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0107 CLIFTON LANE - Health
1 107 Clifton Lane Centerville P A = 247 205 O,-)ADkIl" ,rd� NrJ. 15 2 1/3 0 R A 10%enk /ahk �+.� r•r-,�..,.'+.—rev - t �-..� ..� �. --e.__ .,,. �`*1 �,►tE Town of Barnstable P# Department of Regulatory Services M : Public Health DivisionKAW Date 200 Main Street,Hyannis MA 0260 f Date Scheduled , /. aft`t Time l Fee Pd. A E. So . / il Suitabillity Assessment for S e is O Performed By: Witnessed By: LOCATION& GENERAL INFORMATION Location Address I07 G1r A LOB-NCB Owner's Name �rQ, ���j ���ri>�p/� 7 J p V t Address S 1,1: of cc Assessor's Map/Parcel: Z C p.S '�- Z / Engineer's Name NEW CONSTRUCTION REPAIR , Telephone# v- -?X Z. Land Use /dA41'p7 A-e Slopes(R'o) — Surface Stones y Distances from: Open Water Body >- ft Possible Wet Area 7/5y ft Drinking Water Well ft Drainage Way I ft Property Line �'/� ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) a� to C� 6 rri I Parent material(geologic) V 4-wt:llllJ y1 Depth to Bedrock. 73o0 Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: In. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adi,factor Adj.Groundwater Level_ Observation PERCOLATION TEST bate Zy/3T me 11 / Hole# t/ Time at V - - Depth of Perc 3 -soy/ Time at 6" Start Pre-soak Time @ U / - Time(9"-6") End Pre-soak //r/7 Rate Min./Inch Z Site Suitability Assessment: Site Passed_ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first' otify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\S EPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) o- L S I a�z `? - 6 l© �`�S/G v frrw. A eef-Cs fotMd 2,S Y 6 DEEP OBSERVATION HOLE LOG Hole# Z- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. // C nsis en % el Q_ e4b S 8-3 r— Qw L S 35--IZv G .1eP1-Cr.f&,d z,J)/ y rvd sp'�r fe DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi to Gravel) i4 [ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, I ti Flood Insurance Rate Map; Above 500 year flood boundary No_ Yes JK— 'Witbin 500 year boundary No Yes ~ Within IW year flor.0 boundary No.r,,, Yes Depth of Naturally Occurrine Pervious Material Does at least four fee of naturally occurring pervio,u mle I xist in all areas observed throughout the area proposed for the suil absorption system? -ateria If not,what is the df-pth 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�tri 'rl ex%Ise and per' ce described in I10 CMR 15.017. Signature Date �9l WS131`71LAPERCFO RM.DOC * s Commonwealth of Massachusetts Title 5 Official Inspection Form szoS Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F °M 107 Clifton Lane, Centerville _ Property Address Katya Rosenzweig___ Owner Owner's Name information is 45 Johnswood Road, Roslindale MA 02131 April 6, 2010 required for every P page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms COPY on the com uter,use only the tab 1. Inspector: key to move your cursor-do not Troy Williams _ use the return key. Name of Inspector Troy Williams Septic Inspections 1111`5��l Company Name -- 19 Hummel Drive Company Address South Dennis _ __ MA _ 02660 City/Town State Zip Code (508) 385-1300 _ _ _ S1682 411772 01 Telephone Number License Number i ~7 P�. 1� B. Certification - Ln I certify that I have personally inspected the sewage disposal system at this address and thaMe information reported below is true, accurate and complete as of the time of the inspection. Thainspt- was performed based on my training and experience in the proper function and maintenancebR 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 April 6, 2010 Inspector's Signatute 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-09/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 I _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 107 Clifton Lane, Centerville Property Address Katya Rosenzweig _ Owner Owner's Name information is 45 Johnswood Road, Roslindale MA 02131 Aril 6 2010 required for every —_— _�, _ page. Citylrown 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: This inspection is not a guarantee or warranty on the future working conditions of cesspools, pipes or the structural integrity of cesspools. Cesspools or pipes may need repairs prior to the expiration of this report. 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): N/A 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts % Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 107 Clifton Lane, Centerville Property Address I<atyaRosenzweig ______ Owner Owner's Name information is 45 Johnswood Road, Roslindale MA 02131 Aril 6 2010 required for every _ p , page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N . ❑ ND (Explain below): 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =t w 107 Clifton Lane, Centerville Property Address — Katya Rosenzweig Owner Owner's Name information is required for every 45 Johnswood Road, Roslindale MA 02131 April 6, 2010 page. Cityfrown 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 aseptic 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 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 El ® 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 107 Clifton Lane, Centerville Property Address Katya Rosenzweig_ Owner Owners Name ---- �-- .