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HomeMy WebLinkAbout0029 CAPTAIN LUMBERT LANE - Health 29 CAPTAIN LUMBERT LANE Centerville A = 147 - 011 ® �I S M E A D KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED INITIATIVE CONTENT 10% Cerdfied Fiber Sourcing POST-CONSUMER www.sfiprogrem.org $"IWO MADE IN USA !GET ORGANIZED AT SMEMCOM Floor Plan 29 Captain Lumbert Lane ' Centerville MA, 02632 Prepared for Barnstable Heath and Building Dept. ,` Basement floor plan First floor plan Second floor plan VJ �. o � t . � . p 77 ! � \ NO CONCRETE SLAB FOUNDATION, NO ACCESS \ � ` \ \ � � \ \ � \ \ j \ \ BULKHEAD ACCESS \ ^ \ » ?. \ |� \ j \ LAUNDRY 1E x ,E j 9 � \ � d . » > .p j STAIR a d ^ « \ / BASEMENT 38 X 7 \ \ \ \ \ \ ^ \ \ \ \ \ \ STORAGE ROOM 4ax ,e \ , r \ ZZ \ � d \ \ � \ j § � \ \ \ \ \ \ j d \ — . cam=- 9 � All dimensions-size designations This is coriginal a and in Designed: !m&8 c_��lm« � on A TECHNOLOGIESE2 �be m�a=copied�� Printed:1/122zes @b site saadjustment to fit job applicable fee has beenpaid=»b conditions. orderplceI b__±A All Drawing+ IN kale. EXT.SIDE DOOR 22' - p SIDE ENTRY CLOSET �n 4nw 1`0 14' 14' FAMILY ROOM 21'X 13.5' �0 {m� • �.u4 I•�,I 3` I•,3i1 2' __ .. CASED OPENING SHEET ROCKED OPENING 32" FULL BATH 13'X 7.5' OFFICE 13'X 13' 14 BI-FOLD DOORS LINEN CLOSET z E PANTRY CLOSE I< C�/ 36"FRONT DOOR BASEMENT O _...._ 36' KITCHEN/ DINING ROOM 23''X 12' LIVING ROOM 22 23'X 13' -36"BACK DOOR 7'CASED OPENING 12'X 12'BRICK PATIO �- NO ta�� _26 j, All dimensions_size designations /�/�(/��/� E �� This is an original design and must Designed: 1/8/2018 given are subject to verification on TECHNOLOGIES not be released or copied unless Printed:1/12/2018 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. �rni�y first floor.kit All Drawing#: 1 No Scale. CLOSET lauanE X-yD !Lnra I...ad 3 Yd44 �4�l BED 3- 13'X 9' "'1 L4 I .I kay'i ZZ ZZ DEN 27'X 10.5'AND 8.5' I BED 2- 12.5'X 9' TINE OF ROOF PITCHING INTO ROOM HEIGHT _ �L4 I CLOSET i f STAIRS .,FULL BATH 8'X 7' LANDING CLOSET BI FOLD DOORS/ATTIC ACCESS ?� VAULTED 1ST FLOOR CEILING BED 1 - 15.5'X 11' Z(1 All dimensions size designations 7f'1 _ This is an original design and must Designed: 1/81201 g ) iven are sub to verification on w J not be re P leased or copied unless Printed:1/12/201 E TECHNOLOGIES job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. 2nd floor.kit All Drawing#: 1 No Scall Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 29 Captain Lumbert Lane .3 Property Address Sierra Pougherty Owner Owner's Name information is -r.. required for every Centerville Ma 02632 12-21-17 0 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 51-4f lad qS 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 City(Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification 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 12-21-17 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 , 044dVS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 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: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °.H 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 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 1h 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 ;M 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system.is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 is Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. CityFrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 --Number of bedrooms(Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 7 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2017- 100,000 allons 2016-79,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts V�jp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. Cityrrown State Zip Code Date of Inspection D. System Information(cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner-date of last pump is unknown 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: A new SAS was added to existing leaching in 2003 per COC Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28 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: 20 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: 1000gallons Sludge depth: 8 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 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 13" 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 with liquid level equal to outlet invert. The 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: NAfeet 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is Centerville Ma 02632 12-21-17 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'M 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. 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: l5ins•3113 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 °wM 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1 trench w/5 infiltrators39'long ❑ 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 working order at time of inspection with no sign of hydraulic failure. Leaching had 5" of standing water. 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 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately REAR B A Al- 11' B1-32'4" A2-217" 132-36'1" A3-32'9" 133-2910" FG) 0 2 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is Centerville Ma 02632 12-21-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: Observed GW @ 144" per plan 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: 1-10-23 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. 