HomeMy WebLinkAbout0047 CENTERVILLE AVENUE - Health 47 Centerville Avenue
Centerville P
A = 226 116
No.42101/3 ORI
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Commonwealth of Massachusetts L
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M SV•��
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
�G
Important:
When filling out 1. Property Information:
forms on the
computer,use 47 Centerville Avenue - Centerville, MA
only the tab key Property Address
to move your Thomas and Ellyn DiRienzo
cursor-do not Owner's Name
use the return
key. 37 Acorn Place
Owner's Address
VQ Franklin MA 02038
City/Town State Zip Code
, Date of Inspection: May 8, 2006Date
2. Inspector:
David D. Coughanowr, R.S.
Name of Inspector
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364 0894' _
Telephone Number
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this address Ind that--the
information reported below is true, accurate and complete as of the time of the inspection. ThOnspection
was performed based on my training and experience in the proper function and main enancelof on sl e
sewage disposal systems. I am a DEP approved system inspector pursuant to Se�tion 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
KI Need,�Furthe Evaluatio by the Local Approving Authority
S May 8, 2006
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.
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Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'G^M
A. Certification (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
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:
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Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
A. Certification (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
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
❑ 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:
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
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Page 3of16
Commonwealth of Massachusetts _
Title 5 Official Inspection Form
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
A. Certification (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (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
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:
I
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Page 4 of 16
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'GSM
A. Certification (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
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 '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified _
laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered. A copy of
the analysis must be attached to this form.]
Yes No
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
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Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
A. Certification (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form _
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
B. Checklist
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
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, including 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(3)(b)]
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Page 7 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
47 Centerville Avenue
Property Address _
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection .
Residential Flow Conditions:
Number of bedrooms (design): n1a Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan
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 ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 25 gpd
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 1 week agoDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other (describe):
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Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
C. System Information (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
CityFrown State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information:
owner
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 bex, 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:
Age: 16 years. Certificate of Compliance issued 511189(Board of Health Permit#89-104)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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Page 9of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
C. System Information (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 3feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer appears structurally sound with no evidence of backup or leakage into dwelling
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 11.5 ft x 5 ft x 5 ft(1500 gallon)
Sludge depth: 4 inches
Distance from top of sludge to bottom of outlet tee or baffle Winches
Scum thickness 1 inch
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined? Previous inspection report
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Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
M Subsurface Sewage Disposal System Form
C. System Information cont.
Y (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
•-
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
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Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
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.):
Distribution Box (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(locate on site,plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
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Page 12 of 16
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'LAM
C. System Information (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1
❑ leaching chambers number:
® leaching galleries number:
1
❑ 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.):
Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils.
No standing effluent was observed to a depth of 2 feet below the top of the leaching gallery
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Page 13 of 16
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
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.):
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Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
C. System Information (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
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.
LOCATIONS
A B
LEACHING GALLERY LEACH 1 25 FL 11.5 F E
PIT 2 29.5 f E 13.5 f E
3 33.5 FE 1B FL
2
SEPTICa
TANK a "
A
EXISTING
DWELLING
# 47
W
_Z
J
W
H
G
3
CENTERVILL_E AVENUE NOT TO SCALE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
47 Centerville Avenue
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas and Ellyn DiRienzo May 8, 2006
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: 15 feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
Barnstable GIS information
You must describe how you established the high ground water elevation:
Barnstable GIS department records indicate property is 15 feet above groundwater table.
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1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE'OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
�y
bQ
350 MAW STREET
WEST YARMOUTH,MA
Lz&MFXZO 508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME TS RECEIVE®
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION MAY 2 12002
MAP 226 PAR 116
Property Address: 47 CENTERVILLE AVENUE TOWN OF BARNSTABLE
CENTERVILLE,MA 02632 HEALTH DEPT.