�— �- ---^----information is 45 Johnswood Road, Roslindale MA 02131 April 6 2010 required for every _ � , page. CitylTown State Zip Code Date of Inspection B. Certification (coat.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ H 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•09/08 Title 5 Official Inspection Form:Subsurface.Sawage Disposal System•Page 5 of 17 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 107 Clifton Lane, Centerville _ Property Address Katya Rosenzweig Owner Owner's Name ------ - ----- ---- information is 45 Johnswood Road, Roslindale MA 02131 April 6, 2010 required for every p page. 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? ® 0 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? ® El 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. ® El approximation 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): --- Number of bedrooms (actual): 2 DESIGN flow based on 31.0 CMR 15.203 (for example: 110 gpd x#of bedrooms): ?20 gpd_-- 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 107 Clifton Lane, Centerville Property Address Katya Rosenzweig Owner Owner's Name information is A rll 6, required for every 45 Johnswood Road, Roslindale MA 02131. 2010 _----------------- --------- — — —p --- page. City/Town State Zip Code Date of Inspection D. System Information Description: N/A Number of current residents: 0-2 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? 0 Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 09= 24,000 gals. 9 ( Y 9 (gP )) 08= 30,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occud pie _ Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A _— l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 107 Clifton Lane, Centerville Property Address Katya Rosenzweig Owner Owner's Name information is 45 Johnswood Road Roslindale MA 02131 April 6 2010 required for every � _ _ _� , page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): N/A General Information Pumping Records: Source of information: Last pumped in 2008 per info from home owner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 107 Clifton Lane, Centerville_ _ Property Address Katya Rosenzweig Owner Owner's Name information is _� 45 Johnswood Road, Roslindale MA 02131 Aril 6,2010 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Original to building_u approx. 45 years ago. Were sewage odors detected when arriving at the site? ❑ Yes M. No Building Sewer(locate on site plan): Depth below grade: 18"+ feet Material of construction: ® ❑ 40 PVC orangeburg, sch 20 pvc cast iron ® other(explain): Distance from private water supply well or suction line N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Note :'Orangeburg pipe is prone to root growth, blockages and other problems that may or may not be of concern in the future. Recommend replacing oraneburc,�pipe and lower pipe between cesspools. r Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete. ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) N/A If tank is metal, list-age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: N/A Sludge depth: N/A 15ins•09108- - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - t 107 Clifton Lane, Centerville Property Address Katya Rosenzweig Owner Owner's Name information is required for every 45 Johnswood Road, Roslindale MA 02131 April 6, 2010 page. Citylrown 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 N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? N/A 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 Grease Trap (locate on site plan): Depth below grade: N/A� P 9 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A N/A Date of last pumping: Date t5ins-.09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y 107 Clifton Lane, Centerville Property Address Katya Rosenzweig Owner Owner's Name information is required for every 45 Johnswood Road, Roslindale MA 02131 Aril 6, 2010 - 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal El-fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: gallons N/A Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A. Alarm in working order: ❑ Yes ❑ No N/A 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 107 Clifton Lane, Centerville Property Address Katya Rosenzweig _ Owner Owner's Name information is 45 Johnswood Road, Roslindale MA 02131 Aril 6 2010 required for every P 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 NIA 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.): N/A 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.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not,required): If SAS not located, explain why: N/A 15ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 107 Clifton Lane, Centerville Property Address Katya Rosenzweig Owner Owner's Name information is required for every 45 Johnswood Road, Roslindale _MA 02131 April 6, 2010 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length.: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1_6'X 5' ❑ 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.): Cesspool was found with 10"of water present with a visible stain line approx. 