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 Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �w 29 Captain Lumbert Lane Property Address Sierra Pougherty Owner Owner's Name information is required for every Centerville Ma 02632 12-21-17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -:.—....,... .�....�..........--............�..�........�....r_—•—�a-m----�,-..•..•..��+.. �TLs-&�'�.'!'....,......--r..+ ..........,-...�..,_„�- .-�.4!".,�,_".bra'! ,.e....._,,.... ..,�....�. ,........... .- �, �n J 1 � 1 J e --- /r� I-v7 LU CO "CIA LL- ; _i�� e per+ I t h } ' f ' �- nn Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments29 Captain Lumbert Lane Property Address McLane Owner's Name i Barnstable 00fi V V I I I G MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III I Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: o ® Passes ❑ Conditionally Passes ❑ Fails; c; -a� ❑ Needs Further Evaluation by the Local Approving Authority W , 9/17/13 � Inspecto s Signature Date r Lv en 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. 29 Captain Lumbert Ln.•03108 Title 5 Official Inspection Form: s ace Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Pumping suggested eve 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND)in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 29 Captain Lumbert Ln.•0308 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑.The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 29 Captain Lumbert Ln.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owners Name Barnstable MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 29 Captain Lumbert Ln.•03108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D► System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. F� Z 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 16,000 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. 29 Captain Lumbert Ln.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 Cityrrown 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)] 29 Captain Lumbert Ln.•0=8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ug 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 City/Town State Zip Code Date of Inspection 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Vacant 1 yr per owner Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a 29 Captain Lumbert Ln.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts UluTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No pump history 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): Approximate age of all components, date installed if known and source of information:9 P ( ) o atlon: Original septic tank new d-box and SAS 2003 per BOH ecord Were sewage odors detected when arriving at the site? ❑ Yes ® No 29 Captain Lumbert Ln.•03108 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Inlet cover raised If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle >12' Scum thickness trace Distance from top of scum to top of outlet tee or baffle >211 Distance from bottom of scum to bottom of outlet tee or baffle >2° How were dimensions determined? measured 29 Captain Lumbert Ln.•03108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 Citylrown 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): n/a 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.): n/a 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): n/a 29 Captain Lumbert Ln.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °y< 29 Captain Lumbert Lane Property Address McLane Owners Name Barnstable MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): n/a Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): Plastic D-Box 2' below grade. No adverse conditions Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 29 captain Lumbert Ln.-03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Top of chambers at 3'6" below grade, chambers dry at this time, no indication of past backup 29 Captain Lumbert Ln.•03!08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y` 29 Captain Lumbert Lane Property Address McLane Owners Name Barnstable MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a 29 Captain Lumbert Ln.•03f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 6 II L '31 29 Captain Lumbert Ln.-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Captain Lumbert Lane Property Address McLane Owner's Name Barnstable MA 02632 9/17/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2003 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: see above 29 Captain Lumbert Ln.•03/08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 15 of 15 No. 90 J y d S a Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migool *pztem Comgtruction 3permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 21 c ,^ Owner's Name,Address and Tel.No. Assessor's Map/Parcel cr '�er•�10 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 — Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank tw dv U Type of S.A.S. 0 6' 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 Certifi- cate of Compliance has been' sue by this o of Health. Signed Date Application Approved by qr Date / $ Application Disapproved for the ollowing reasons Permit No. Date Issued i No. UJ 3 oar i_mow, -' : ;, Fee .. _ Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes x.r PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for Migpoear *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. `� (�[I ^ L Owner's Name,Address and Tel.No. Assessor's Map/Parcel L11 u i l-602, + 7 eY l / ri✓r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: a Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow g 3o gallons per day. Calculated daily flow 3 7G y gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank e , / h l d t)d q A 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 afo a described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i sue by this o of Health. Signed \ Date 1 U 3 Application Approved by Date Application Disapproved for the following reasons Permit No. 2 i��> -U a :> Date Issued I �� ---------=----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded( ) Abandoned( ) y at f7 ( od ! �Pr has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.?0&0)<_ dated l/I V �3 Installer Designer + The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 1� 5 / U Inspector' �.