily flow-------- _- .. ............ .. WSeptic Tank—Liquid capacit}�l____._._.__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 ( ) Dosingt�ank ( ) '-' Percolation Test Results Performed by....,\j .... .__.. 1.._!1JlL- ------ Date... �a tJ_-L _ ___.._.. Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ (1I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ............. D cription of Soil �'. -_.._.. rn �t..._/)s.a. .j...... Des c1. ---...•••--.• ........................... UW ------------------------•--------------------------------------------------------------------------------=..------------------------------------------------•------------------•------...•...---------.. 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. r� ..-.-.......... Application Approved By...... ...:... ---- "" •- ------------•-•---------------•---•-------------------....---------- . ....... Date Application Disapproved for th ollo ng reasons---------------- .......... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...,.,,h_.� ...'...............OF........... -f '."'.'............ Tntifiratr of Tomplittnrr THIS IS TO CERTIFY,„ at the Individual Sewage Disposal System constructed ( or Repaired ( ) by-_•-.�.e.. .............);&R::L............................................................................................................................ Installer at-•_-•- Q \. .... t-�Gv ...----------- ---••-......-"'_.."C'. AV..,,-e..."-•--------..................-- 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. __ ......... dated................................................ THE ISSUA CE O THIS CERTIFICATE SHALLNOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM IL UN ION SATISFACTORY. DATE... ... . v-�•. ---------•--•----•-•------------------------- Inspector---- ... ........................................................................ i THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF, HEALTH ......................OF......... .0 J I�-o. N �. FEE, f-- ........... Dispoal Workii ToniV!n rrntit Permission is hereby granted v R�ol�lr,..........................................•-----•---------=�---••--••---------...-----......------••----...... to Construct (L�or�Repair ( ) an Individual Sewage Dispo ystem `} --------- ----•.Qn ------- Street as shown on the application for Disposal Works Construction Per . . .................... Dated.......................................... Board of Health DATE............�p ............................................................. FORM 1255 A. M. SULKIN, INC., BOSTON hlO G►A�Barcb G¢.t4.lt�t� ...---- -----___._.___._....___....._..-._..�;.--..�---- --�-` ; ' ' ---_ , VA,%"-4 1~'14p�:�/ . 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' SGhI_.� '!! �� �AT t.,- d, (�,� tZcF=Est G-W c.E• 1 CrLr-TI PK TµAT T-w- r-;uu WD 1-1t E 2_E.o N ' GO M P L-`(S WIT*" T"E AWI> �itT13AGK 2 Jl2E•Mfi►.lT� CIF 1'WE• �L✓A►� �2 ; -- 5:;-M►Tfi1 • l UC-AT"E:t-n TkE: G't-oot� Pt-AtU. ww + ATE L� l_A�l___ I U4C.. �LlaL tST" rLN LAW T41S PL.ALJ Ier LIOT BASED OL4 AU IQ4 A Et 11T OrPTE:-zVtt , gUZve�( T► G► OFFSQ•T; i14t>ULt> UOT VSG USA APPLIGA" r 11 TO *PeTr-Tr yO7 Ltu54 4, TOWN OF BARNST LE �c, SEWAGE # LOCATN IO --- V1LL Ile ASSESSOR'S MAP&LOT H INSTAL!-EWS NAME&PHONE�NO- SEPTIC TANK CAPACITY LEACHING FACUM7Y: (hype) T 1 (size) OO� No.OFBEDROOMS 3 to BUILDER OR OWNER pERMITDATE: CONTLIANCE DATE: Separation Distance Between thc: Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any Welk exist on site or within 200 feet of leashing facility)I Feet - Edge of Wetland and Leaching Facility(If any wettands exist within 300 feet f g eachun fact'ty) Feet Furnished by �✓� � �4 N Q�C o N /4 00 .�" tY-F- q-?'6 D�' L: C A T I / C S v E PERMIT NO. VI'LLACE C� �INTA LLER'S NAME i ADDRESS IUIL0ER OR OWNER iN LmF_ i � DATE PERMIT ISSUED ® l - DATE COMPLIANCE ISSUED �� �� GA�Z/�GF d . � � o` _ . .. � �� �� ` �� �, t .. y- F