1' higher. Good capacity is still available in overflow cesspool. No evidence of hydraulic failure or problems in the past were found rp esent.at the time of inspection._ Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration main cesspool Depth—top of liquid to inlet invert ?"_above 3„ Depth of solids layer Depth of scum layer Thin layer Dimensions of cesspool 5'X 5' Materials of construction cesspool block Indication of groundwater inflow ❑ Yes ® No l5ins.09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -,Not for Valuntary Assessments 107 Clifton Lane,_Centerville Property Address Katya Rosenzweig _ Owner Owner's Name information is 45 Johnswood Road, Roslindale MA 02131 April 6, 2010 required for every P page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Comments (note condition of soil, signs of hydraulic failure, level ofponding, condition of vegetation, etc.): Cast Iron outlet tee and pvc inlet tee were in working order.Working water level in cesspool is a little above the inlet invert. Flush from home came through OK with no backup into home and had good flow through to overflow cesspool. No history of clogging in the past was available and this condition has existed since install in 1965. It would be recommended to replace and lower pipe between cesspools to lower water level in cesspool.I have seen both cesspools in past empty with no evidence of groundwater. No evidence of hydraulic failure was found at the time of inspection. Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A - -- --------—------------------ ---- t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments 107 Clifton Lane, Centerville. Property Address Katya Rosenzweig _ Owner Owners Name information is 45 Johnswood Road, Roslindale MA 02131 Aril 6, 2010 required for every P 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: 3� ® hand-sketch in the area below ❑ drawing attached separately A t � 0 1 .2-P I i r t l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 107 Clifton Lane, Centerville Property Address Katya Rosenzweig _ Owner Owner's Name information is required for every 45 Johnswood Road, Roslindale _ MA 02131 April 6, 2010 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: 25.T+ 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: MIW 29 Zone C 6.0' A' adjustment You must describe how you established the high ground water elevation: USGS groundwater map for Barnstable showed home at elevation 39.0' and groundwater at 12.9' making groundwater approx. 26.1'below grade. Groundwater adjustment in area at the time of inspection was A'with a max. HGWL of 257. Bottom of cesspool at 8.5'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 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 M 107 Clifton Lane, Centerville Property Address Kea Rosenzweig Owner Owners Name information is 45 Johnswood Road, Roslindale MA 02131 April 6, 2010 required for every P page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ` - TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 585-1500 19 Hummel Drive South Dennis, MA 02660 -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Propert% Address: 107 Clifton Lane (,JH IVED Centerville,MA Owner's Name: Maya Lebedinsky s 20�� Owner's Address: 107 Clifton Lane Centerville,MA 02632 ARNSTABLE Date of inspection: July 30,2003 DEFT. Name of Inspector: . Troy M.Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis,MA 02660 Telephone Number: (508)385-1300 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sveaenv Passes Conditionall%- ['asses Needs Further Evaluation by the Local Approving Authorit) Fails Inspector's Signature:��, � ,(�' Date: $ /`/ A 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ****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 pace 1 of I I • y ' I Page 2 of I 1 OFFICIAL _INSPECTION FORM .NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 107 Clifton Lane Owner: Centerville,MA Date of Inspection: Maya Lebedinsky July 30,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 have not found any infofrrtation which indicates that any of the failure criteria described in 310 C%4R 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 laced or to be repaired. The system, upon completion of the replacement or repair,as approved by the Board o ealth,will pass. Answer yes. no or not determined(Y,N,ND)in the_ for the following statements. "not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(wh ter metal or not)is structurally unsound,exhibits substantial infilFration or exfiltration or tank failure is i minent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by a Board of Health. 