� A N . � . --------------------------------------- No. �2uo3- U2r Fee SD THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1wigpo5ar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair/( )Upgrade(V)Abandon( ) System located at 9 CO-I a a-1 2--14 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of th* ermit. Date: I/t�/U? Approved by �� ' TOWN OF BA.RNSTA.BLE P, LOCATION t tr Z/V SEWAGE # r-VILLAG,, p / ASSESSOR'S MAP & LOT 1117-011-003 INSTALLER'S NAME&PHONE NO. 1®�u i� W�► P a�yak g � SEPTIC TANK CAPACITY LEACHING FACII.=: (type) P * 7 Iel (size) 1 NO. OF BEDROOMS 3 } BUILDER OR OWNER �w xl PERMIT DATE: / �y �3 COMPLIANCE DATE: i Separation,IDistance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility y Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ td,? 'feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o leachin ac ), _ i _Feet Furnished by t r' ,, N ,� , , �g ��` �. � s 1 �. �w d ` 1 v� I �� � . . O`` � �� - . �� I � �` ,1 TOWN OF BARNSTABLE LOCATION ` )—Al SEWAGE # • VII,LAGE P ASSESSOR'S MAP & LOT 1 t(�'011'003 INSTALLER'S NAME&PHONE NO. �1 d u W�, I�'I o�yak 9`f SEPTIC TA CAPACITY ,D ` N�C p�/ LEACHING FACILITY: (type) k�Y r•P/YG (size) ?' I 2 NO.OF BEDROOMS 3 BUILDER OR O PERMTIDATE: b COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility F Q y Feet Private Water Supply Well and Leaching Facility (If any wells exist �/ ,_ beet on site or within 200 feet of leaching facility) �— Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet o leaching ac ). Furnished by IY I I J A ,� Town of Barnstable P# 01 3ZP Department of Regulatory Services Public Health Division Date 11 13 200 Main Street,Hyannis MA 02601 s awsreBL& Date Scheduled 1 a /dd 2 Time D:oo 4r''l Fee Pd. '°rEo fir" Soil Suitability Assessment for Sewage Disposal Performed By:�T-FDA ll / GL � Witnessed By: 4 _ _ 9© ........................::.. ........:.::.::.......:..:::::::...........:::.:...:.:::::::.. ...........:....:...:.:.::............ ,.._....._,......,... _,......... • :, A. .... ! ' 15 } Location Address Owner' e _ / ,r��✓� "`� eII Address 7 , Assessor's Map/Parcel: y v a / Engineer's Name V J, NEW CONSTRUCTION REPAIR Telephone# �C6 Land Use Slopes(%) %) Surface Stones OyOf�� Distances from: Open Water Body;+�M f ft Possible Wet Area U ft Drinking Water Well z ft Drainage Way /Sd ft Property Line �Z r f ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) a 3 ; 1 '0 i 7�-a f � O Parent material(geologic)����� . Depth to Bedrock U„ Depth to Groundwater: Standing Water in Hole: Weeping from Pit Faceyi e Estimated Seasonal High Groundwater 2. y�;� „ ...... �y Method Used: Depth Observed standing in obs.hole: /'y'Y in. Depth to soil mottles: nbNr— in. Depth to weeping from side of obs.hole: / in. Groundwater djustment` 2� ( ft. Index We�#,A, Reading Date C©L In Well level Adj.factor Adj.Groundwater Level y 'EItCL�TIDN TT n;rte T�m� Observation Hole# / Time at 9" Depth of Perc ,f �trl'!D!1'1) Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Q ii Rate Min./lnch Site Suitability Assessment: Site Passed 110" Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back------- Q:HEALTH/WP/PERCFORM :...;::..::.:::::.::...:::....:: . . Tt. ...::; TU .. .; ..................................................... Depth from Soil Horizon Soil Texture Soil Color , Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % i3" -3A"' io - G� Co ..ba T-C I�� Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % ........................:.............................................. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. %Gravel) . REF:OB. �RAT....:.: :............................................:...:.:..:::.;<..:::;:.::;:.... Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. oGravel) S_ Flood Insurance Rate Man• Above 500 year flood boundary No— Yes—Z, r Within 500 year boundary No_ Yes 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 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 consistent with the required train' a pertise and e p nee described in 310 CMR 15.0.17. Signature _ Date / /3 03 Town of Barnstable P# Department of Regulatory Services �FIME A Public Health Division Date 13 200 Main Street,Hyannis MA 02601 r BARNgrABL& - MASS. 039.r" � Date Scheduled d 1 Time JL.UO ^'7 Fee Pd. Soil Suitability Assessment for Sewage Disposal /'%G6. Witnessed Performed By:�7-��3t9r.� Y� ?;...,.. -:,..._.,..: 'd:.,..:_i�' ............ 41 j p_r(1 Location Address Owner sName ,�// v✓i Address Assessor's Map/Parcel: I y-7—o a a Engineer's Name NEW CONSTRUCTION REPAIR Telephone# �6 Land Use � j�7//`/L Slopes Surface Stones Distances from: Open Water Body --t-ft Possible Wet Area 6�t ft Drinking Water Well:� ft Drainage Way :7 /.Sd ft Property.Line 2 r f ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ZLK 3� <— e% ' D a ti _ _.. 7 oO w Parent material(geologic) %� Depth to Bedrock 176?