Owner's Name: GIANNETTI,TONY ZZ.�
Owner's Address: 47 CENTERVILLE AVENUE iAAP
CENTERVILLE.MA 02632 PARCEL = d
Date of Inspection MAY 3,2002
� -
Name of Inspector:(please print) JAMES D.SEARS LOT
Company Name: A&B Canco
Mailing Address: 350 Main Street West Yarmouth,MA 02673 (:� /'L 4(DZ-
Telephone Number: 508-775-2800
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: h z 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 tot
he 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 1
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
_ 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: N/A
_ 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 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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
C. Further Evaluation is Required by the Board of Health: N/A
_ 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 CNIR 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 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 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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in galley is less than 6"below invert or available volume is less than'/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
X Any portion of a cesspool or privy is within a Zone I of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (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 or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. 1 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: N/A
To be considered a large system the system must service 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 11 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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X 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
X 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)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X 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)] '
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms: 330
Number of current residents: _ 3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2000 95,000/2001 102,000
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
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
X Septic tank,soil absorption system
Single cesspool
X Overflow cesspool
Pri vy
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 copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
BUILDING SEWER(locate on site plan): N/A
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 onsite plan): X
Depth below grade: 21"
Material of construction: X 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: 1,000 GALLON
Sludge depth: 4"
Distance from top of sludge to the bottom of outlet tee or baffle: 21"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 26"
How were dimensions determined: ASBUILT AND TAPE
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 AT WORKING LEVEL.TANK AND INLET COVER 21"BELOW GRADE.OUTLET COVER 10"
BELOW GRADE.ONE INLET TEE,OUTLET TEE.NO SIGN OF OVERLOADING SEEN IN TANK.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete a metal fiberglass e 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.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
TIGHT or HOLDING TANK: N/A (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: N/A (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.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632 _
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
X leaching galleries,number 3
leaching trenches,number,length
leaching fields,number,dimensions:
X overflow cesspool,number: 1
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 IS THREE GALLEYS AND ONE CESSPOOL.GALLEYS ARE 3' BELOW GRADE.COVER AT
18". 18"WATER,NO HIGH STAIN LINE.CESSPOOL 5' COVER AT 2', I' WATER.
CESSPOOLS: N/A (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: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
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.
��
W�
z�k
5.3
lot
Title 5 Inspection Form 6/15/2000 10
Page 1 1 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 CENTERVILLE AVENUE
CENTERVILLE,MA 02632
Owner: GIANNETTI,TONY
Date of Inspection: MAY 3,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 16.3 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:
Observation site(abutting property/observation hole within 150 feet of SAS)
X 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:
BARNSTABLE BOARD OF HEALTH GIS MAP.
Title 5 Inspection Form 6/15/2000 11
B TOWN OF BARNSTABLE p
,P.00ATION- 7 7 SEWAGE #
VILLAGE C£/_T ASSESSOR'S MAP& LOT 6 �d
ll N��£crb4�c
R4TAJ=L£ 'S NAME&PHONE NO. & 166 ej4'1✓Ca ,Sae 9 9t' 7--e"
SEPTIC TANK CAPACITY ..�� �� /N�®f C
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
A,11,Cf C
P)✓RMTT DATE: LIANCE DATE.-
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
j
„ 3r
64
�s
r
�m
O
DATE: 7/8/97
- 9
PROPERTY ADDRESS: 4.7 Cc-rrt-ervil•le Av.e % d0
s"�' a-nspart— RECEIVE
Mass .
J U L. 2 1 1997 W
TOWN OF BARNSTABLE
HEALTH DEPT
On the above date, I Inspected the septic system at the a �e addres�s��
This system consists of the following:
1 . 1 -1500 gallon septic tank.
2. 3-gallies
3 . 1 -61x6l block cesspool.
Based bn my Ineraction, I cerl.Ify the following conditions:
This is a title five septic . system.- ( 78 Code )
The septic systemis in proper working order.
at the present time .
SIGNATURYF: f0
Name J P Macomber Jr...
-- -------
Company J^ P_Macomber &- Son•_Inc
Address _ 8eac-b6------- -- -
Cente rvi1Le LMass__02632
Phone:___548.�Z7S-�338______- - t
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
•
JOSEPH P. MACOMBER. & SON, INC.
Tanks-C*s4pools-Laachflelds
. Pump+d & Installed
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
775-33M 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE HINTER STREET. BOSTON, MA 02108 617.292.5500
N ILLIANi F ti ELD TRl Dl'CO\E
Governor Sccrc Lan
ARGEO PAUL CELLUCCI DAVID B STRUIrtS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: Address`of Owner:
Date of Inspection: (If different)
Name of Inspector: _Joseph P. Macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Joseph P. Macomber & Son. Inc .
Mailing Address: � een erville_ . Ma . 02632-0066
Telephone Number:508 '7g>—T 38
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date: 7—
The System Inspecto all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
_j,ZI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B) SYSTEM CONDITIONALLY PASSES:
L One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yesjlo, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revimad 04/25/97) Day• 1 of 10
DEP on the World Wide Web: httpJtwww.magnel.state.ma.uydep
Printed on RecycJed Paper
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
Zbtt Sewage backup or breakout or high static water level observed in theCdbution bo is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The sywill pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
d)Q Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
�JQ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
AM The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
/L The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
1 CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DI SYSTEM FAILS:
You must indicate ewer "Yes" or "No" as to each of the following:
14)0 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CN1R 15,303. The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cornea
the failure.