'A metal septic tank will pass inspection if it is structurally sound of 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 o or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled uneven distribution box. System will pass inspection if(with approval of Board of Health): br en pipe(s)are replaced struction is removed distribution box is leveled or replaced ND explain: The syste required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspecti if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: -Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: 107 Clifton Lane Centerville;MA Date of IgsPectionc Maya ppLebedinsky 00 C. Further Evaluationyis Reg4ired by the Board of Health: Conditions exist which require further evaluation by the Board of Health ui order to determine if the system is failing to protect public health. safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)Ahat the system is not functioning in a manner which will protect public health,safety and the envir ment: — 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 mar 2. System will fail unless the Board of Health(and Public Water pplier,if any)determines that the System is functioning in a manner that protects the public bealt ,safety and environment: _ The system has a septic tank and soil absorption sy m(SAS)and the SAS is within 100 feet of a surface %rater supply or tributary to a surface water s ply. — The system has a septic tank and SAS an lie SAS is within a Zone 1 of a public water supply. ti — The system has a septic tank and S and the SAS is within 50 feet of a private water supply well.. _ The system has a septic tan - and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ethod used to determine distance ••This system passes ' he well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volat' organic compounds indicates that the well is free from pollution from that facility and the presence o monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure Grit a 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: 107 Clifton Lane Centerville,MA Owner: Maya Lebedinsky Date of Inspection: July 30,2003 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 intp 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 �IL 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''/:day flow Required pumping more than 4 times in the last year VQT 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. _Z 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 afceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the,presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A,copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the systern fails. The system owner should contact the Board of Health to detemtine 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 ign 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 crit to above) yes no _ the system is within 400 feet of a surface drinki water supply the system is within 200 feet of a tribu o a surface drinking water supply _ — the system is located in a nitrogen nsitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water sup p well If you have answered"yes"to an uestion in Section E the system is considered a significant threat,or answered "yes"in Section D above the 1 e system has failed.The owner or operator of any large system considered a significant throat under Sec ' n E pr failed under Section D shad upgrade the system in accordance with 310 CMR 15.304.The system own should,contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 107 Clifton Lane Owner: Centerville,MA Date of Inspection: Maya Lebedinsky July 30,20Q3 Check if the following have beer)done. You must indicate"yes"or"no"as to each of the followine: Yes No information was provided by the owner. occupant, or Board of l lealtl, Were any of the system components pumpers 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 ofbreak out ? ✓ ._ Were all system components,excluding the SAS, located on site ? ALm Were the septic tank manholes uncovered,opened, and the interior of the nk inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of srudge 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 _ _k/ 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)f 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: 107 Clifton Lane Owner: Centerville,MA Date of inspection:Maya Lebedinsky July 30,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): R Number of bedrooms(actual): oZ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): o?2 v Number of current residents: 2 — Does residence have a garbage grinder(yes or no):Lv u Is laundrN on a separate sewage system (yes or no) /jo [if yes separate inspection required) Laundry system inspected(yes or no):AL,�y Seasonal use:(yes or no): No Water meter readings, if available(last 2 years).isage(gpd)): D 2 = 1 'I fU Sump pump(yes or no): avo Last date of occupancy: C)G ct..)F" COMM ERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203)- _ Zno): . 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 ( Water meter readings, if available: — Last date of occupancy/use- OTHER(describe): GENERAL, INFORMATION Pumping Records Source of information: P �,`� Was system pumped as pan of the inspection(yes or nu): If yes, volume pumped: 800 gallons-- How was quantity pumped determined? Reason for pumping: R /� —ram ..T/G u L!, c/L 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:- Were sewage odors detected when arriving at the site(yes or no): Nu i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 107 Clifton Lane Owner: Centerville,MA Date of Inspection: Maya Lebedinsky July 30,2003 BUILDING SEWER(locate on site plan) Depth belu%k grade: 19114 Materials of construction: cast iron _40 PVC , other(explain): ( rw,,, Distancehon. pri%ate water supply well or suction line: A Comments(oncondition of joints,venting,evidence of leakkjage,etc.): /7 s4 LO-__�I he- S —Ka A-'-.1� C�C ! .