�L Depth to Groundwater: Standing Water in Hole: /yQ" Weeping from Pit Face r Estimated Seasonal High Groundwater 2.to .. ......_............_...._............... ....._.......:........_......:..:.:::::.::u--+.an.::,.x:::...r.ne::....::::::.:r::::::c:m:nsm:....n::@`I:;!:ii!:FRIi!:il'r]::,;L::im: U. ASQ1 ,'HAT .... .. Method Used:Depth Observed standing in obs.hole: /'f r f in. Depth to soil mottles: ^,6n/E in. Depth to weeping from side of obs,hole: _ / 4't in. Groundwater Adjustment 4e, ft. Index We #�SL Reading Date�SG©L Index Well level Adj.facto Adj.Groundwater Levely .........:::. ......_........-. .. .... . .............._.........::_:: :_.::::::— ....._.......... ,.. r...:........:.•...• :......: ::.__:_:, •... Trti Date:,!"i:":a._ Time`;;::,?;: _�:nJ,,:l�'..: :.,4�!!!i ._ ... ..., Observation Hole# / Time at 9" Depth of Perc Time at 6" Start Pie-soak Time @ /.D' / Time(9"-6") End Pre-soak D tis Rate'Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- Q:HEALTH/WP/PERCFORM ..:., :.:. . ale..#::::::. :::.::..::.::..::..: ..::::::.:.::.::.�:: Depth from Soil Horizon Soil Texture Soil Color Soil_ Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency % !o s — t^_� mez> n Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Munsell) Molding (Structure,Stones,Boulderes. r . ::.;>;::;•xao;;r:::>::>:>:>:>::•>:: ............................ :,.::.»"::: i"i::.,.:.;,..:..:.. .,:..,:..:.:..:.:::i:":;f';`'S:.iii:i;:;i5;:;i;'•i 't!i''."`:h%... :`•?i i i iii i i G:r ii i isii isi?t i iiii i>i is S;; ? Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Am�a +oL :LOG.::. :::::::::::::.zo��.#:::..: ........................ ...:.......... oaas ..:..:....::..: .................... :: :.::.::::.:.::. :.:::::::: :::::::::....::: ......... . ...�,,::.::::. ..::..::... .:.... Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes: Flood Insurance Rate Man: Above 500 year flood boundary No— Yes r Within 500 year boundary. No_ Yes Within 100 year flood boundary No— Yes De kj� h 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 1 certify that on / /C (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required train a pertise and e p nce described in 310 CMR 15.017. Signature Date ,✓ !3 d3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIO_N FAILED INSPECTION Utc 0 4 2002 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 29 Captain Lumbert Lane -T, 16 Centerville, MA 02632 Owner's Name: Roy Lithwin Owner's Address: Same Date of Inspection: November 26, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 147 Osterville,MA 02655-0049 Parcel. 011 Telephone Number: (508)862-9400 Lot:23 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Need Further Evaluation by the Local Approving Authority ✓ Fail Inspector's Signature: Date: December 1, 2002 The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Captain Lumbert Lane Centerville, MA Owner: Roy Lithwin Date of Inspection: November 26, 2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Captain Lumbert Lane Centerville, MA Owner: Roy Lithwin Date of Inspection: November 26, 2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require f irther 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: _ or Cesspool privy is within 50 feet of a surface water P P �'Y Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Captain Lumbert Lane Centerville, M4 Owner: Roy Lithwin Date of Inspection: November 26, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board bf Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat,or.answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 29 Captain Lumbert Lane Centerville, M4 Owner: Roy Lithwin Date of Inspection: November 26, 2002 Check if the following have been done: You must indicate`yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 29 Captain Lumbert Lane Centerville, MA Owner: Roy Lithwin Date of Inspection: November 26, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in 2001 -per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Jun. 10183-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Captain Lumbert Lane Centerville, MA Owner: Roy Lithwin Date of Inspection: November 26, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 2' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present The liquid level was even with the outlet invert. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Captain Lumbert Lane Centerville, MA Owner: Roy Lithwin Date of Inspection: November 26, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: n/a (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Captain Lumbert Lane Centerville, AM Owner: Roy Lithwin Date of Inspection: November 26, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 4'x 6'-600 gal. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The pit was full The liquid level was above the inlet pipe and up to the cover. The pit was in failure. The cover was approximately 1 S"below grade CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 T Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Captain Lumbert Lane Centerville, AM Owner: Roy Lithwin Date of Inspection: November 26, 2002 Map: 147 Parcel: 011 Lot:23 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. TA I O a 3 � 3a 30 a3s� 3y 3 0 10 I } Page i l of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Captain Lumbert Lane Centerville, MA Owner: Roy Lithwin Date of Inspection: November 26, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 15 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 7'6" Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 15'+/-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties' or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCATION /U �C—er 1AA1L SEWAGE # VII,LAGE d2A DUX ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. L Oi-- 0�3 SEPTIC TANK CAPACITY law EA11 Fn INSPECTION LEACHING FACILITY: (type) A7— (size) db NO.OF BEDROOMS 3 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 leachi g facility) Feet Furnished by e an FOB !"1 L 1 O 3 / 3a 3o a 3 5r 3y 3 0 4 Fmc.... ®................. A THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ApplirFation for Uispoii al Vorkg Towi rurtion ramit Application is hereby made for a Permit to Construct (1,,j"or Repair ( ) an Individual Sewage Disposal System at: ...CA , 4ej:!.5 LC.N..C.......