Yes h'�
Backup of sewage into facility or system component due to an 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.
&d/bIL— Static liquid level in the istribution box bove 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes ,N,oA
VZ the system is within 400 feet of a surface drinking water supply
. 0 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Day• 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and'the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,�luding the-Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
— The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (t 5.302(3)(b)J
(revised 04/25/97) Pegs 4 of 10
i ^
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:�g.p.d./bedroom for S.A.S.
Number of bedr0oms:�
Number of current residents:
Garbage grinder (yes or no):
Laundry connected to systein (yes or no);�
Seasonal use (yes or no). ho ,�} p
water meter readings, if available (last two (2) year usage (gpd): ' 6�1 Qr�6'l � J
Sump Pump (yes or no):-920 1 ti f��a'
Last date of occupancy._1V'd_
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: AJI xallons/day
Grease trap present: (yes or no&-4
industrial Waste Holding Tank present: (yes or no)"/
Non sanitary waste discharged to the Title 5 system: (yes or no)-,&y7
Water meter readings, if available:
44
Last date of occupancy: V
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RE RDS and source of in ormation:
System pumped as pan of inspection: (yes or no)�L)
If yes, volume pumped: gallons
Reason for pumping:
;;��Single
SYSTEM
Septic tank/d«str+botiorr box/soiI absorption system
cesspool
/ Overflow cesspool
X,)P Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
1/A Technology etc. Copy of up to date contract?
Other
APYOXIMA E E of 011 compon Is, date instalied (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) _
(rwi..d 04/25/97) page 5 of 10
TOWN OF BARNSTABLE
LOCATION 4—'77 �� T-e—vAf ll�E EWA�Y7�
VILLAGE /��' Q��t ASSESSOR'S MAP & LOT
J. CRAIG MEDEIROS ���
INSTALLER'S NAME & PHONE NO. 78 LINDFN S"n
SEPTIC TANK CAPACITY �A)VNIS, MA 0260f 71S'-o 6y
LEA CHIN:(, FACILITY:(type) (size)
NO. OF BEDROOMS � PRIVATE W1;I.L UR�P,UIILIC WA1'O_
EkUr=9-R-4QLR. OWNER_ ,� 2) v! !�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED_
VAR.I.ANCE GRANTED: Yes No 1/
x
3l y�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron 00 PVC _ other (explain)
Distance from private water supply well or suction line
Diameter
Com ents: (condition of I rots, venting, evi ence of leakage, tc.) sue, 1
u �Z
SEPTIC TANK:,ZRd 9.,Wdws
(locate on site plan)
Depth below grader
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age 4W— Is age confirmed by Certificate of Compliance j0*(Yes/No)
Dimensions: l"�[(o ��X:�3 6r '?�[1li�G 6�Z»
Sludge depth: ! ct
Distance from top of Judge to bottom of outlet tee or baffle
Scum thickness:��
Distance from top of scum to top of outlet tee or baffle e—
Distance from bottom of scum to botto of outlet tee r baffle: P
How dimensions were determined:
Comments:
(recommendation for pumping, condi Kin of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inven, structural
integriry, evidence of le kage, etc.)
16 L~ 7 r
GREASE TRAP:—d2"� '
(locate on site plan)
Depth below grader
Material of construct ion;�)Aconcrete4A etal.fiberglass AVA Polyethylene24other(explain)
Dimensions: AA
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 11)4 1.6
Distance from bottom of sc m to bottom of outlet tee or baffle: '
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
-aAse Ti- n is our T
(revised O4/25/97) Paq• 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: 40Ue-Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grader
Material of construction:t),4concretetj&etal4gFiberglasstL Polyethylene4,Aother(explain)
Dimensions: d),4
Capacity: 4L gallons
Design flow: gallons/day
Alarm level: Alarm in working order/4 6 Yes; jjNo
Date of previous pumping: _fiL14
Comments.
(condition of inlet tee,,-Bson,di}}ion of (arm and float switches, etc.)
'��flT B r /t� S j9/'B tiDT ®/ '�'P��T'
DISTRIBUTION BOX:A-lQvll?
(locate on site plan)
Depth of liquid level above outlet invert:��
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
1 Try X /S ya /t'?Cd rV7—
PUMP CHAMBER:.A LWlp
(locate on site plan)
Pumps in working order: (Yes or No),,&4
Alarms in working order (Yes or No)�jf
Comments:
(not Condition of pump ch tuber, condition of pumps a d appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dime sions: in
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegeta ion, etc),
of
CESSPOOLS:
(locate on site plan)
Number and configuration: r
Depth-top of liquid to inlet vert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater: end
inflow (cesspool must be pumped as part of inspection) .4,719-
Comments:
(note conditi n of soil, signs of ydraulic failure, level of ponding, condition of vegetation, etc.)
r �
PRIVYA:�V'e,
(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.)