►hh.� 'T7 s.t .�+ T1�_dH Alo .c C!-"- b t 7M h- <j P'P / h .moo l (, SEPTIC TANK:—(locate on site plan) Depth below grade: Material of construction:_concrete_/ffl**-e-: berglass__poly ylene —other(explain) If tank is metal list age:_ Is age conertificate o ompliance(yes or no): (attach a copy of certificate) Dimensions: __ _ Sludge depth Distance from top of sludge to bottom oSaflle:Scum thickness: ----- Distance from top of scum to top of outlr:Distance from bottom of scum to bottom or bafle _How were dimensions determined: _ Comments(on pumping recommend ions, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence f leakage, etc.): GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass pol thylene_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 r baffle: Date of last pumping: Comments(on pumping recommendations,inl and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leaka ,etc.): 7 I Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 107 Clifton Lane Owner: Centerville,MA Date of Inspection:Maya Lebedinsky July 30,2003 TIGHT or HOLDING TANK: (tank must be pumped at time of ins p ion)(locate on site plan) Depth below grade: Material of construction: concrete metal__fiberglass olyethylene other(explain): Dimensions: -- —�-— - --- Capacity: gallons Design Flo%%: gallons/day Alarm present(yes or no): Alarm level: Alarm in working ord (yes or no): Date of last pumping: Comments(condition of alarm and flo switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlet qual,any evidence of solids carryover. any evidence of leakage into or out of box,etc.): ti PUMP CHAMBER: (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 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: 107 Clifton Lane Owner: Centerville,MA Date of Inspection: Maya Lebedinsky July 30,2003 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain wh). Type leaching pits, number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: ,) - 6 x S — 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.): C J tS S,- ( D`<t�.a w Cj �� A. I ti ti (v t�.�<✓ 1<..J.c 1. No .0 v cL.,q L.c c�lC A V I y A �/ (- ` Tom.t'ur�. r ✓ W Sl cw.S L p�S1- CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: oi,{ &,m ..,, ccs�_N�c,.►_ Depth—top of liquid to inlet invert: Depth of solids layer: 3 Depth of scum layer. Dimensions of cesspool: Materials of construction:_C,- 1 l o tA Indication of groundwater inflow( -es or no): No Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): '�rrV)-�' i✓u ., p�/'�I a} �t.� « ..of ITV C� �'L�� +-e.� .d of s.. � •. ..0 v;t� b. o v di_c IdJU✓� +S ItJt / / h LCS ] �9yU� ; f' /. L � � L,. GC�tJ c. rh �t'F •.0 f-, �IUS � �a.•., I,JvL,.� cw,w,.� /Mw.,) !.� -/�+ CccsPJu t. Uk� ---- PRIVY: (locate on site plan) Materials of construction: Dimensions: -- - Depth of solids: Comments(note condition of soil,signs of hydr is failure, level of ponding,condition of vegetation,etc.): 9 c . Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 107 Clifton Lane Centerville,MA Owner: Maya Lebedinsky Date of Inspectign: July 30,2003 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. I I I I � I i3 � 36 ' C OVL•,G/��.1 GGS},Poo P00 1 c�sS 10 f F�age I I of 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 107 Clifton Lane Owner: Centerville,MA Date of Inspection: Maya Lebedinsky SITE EXAM July 30,2003 Slope Surface water Check cellar ✓ Shallow wells Estimated depth to groundwater a�6-t feet Adjuslcd high ground water elevation �3•S feet Please indicate(check)all methods used to determine the high ground eater 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 I lealth-explain: w Checked with local excavators, installers-(attach documentation Accessed USGS database-explain: r, You must describe how you established the high ground water-elevation: � (n /�-� h.� 4 r,i-: W�cL.....:.. �c-✓ I!J c.( cam,} / •+t. -__L_ This report has been prepared and the system inspected 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. I YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 f sj_A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1'FL.,.367 Main Street, Hyannis, MA 02601 (Town Hall) �4 r� h DATE: -Fill in please: 4Sx � " APPLICANT'S YOUR NAME/S: ( qv, BUSINESS YO�1R HO E ADDRE al J r P>" y�Ciu daL! �.j1dfYc TELEPHONE # Home Telephone Number f � R!"rb r.ur�-44 NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUPATION? E$' NO j (/ `� ADDRESS OF BUSINESS O r� .I MAP/PARCEL NUMBER C ! J�G`�Y�.