�..�►�`�-.............. ..•-------...----......----- • .............................................. ocauo ddress or t No. lap --.-- --�1�..... ........ .. :�1 4�Sf 1 ,C .......................................... iA dress •Installer Address Type of Building Size -------Sq. feet Dwelling—No. of Bedrooms.______________________________________Expansion Attic (yeK Garbage Grinder (,IJZ) ' p4 Other—Type of Building _I Qd ew..__..... No. of persons......_4-.•______-___•___- Showers (�Q — Cafeteria (AD) a' Other fixtures __________________________________ W Desi Flow............. ...................gallons per person per day. Total dailyflow_. gallons. WSeptic Tank—Liquid cap�st cit��''FF_ h_ _gallons Length._.. P....... Width.....�A....... Diameter-------� Depth................ x Disposal Trench—NO...N.OKC. Width.................... Total Length.................... Total leaching area_..,1.(A_y----sq. ft. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tan ( /w, aPercolation Test Results Performed by...__�......(Zi� .___Cnb,!.A1C ! _ ___ Date......_s .3......_.. 14 Test Pit No. 1................minutes per inch Depth of Pest Pit-------- Dept-h to ground water_____-_I- . ......... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •--•----•----i----..--•---•------••--••-----•-•----•••-----------------------------•-------•------....-••-----•••-••••--••--•-.................-•-•--•...... 0 Description of Soil--------- ---•--•_..._ ......`!".... ------------ V `��- 1D in!1 �Q; ...N�--------••. --•--------- 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 iITIE 5 of the State Sanitary Code— The undersigned further agrees not i place the system in operation until a Certificate of Compliance has been issued by the board of health. Q � ' ign � ate Application Approved By.. ••-- .......... �1,1'_.-....................... Date Application Disappro for e following redsons--------------------------------••-•------•-----------------•-----•-----•--------------•--•--••-••-------....---• ............................................................•............................................................................................................... ............................ Date PermitNo......................................................... Issued....................................................... Date FEs...1 a................ A THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 qw..0...................OF.......... .1�.IZ TA .................................... Appliratinn for Disposal Works Tonstrnrtiun Prrmit Application is hereby made for a Permit to Construct (VI"or Repair ( } an Individual Sewage Disposal System at: .. ? �: .L�:cnt ::9 •-L fmiv_C........ ' --------------- ........................................... .....- „- ocatioq-4ddress c or. t No. _ t t1 3 .C-±�{ fl J 1 •-----•-= •-•._j0� .,�.... ..................... .................................... �1`�`�ress a � °�.1.�.C•v:l.l. t:4.?:. .f._1.4 ...............•--•--•-• ... ..............•••-•-----•--•--•-•--•-•-- -•----•••-•_... Installer Address UType of Building Size LotA3.j3..LJ.......Sq. feet Dwelling—No. of Bedrooms......3----------------------------------Expansion Attic (t .}5 Garbage Grinder (A)4 Other—Type of Building --------- No. of persons........4'.............. Showers ( .) — Cafeteria (N4) a Q Other fixtures ------------------------------------------............................................................................................................. w Design Flow............... _S....................gallons per person peer day. Total daily flow..J.)....../..�.....................gallons. 1:4 Septic Tank—Liquid ca acitv.J.D......gallons Length....LP....... Width.....4P,__-__-- Diameter-------4P..... Depth................ Disposal Trench—No. _.�_0.N_ ".. Width.................... Total Length.................... Total leaching area----o�kl----sq. ft. Seepage Pit No--------------------- Diameter.........._......... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box (A Dosing tan ( _ J Percolation Test Results Performed by........ .� . :-: _._.: __''`-�!e1( tR Q A�j.__. Date_...._..s - �Av_,� V•' , cy Test Pit No. I................minutes per inch Depth of est Pit........ _______ Depth to ground water..__.__t ..__..____. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P ----------•-- ••-----•-•• •-•-...--•.......••--•--•----•--........-•-...--•--••-----------......................................................... O Description of Soil Q-""........................._�..._.... .. `.....� a_S-Z>i -----•----------------------------------------- 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 LITiE 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. ......................... + t �. .7 �r.. ...... ...4_.____ ----- ate Application Approved By t `:-------------------------------- ....