(rwlsad 04/25/97) Pag• 8 of 10
I
L�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propeny Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
f.� 0 C4 s
0
X
(r.vi..d 0i/25/91) ➢age 9 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
rr
Depth to Groundwater l� Feet
Please. indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
-zObservanon of Site (Abutting property, observation hole, basement sump etc.)
_J,/Determine it from local conditions
Check with local Board of health
Check FEMA Maps
—/Check pumping records
heck local excavators, installers
Use USGS Data
Describe in your own words how- you established the High Groundwater Elevation. (Must be completed)
Shot elevation in relation to Red Lilly Pond.
(revised 04/25/97) Page 10 of 10
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TOWN OF Barnstable BOARD OF 11EALT11
SUIISUI(FACF SEWAGE I)ISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
—TYPE OR PRINT CIX ARLY—
PROPERTY INSPECTED
STREET ADDRESS 47 Centerville ,Ave West Hyannisport ,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Patrician M. Huff
PART D - CERTIFICATION 1
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAME Joseph P. Macomber & 'Eon , Inc .
COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066
S t r e v t Town or City State t I P
COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa-1 system at
this address and that the information reported is true , accurate , and
complete as of the time of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check o
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or Llle environment as defined in 310 CMR 15 , 303 , Any fail(Ire
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED* \
The inspection which I have cona-ucted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature i Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF II EALI')I .
It the inspection FAILED, the owner or"oPa rator shall Up
grade pgrade the eyotem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CPIR 15 . 305 ,
partd . doc
W
(n Z7
7 I�i
y
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIERONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided M 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws_ Issued by The Department of Environmental Protection_
Junc 8, I995
Acung Dirccior of the on of Watcr Pollution Control
� (7 Fps....:$.....2 0.0 0
N&D...1------__. ....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town OF.............Barnstable
..............................
Applicatiou for Uispoii al Works Ton.6trurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (gX)c an Individual Sewage Disposal
System at:
47 Centerville Ave: Il�annis
_. ---- --- . ---------------------------------------------•----•---•----....------------..._..------......---•-
Location-Address or Lot No.
David Huff
......................_.......................................................................... --•.......-----.......----......_..-•--•--•...._.....--•---•-----..._...........................--
Owner Address
J.P.Macomber Jr .
Installer Address
QType of Building Size Lot------_.....................Sq. feet
U Dwellings No. of Bedrooms..........3................................Expansion Attic ( ) Garbage Grinder ( )
4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Pa Other fixtures --------------•-••------•---•-•- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
fY4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date-------------------•--------------------
,.1 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---------____________--.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-___-____-__.______-_.
a •----•----------------------•-•-•-----••------•------------------•--------------•-•---•••-•--•-•.............................................................
Descriptionof Soil Sand................•---.._..----------------------------------------------------•--------------------------------------
x
V ---••-••-•--•••--••--------••-•••-••-••---••---••---•-----••••----•-----------------•----•-•-•---•----------•-•--•---------------------------•------••......--•••-----------------------------------•--
W ---------------------------------------------------------------------------------------------•------••-•----••-•---•••-----••-•-------••---•--•--••-•----•-•-•--••---•-•--••-•-------•......------•-•--
UNature of Repairs or Alterations—Answer when applicable.............................. ............................•...........__._._.__...._._.._.._..
1—leach pit
..••---•---•--•-----•--•--•--•-------•••------•--------•-----------------•---•----•-----••------••--•••------•-•---------•------•---- -••------------•------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:i:LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by he bo rd of li -th.
2/21/89_..._
.... __...................
— --
Application Approved By...........................-------•------- •--•---•.......... ................................ ---- =� ----
Da
Application Disapproved for the following reasons---------------------------------------------------- ---•-----------------------------------------------------••-
------•---- ----•-----•-•.....................•----------------------••-------------...-•---------...--•--•-----------------------•----------------------------------------•------••-••----•--------
y/ Date
Permit No. !- Issued-------- ;...`3...............
No:=' ..._..:� Fes , 2 0_-0 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town BC rz .;t a i e
...........................................OF..........................................................
{
ApplirFation for Disposal Works Toustrurtiun JIrrntit _N_�
Application is hereby made for a Permit to Construct ( ) or Repair (x-x);an Individual Sewage Disposal
System at:
47 Centerville Ave . Hyannis (11
.._.... __ ..............................................=........................ --........--------------......----•-•-----------•-----._..._..._._._..----------------•-----------
Location-Address or Lot No.