[Assessing) When starting a new business there are several things you�uso in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual ha inf ents that pertain to this type of business. Authorized nature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY] This individual h s been ' rmed 9 4 the lice requirements that pertain to this type of business. uthorize ignature** COMMENTS: f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION roRM Address of property /U 7 C t 4" f'I o Lon L tiOwner's name7=y® -- Date of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, Health. P and Board of None of the system components have been pumped for at least two and the system has been receiving normal flow rates during that and 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 site was inspected for signs of breakout. .__L A1-1 system components, excluding the SAS, have been site. located on the 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 SAS on the site has been de termined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of- SSDS. 19 s ev E SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents .Yo garbage grinder, yes or no* NO laundry connected to system, yes or no �(o seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: C/41 VS4- d a s by 5 . Last date of occupancy O C.c�Apr c� eel��;•,�% 7�•S p e�Rio,� GENERAL INFORMATION Pumping records and source of information: u ♦ Vto CA VCti / r �^ `JC, K�hs lC 1 G� System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Septic tank/distribution box/soil absorption system Single cesspool VOverflow cesspool Privy Shared system (yes or no) (if:. yes, attach previous inspection records, if any) ' Other (explain) Approximate age of all components. Date installed, if known. Source of information: A t�/ J. cl Vj 2Y-6 Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART B SYSTEM INFORMATION continued SEPTIC TANK:1Lz1q (locate on site plan) depth below grade: material of construction: concrete metal FRP other(explain) dimensions: sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) DISTRIBUTION BOX: (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, recommendation for repairs, etc.) PUMP CHAMBER (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORH PART B SYSTEM INFORMATION continued 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 and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number tic c✓ .7 ,.� Cc c �Ou / Comments: 4. J _en x S cl (note condition of soil, signs of hydraulic failure, level of ponding, conditio of vegetation, recommendation for maintenanc o repairs etc. ) Soi / Uv vc/ o PCs O7 ru c .J12 Id/ r ✓uv(n� CESSPOOLS (locate on site plan) : number and` configuration 0� � depth-top._of liquid to inlet invert depth of solids layer depth of scum layer � .. dimensions of cesspool materials of construction indication of groundwater C �s "' l ' ` /< inflow (cesspool must be pumped as part of inspection) p UVC✓ 1y ,A Comments: - �.i red Go (note condition of soil, signs of hydraulic failure, level of ponding, conditi n of vegetati n, recommendations for maintenance or repairs,etc. ) e c� G.c. G-�/-c, ✓ �c,� lJ a S J� PRIVY: N Xccl {Cl«.c � ). CGSs �� �" l Gto ih ti«d v�' (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, recommendations for maintenance or repairs,etc. ) • 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE E'_SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' l a2 ' • i DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: v O V l: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? ..� Discharge or ponding of effluent to the surface surface waters? of the ground or Static liquid level in the distribution box above outlet invert? N Liquid depth in cesspool <6" below .invert or available volume< 1/2 da}- flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? .,A/ Is any portion of the SAS, cesspool or privy: _ below. the high groundwater elevation? within 50 feet of a surface water? , N within 100 feet of a surface water supply or tributary to a surface water supply? N within a Zone' I of a public Well? .L within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? /Y within 50 feet of a private water supply well? lV 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 analy. . for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORM PART D CERTIFICATION Name of Inspector ku 3 y . Company Name S/ r a � �c-!o �-��S�o�c74a.- Company Address / �a o / C( 460-ss X-J �41- ICA Certification Statement I certify that I have personally inspected the sewage disposal 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 . manitenance of on-site sewage disposal systems. Vone: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303.. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature Date Original to system owner Copies to: Buyer ( if applicable) Approving authority TOWN OF BARNSTABLE C LOCATION �O 7 ,�� SEWAGE # VILLAGE �� ce N4(/ ��-» S �✓ ASSESSOR'S MAP & LOTJ INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY o / S 9^ LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERS BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANT -D• Yes too 2d � .2.7 ' 3�' r - J l 2 ' 41 er L V o r i o � o i MEIS IN ( `k 01t�"� .. bn Q _ 3Jp lD _ `.0 - r _ '0 o C+p port; ^ i ri 711 Lrr\,n (5 n rn s IY I 4 , . l , 'T 7fU +- 7 r . , a 1 • ti 1 TOWN OP BARNSTABLE Z013 APR -2 PI 3• 41 DIVISI