-•--••••-•--•--- Date Application Disappro - f o e following reasons:................................................................................................................ .......-•-----•----•••-------------••---•••----••••-••••-----•-•-------•--•---•-•••••------•----•------.....-----------•----••-----••------••----•-----••--••••--••-•••--•-----------••--•••----......._. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ^1..................... oF........... .cA. L ............................... Currfif iratr of Tuntplianre TH14_I5._T0 CERTIFY at the Individual Sewage Disposal System constructed (4"or Repaired ( ) by......: 1. .._.... I�.i_ .��:�------••----•---•-•-•............. nstaller at............!-, D-�-•••...... ----------( - -31? 'j -----------------------------•--- has been installed in accordance with the provisions of TIT LE 5 of The State Sanitary Co cribed in the application for Disposal Works Construction Permit No...Y ""•71(1................ dated. ..................................... THE ISSU CE F THIS CERTIFICATE SHALT. NOT BE CONSTRUE S A GUARANTEE THAT THE SYSTEM W1 FUN TION SATISFACTORY. DATE._..._f?. .`� --••----3------•--•-•-••---•--••••--••-•----...---_•--• Inspector ----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - FEE........................ Disposal Works ONInstnution Prrmit t Permission is hereby granted.....���.................�':��!:`.::�*�._...... .__r__._..__ A__1.S L 4"r--•__---- to Construct (✓) or Rep it ( ) an Individtual Sewage Disposal System at No........ -C ..... - c3.vt!i _......1f!!_ir_4—-------------------------------------------------•--•------------- Street �� as shown on/thn.eapficati n for Disposal �t�orks Construction Perml N ...... :........... ated.._...:, ...........ate_. ._ .................•--.---••-_Board of Health DATE-----•-•- • ......-•--•-•••--•......... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 4 tY ' ' 1-1 F,� P'r A?l IME EXIS1t1,J6- WED \ I \ t� \t SeAT'c � J ,( r � ooa'C­ ' QW LOrT Gc� 'tJt(L,LuMEcET ,4\ CEA 10 i 10Iq uQLEQ r IIa ��ose I 10 TrJWtii vJn 1�.'P '�•r y b Jam_ J,_---•__"'` wu r p ° ' t &�3 l-.•L r LaT 2 00 M ri Li Li I � NOFAg . 7 p,5a .1ss9r 1 jZ' I �OE�EftD 18TE��o4 0 p suR�E` LEGEND EXISTING SPOT ELEVATION OxO vI May, ?�, CERTIFIED PLOT PLAN EXISTING CONTOUR 0 — ,�`�� s,� Lvy -3 C>-1 r,1'.. I!: & FINISHED SPOT ELEVATION ART, FINISHED CONTOUR 0 a n p - No,1U951 N IN • APPROVED , BOARD OF HEALTH �F .,sTEa A p)) 5 "f • 1 8 AJ A t OATS A'©ENT;:: DATE ' SCALE� / ' =° 4 0 �- `• L.DREDGE,ENGINEERING COIN SAY oE - CLIENT I CERTIFY THAT THE PROPOSED f QISTERE RGISTENED JOB NO. �'!z '3 BUILDING SHOWN ON THIS PLAN CIVIL, LAND �• CONFORMS TO THE ZONING- LAWS N©INFER R EY0 OR.BY+ OF BARN5T�48L E ► 'MASS. 11'2 MAI N STRI~Et CH.'®Yl �J-- ' HYANN1S, MASS. . � 3 - �----- i;'; SHEtT:.... OF. DATE LAND SURVEYOR /YpTE /F EITHER T//E.S EPT/C TANK OR 20 FT. MIN. iE,4C.�//NG P/T AR,6 MORE T�dA:^/ /2"EEtOK/ _ ,. /D �T /►9/N. - 1RAOE� f� 24'D/AM ETt�R C'OiyCRETE COYE.�P SXALL ®E B ?OUGNT TO 1:7/;AOE.6f+N EXTRA — COq/GRETL° q"PYC P/PC t,+EAY y CAST IRON C o NER $/�+,Q L L 13E U S E-0 P/TCN IF/N DR/VEK/A Y covERs yB F,P FT s• CONCRETE _ 2 9 W,N. " •: GRADE CdVER CLEAN .SAND eACK�ILL. 1�• ___ Uri//�LEYEL . . _ _ .�.s.. : . - (� ;; 2�LAYER 4"CAST� _ IRON P/Pg / o:v .�. , •e GrtL. • • •. . . . . . o WA sHFo sTnn/YC b .MIN..P/TGl1 D/ST. • • • • s • • • a ��'pErs PT SEPTIC TA/YfC ®ox ' ' • • t • t •, e ° .'o •+ n • 1 • / , • ° o • DEPTt/ ° ® • ° o ® l�i�.45,YAFD STONE 7 = .. • p ' PR- 457 SEEPAGE E. MA-C WrQ L= 93.2 - /J 3. e • s s t • s • • D • v _-'fAIV&A" ►' ELEVA774ONS T/T.C�na cl"r yAso at 6 p=T. DlA/69. /�YERT AT OUILD/NG I Ca O/.�11+9. C(5 FS'PW4,1 4TJON, IAtLE-r .WP7/C T.4NK ke- �416H OCJTLET SEPTIC rANK iOf.B -FT, IGP�sva.►� MAX G,Qoc1ND btG4TER TABLE EL= 13.2 \ W rP-C,0AAP5 1AIU T D/3Ti4>40uTiDM BOX �L�_ .SECT/ON OF OtJTLETD/STR/BtrT/ON BOX101.4_Fp SEWA0,6 O/SI®CaSA L .�Y•S7',ff, 1 _T�V4R7 LEACHING PIT 10 .lL° FT, L�ACN1N�s Ia/T 7"A�tJ1.ATlo v SCAtE %qr _ / - o D//►iENS/ON A �- FT D,E'3/GA' CRITERIA D/�v.�n/s/o w —�-fT• /t/1/I�1dER OF BEDRaOMS 3 D/MEl1/.•e/O//1/ Ci �" F���N C%IARe eG,ED/SPOsAL uv,r �ro�rE SOIL_ LOG S OI.A. Tg.1T r07AL EsrlAlA7'w FLos�V 3 3 GAL.IDAY SOIL TEST �#/ SOIL TEST 2 NUMBER. OF [EACNING p/r.5_I E��y, 1va AM Awl DATE OF SOIL TEST SIDE L,CACH/NG PBR P/T S 1 SC•t /=T. �- / RESULTS iV/TNE.SSED BY cJ•R,E- .G��FoR P f'CI�CQLAT/Ol1° AA / L�� All" /NCH B07TOM L,�ICN/NG PER P/T // 3 So. FT. L.o / PERCOL/A7'/aN RATE/*2 Z y M/N.�INGfi TorAL LEACH/NG.AREA Z �' `� SQ. FT. ?-v/'sv.r- r Q6sFRVELEAG'f//N6AREA Z� `� SQ. FT. '%j Of At 5�ht s,` �e — 2EL- 93.2� AL `1?T HrnrEQ caaPs - y EL-DRE,�aEENG/NRi�G e®,llVc. i U o.1095i�O�Q 7/2 MA/lY STsu . , HYANN/S, MASs, FSS�oNA1.F-a Q NO GR0f1NJ yv�4TCaR OWC'OUNT 9S. 3 CL/eE/V)'; Sf+r �RTE DaGROUND LvA TE.P A7- EL_E(/ ✓C►B N®: Ff/2 2 3 SHEET�OF 3 �k lR FIIL�N GQac�uD v1f�`IEQ C[7AAPS �- Permi t. Nun1)cr: Da c: Completed by HIGH GROUND-WATER LEVEL "COMPUTATION Site Location:__ 1� Lot No. �• Owner Address: G - Qy� i titf}S__ •cam, �/L4,a Contractor: 7OVS A41.ciVE Address: Notes: STEP 1 Measure depth- to water table f 10 , O� to nearest 1/10 ft. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .5/19 /821 � date STEP 2 Using Water-Level Range Zone . and Index Well Map locate site and determine: . `A) Appropriate index well . . . . . . . . � 3Q B) Water-level range zone . . . . . . C STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well 3/81 L mo yr ` STEP 4 Using Table of Water-level Adjustrnen.ts for index well STEP 2 AT, current d&pth to water level for index well , (STEP. 3)., and water-level zone (STEP 2B) determine water-level adjustment . . . . . . : . . . . . : . . : . . : . . . �— J . . . . . STEP 5 Estinate depth to high water' by subtracting the water- level adjustment (STEP 4) from measured depth to water level at sito _(STEP l ) . . . . MA-(I, 4 18 3 LO CAT IO SEWAGE PERMIT NO. . 