David Huff
Owner. Address
a J.P.Macomber Jr.
--------- ------ ........
Installer Address
Type of Building Size Lot............................Sq. feet
+-+ Dwelling x-No. of Bedrooms..........3........................_.......Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building
� yp g ____________________________ No. of persons------------------------__-- Showers ( ) — Cafeteria ( )
d Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—N?o_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date-.------------------------------------.
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water_-___-_- ________-___---
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_.................
a .---------•--•-•-----••••-••-----------------------------------•-----------------------...-•--------------•-•-----------------------------------------------
DDescription of Soil. San'I---•-------...--•----------•------------------------------------------------------------------------•-•-------------
x
W
V Nature of Repairs or Alterations—Answer when applicable________________________________ ___ _ __________ _j_______._____________________________.
1-1;?ac11 Pit
------------------------------------------•-----------------------------------------.....----------•------------------------••--------•-----------•------••-_._...------------------------------------..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of':.'T'IE i of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hajbe
issued by the board of health.
P P
Signed .. f2 /89T------- 2.1. . • ---•--
Date
A lication A roved B __.______ ..
Dat
Application Disapproved for the following reasons:-----------........................................ ..........................................................
-----------------------------------•-------• ----------------------.-.-----------•--------••-
Date
Permit No..�.:'.. .......... ----------------- Issued.......- -
� I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town BarDstable
..........................................OF....................................................................................
Trrtif irFa#r of f omplianrr
THIS�I��aOomF��TYIF�Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ��x}
bY----------------------------------•-------------------------------------------•----------------------
7 Centerville Ave . Hyannis Installer
---------------•---------------_-•-------------- -
has been installed in accordance with the provisions of TIT7.E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... date_d..............._____.___..-_.__._______.______..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE........................ - ................................ Inspector.............. --.- ----•-------......_..-------•----------•-----------.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Toe�n Barest,i�:I
'1 ) 1 .....................OF..............--........_._....._. 70 00
................. FEE.........................
Disposal Works 001.11nstra ion jkrutit
Permission is hereby gra J. P.nL a c o rnb e r Jr .
-------------------------------------................- ----•------------------...........•----................ ....................
to Construct,( or Repair an �I dividual_Sewage Disposal System
4"__n ervla .K.:a '1 ,) . r1W illi[11
atNo..............--•-----------...----•-----•------•--.....-----................................................................................................................................
Street l
as shown on the application for Disposal Works Construction Permit No"1a.....'-1`f Dated..__._
...--....... J- <?-- .............. I Board of Health j
DATE.... >
....................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TOWN OF BARNSTABLE a_
T,QCATION k7 CCUTezV 1'4—C 404F SEWAGE # 1 UT
JILLAGE Cc k)tZV'J L-C C ASSESSOR'S MAP & LOT t6
`INSTALLER'S NAME&PHONE NO. %A VOK 6 P,
SEPTIC TANK CAPACITY 11;C0 r P (-
LEACHING FACILITY: (type) 64-1-LER`C -t 1^ (size) �J • D
NO. OF BEDROOMS 5
BUILDER OR OWNER`T HOM ki X EL.LgU .01 P,1EQ-Z-0
PERMITDATE: 2— 21 — 61 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 �Od
` within 300 feet of leaching facility) t Feet
Furnished by kC0 , TECH EUVlIZOW INTAL COuOeclloW 2006)
` LOCATIONS
` 6 r
LEACHING GALLERY LEACH A 8
O PIT 1 25 FL 11.5 f t YYV`
2 29.5 FE 13.5 Ft_
2
3 33.5 Ft •18 Ft=
SEPTIC
TANK o
i
i
EXISTING
DWELLING
# 47
W
Z
, w
'' . CENTERVIL_L_E /VENUE NOT TO SCALE
4 TOWN OF irs.A RNSTABLE
o
LOCATION �� 4d �► �'GVvij�� �/1�� S EWA�l- #
=! _
VILLAGE ASSESSOR'S MAP & LOT_ __
J. CRAIG MEDEIROS a�+
INSTALLER'S NAME & PHONE NO.
NIS, MA 02601 'a>S'®�-
SEPTIC TANK CAPACITY,/ U 8�
LEACHING F,ACILITY:(type) l (;O1/gyS
NO. OF BEDROOMS. �� PRIVA rri WELL OR(PUBLIC W ATF _
LAX� l 0WNER_ 2)-b v,_40 l� V
DATE PERMIT ISSUED:
DATE COLIPLIANC:EISSUED__.
VARIANCE GRANTED: Yes No �
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