2 y V-F LLAGE L LL& IN TA L AtR'S, NAME ADDRESS t UILDE R •R OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED � r f �� !pyt�l� 4 _ y � I i�0" �) 1 4�r�.< �� L®��-� ��/�� s r�`�-�� cn t LOCATION SEIM GE PERMIT NO. ck c VILLAGE INS A LLER'S NAIVE D ADDRESS G U I L D E R OR OWNER D.A T E P ERM IT ISSN E D -�- �-30-82 NATE CO-MLPLIANCE ISSUED �.�� �cf � �,��` i r � I� `��, � c0 �.. w v �t. No....d! Yd;?_ r Fxs, `3'f........-•..--- �` tt THE 5OMtv101€VrtALTH OF MASSACHUSETTS �- BOAR® QF HEALTH ..............��-- OF........ .... . ....................................... Appliration for Bispviiaal 10orkii Tnnitrnrtion Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal SyeWmat 1�Q......_..._..'..`_........ - . �o Ad ss .............•••�;l! . z -------or t �� - o • •------------. - -• ------- ------- -------------------- a -- �' -. -.... Owne A ' AS. _.� Se ........---•-•-•--•----------........ Installer Address �``/ Type of Building Size Lot..f . ,1_�7S.._..Sq. feet U Dwelling—No. of Bedrooms___-•..............................Expansi Attic Wo Garbage Grinder pa., Other—Type of Building ............................ No. of persons.... .................... Showers (j,. — Cafeteria ( ) Q' Other fixtures . ..... W Design Flow................ .._ ..._.____ allons per person per day. Total daily flow....._.. g g P P P Y Y �3�1.----•-------------•--melons. WSeptic Tank—Liquid capacit .6W.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. Other Distribution box ( ) Dosing tank ( ) / aPercolation Test Results Performedby.__._.. _ ... ...�� .:........................ Date. ..l- �.......... Test Pit No. 1 _Z......minutes per inch Depth of Test P . ............. Depth to ground waterA/01✓IE__----•--- (a Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---____-___•.-_--_.-_--. r ..... ------------ - •-----------------------------------------Soil..... Jxl --------------------------------------------------------------------------------------- ....................-----••---••----•-----------••----•-•--•--......-•---------- ------. -- . ......-----•......----•-----_.. UNature of Repairs tera io s '/ applicable............. . . ..... . -------------------------------------- 1 � �✓ -.........--•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT Ls 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by t board of health. Sig - ---.......J--------- ----------------•--•--••----•---•--•-•• 3G---�••-- Date Application Approved By............... _../fir.. ... --•••--•--------••--•----•-- -•------............................... Date Application Disapproved for the following reasons-------------------------•----------•----•-••--•--...------------••-•------------------•--------•----•--•--•--••- -----------••••---•••-••--•---•-•••-•---•--•--•••----•••---------------•-•-•-----------.....-••--•-••-••.•-•------•-----•--.._._.._.....•--...-•--••••••-•••••--•••---•••---••-•••--------•-----•---•--- Date PermitNo......................................................... Issued....................................................... Date No...-6.Z_:20"). Fps.....3J............... THE COMMON(NIALTH OF MASSACHUSETTS .- BOARD QF HEALTH a .........OF....... J.��rrt.�l•1.� . 1............... .........----.-----....................................... . pptiratiun for Uhipasal Workii Tonutrurtion ramit Application is hereby made for a Permit to Construct (oo ) or Repair ( } an Individual Sewage Disposal System at: rX t t 1. ........ .._. — .... ..................................... ................ .................................p Location-'Addy` j- ............. J° „I fr or I of No / ................. ..................................................... . ....�.• i .. i'......... G+�:w W ¢ r Owner Address ' �• `^ ) �� .1.41:.G ' r l ifs 7 a --------------------------- •-•----- --- .... _..---------- ....................... • Installer Address �• UQ1 a .. Type of Building Size Lot._s ...___________ _____Sq. feet �-, Dwelling—No. of Bedrooms....... ..................................Expansion Attic �"V? Garbage Grinder (4�,6 Other—Type of Building _____------_----•.-____•-• .No. of persons......(..'.................... Showers Cafeteria ( ) Otherfixtures -.. --------------------------------------•---••••••------•--•-•-••-•--------•-•---- - �f WDesign Flow................:.'..:....___._____..__gallons per person per day. Total daily flow_--_____-_:---.---f_--------.-------._-•_--.gallons. WSeptic Tank—Liquid capacity.E :.,-'`_.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft. z Other Distribution box ( ) Dosing tankf( ) aPercolation Test Results Performed by............................................:�-- ....._.. Date_._.._.......-e....................... Test Pit No. 1.``_ ......minutes per inch Depth of Test Pit___ _ __..__ Depth to ground waterY­T......... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a f - ---------- •-------- ••-------------- •------------- •---•--------- x Description of Soil...... f ti }. s ? 1 --•--------------------•---------------------------------------._...••---- U --•••-•-•--•-----•----••-••-•-••-•-•-•. ............................ } �' W x -•••-•--•-•-----------------------•••-••----•-••............--...---•----•--- ••--•-•-••--•--------•----••-•---••--------------•----•-••----•••----••••••-••-----•-•-•-•-•-•••......---•--......._-•_••- U 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.11ndersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued bhe board of health. f h Signed...................................... =- -----------•------------------------- ............ .--.............. . Application Approved B Date PP PP Y x-- /+?... .......---•------------- --------------------------------------- Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------•-••-••...._...._ .-•----------•----- ----------------------..---------------------------------------------------------------------•-•-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH � f r� Currtifirtt#r of Tautplitanrr THIS IS TO CERTIFY, That he Individual�wZge Disposal System constructed (ate<or Repaired ( ) by•-•-••--. E M__ Z__.� ....................... ' t-_L _ : .._. .. ✓ / Installer ,�` •�•- .......................................................................................... 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_____________ ?.10 ............. dated---------------.--------------.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A� A GUARANTEE THAT THE SYSTEM WILL FUNCTION SAT)SFACTORY. DATE. _��rc�._.. Inspector...... : ................................-.......... , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE L H, I Ca: OF �;nff ., ..... Lc__ FEE f �,...� .................................. No. ........ .... .............•••-....... Mapaual Nab Tonstnuiion randt Permission is hereby granted......... _ '- --------- ----�" ------------------------------------•--•-•••-•.--------•--------- to Construct( �) or Repair (-„ ) an Individual Sewage Disposal System ,#f / ar 1'f j t _ Street as shown on the application for Disposal Works Construction Permit No.__-__-____--_____=Dated.......................................... Q / 'Boar DATE------------------••----V�Zl- d of Health �--•- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS L o c vS /'� ,X> a 29 CAT•4��Y,> -�`'.liyHe Z , pc - /� P��� Rom,=C���•�� .���.✓�- .ry�c.wr✓ys car�'S23 �.v.�c ��i.✓ ''�'3�-9 - ,;, •hoc P 3z, FtF'Gc�.,:-<: •y; 8 �'�J. -G�.�..� Cov.�; AST/n/c= Cc.,/ x>caa B�Kr/.� _�3S".Z�' j9 _ Gw✓.�r,/s:ce -yz-- -Lc'�i�I�.✓% - �,G - (.psi.✓G ��Lc � `� oc'- Cu��c'E�� W9i �Z LF✓EL 4 7- 97.d I'-nV-1. f Yami 3 AEA- T/ter✓.t ti�F 3��.r=� p.✓ ,gssv,»�,� : 9i vM /moo G94- EEP'rap D c �un/J CBSEVA �" x, 7�5- _-4 Dr / /cam y 3 ✓¢„ ter, ,f/ ry \ I 0 jI �- /�E.Sf✓s .> c IJcPTy,�S' SSG+ Soi(. �-4iL VOID 07 ti• Iia�,� Tix�r.K 0 9LC Si )L, j - - --—---t-- _ +----- - -- ---- __ ...--- ------ - -- \� a ��,:i i�7:� � - � � -/� +��F/Ca ��✓�Y�i"� `/Gy�S�lo — � �y/ ' TC .LAC,'/�'� !�- r�FX'C ,�� ------• /��� � l� � L•s-fr�,3 r',.! �, r i .� -� i C �fcr:��F�H✓C�/G '�S��i — .t � .!L�/i✓� i I / •.�J < 8 /y� tis Y y c�u.✓a wl,7eAC- - ✓�.�v%s�e�4 Ca' W -� TOP OF rOUN02 1,..N 4"CAST IRON 9'� j '" _ _ - �.✓i.�� �r�Q�9;,�f = 1 - OR SCHEDULE 40 �'� . P.VC. ?lPE MIN- 4"SCH=DULE 40 P-V.C. (ONLY) 9"MIN LEACHING TRENCH (/ )RED. ?ITCH I/4 PF[ PIPE- MIN- "- 1/2" WASHED STONE 1 I PITCH 1/4"Pc .:i. INIVERT GAS M.. •,' =L—Z;��:u,L.A�� I,Af i3BG/A�ZF JF..L;GE-AtiL_. INvf.�`r�L!TSEPTIC TANK ' Al 3 i.N V1.E7,' a :�' INVERT / $ INVERT DIST, - 'N BOX �, � 3/�4.'-I/�2"--/ �6RusHED sroyE Jt 9 INFILTRATOR WASHED SSE _ •�,i •. C I r �.S10 I r 9 ,V BER T L A, E �- _R _7 r SEWAGE DISPOSAL °t'"D *- -_ E�rs.o�• \\\ SOIL LOG SYS►Eiti1 CFNTERVILLF /V 4 SAT=4 4�,t �4�'?�. TI t�- ,o:ate - N SC AL o I_�I HOL I TEST ST ROL 2 . . . DESIGN DA71 A : _T r. FC 1 �~ S . . . . . . . . . . - . _ LC/3�r+-/ TvT.�L :S i Ih'.:. -_D _OW .�.5 . .. rw2 GALLONS/D Y '�"� - G,r B=OM LE 'I ?=A Y .."l � .. SO.:%/ . t I-_Z�=N rr� C�/ Y V& E ,%tD -\/ L I T, lV Y I1 N l COA S9�i�,w SIDE L=^_-41NG A?_A . . . 34 C:Y: y7 _ =� .�:cv✓c u:a:AGE DISPCSAL . . . ./YQ ..(SO 0% ^PEA INC.'.=AS'Z TOTAL L=;+Cn',,iG AR:ZA .��•lo �. S.._- I E� CEsq �SA�L3 ?_RCOL^71UN RATE . .4�!`?:-✓��; =R. INC:-i �C�LE / _ �U Sf�r✓U�I.gY /O Z003 LEACXING AREA ?_R PE:RCOLATiON - I k GROUND WATER TABLE EL2,{ I OF WITNESSED BY :.�_tiT c� Ir,s�=�,sa R ✓ _BEY " . � i ::.1i;4 30.^RO OF S=AL H 26100 Q�:F" ✓/L�fp /�"�/J �/}� // -' j ,'' �FGtS1i�'4� , .. . !r .Q �•./19 � rNGINE=R Q � z � 1 N . r ya -. ._. -.. ,. .,,..-.. ....._...._.__._._,_ .... .._..._. __._.. .-._-.�. _.....� _.. � ..-.......+.., .w... ,--w,+++Nfw-..n.. •s..+,sc a. a, m .., :.., _.,.+ ,-r.. ,. ..-. ..... _s- +..r www:r..-+,.�l...re....w.m..:.4 w�ifw..:w.n.+w' 'r �', `.. �- ^�'-- ♦ ..,v+4W:4w�NAY.•✓rW+_'i,�.PLla.'W'SeV`YV^'4:,rw-,a. .� . ,y»+. �� w.r,•.avaa HR.rw+.,� ,. :Mlh�. �. , �f -..�-,__�..i__�._.�.__.�....._..__....._........_._._-_• -_.. .__._... ,... .. .. -._. .. - ._ _ � x MbW }n. ✓s+uMF+w.S+KaI*wM,wwtl6dv,.+..-: .. �� �� j L z } /{.� ,-• p ��SI T, t�"ul Fi,-F,vA 1°cx.j� Trr� r'h'4 4 14_%L� t CIE r-1'wi A i"lt ,l 1' r 147 4 t 1 4 Jr.PV r 4. 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Q: 1 U .` .La1, M©►.,J V M EFl-.lam i._1UM&E iL V / B 2 .n'• � �p 8C."�'!?:. _ ✓ 1:Jt�7��r^`y'...�'/e`s�'•� t' '`7 p` �r, I Al� � ,_.. , - >~.T,�`-•x�. . ,f : . 3. .,_.t,�_./�>.,..�., ,�,.,� -r1�',.> > �t �c r� 7�'.�r 1��.. . :.j"'�:%l i� ._,.. f s r• d v A .,, r-d_-k';_r;A: A f F.h .f',•., .` -. `_,.. - - .. tr' '9 .'r l,•dE'r?:''"'.- e _ ,r,; ?,.., �;�'�'!- 1' if* �{ ,, �-4 I/..,( L.=t_.." .. . , . ., _. �,>•. / � ; _ ? ram',�'. i �i�•i l - t E &,i,-J 1 t..!u r _ 4 cad 'T r14. ,:y,�.'r)u:l:'r.�' d'tfF:-7'�./• PJr >, r 7'« .'- � ��'it � j �, 2i _r - .f[«.' ✓iN[.� I'V`O( F j�--� f`'i .. F� 4 � +.�_ {=� -\