HomeMy WebLinkAbout0118 CLIFTON LANE - Health 118 Clifton Lane e
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Centerville
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Na 63LOR
UPC 12543
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Bk 33664 Pg19 #1793
01-11-2021 @ 08:22a
DEED RESTRICTION-BEDROOMS
Owners: Boris Shapeton and Irina Shapeton
Premises: 118 Clifton Lane,Centerville MA 02632 Map 247,Parcel 209
Date: January'g , 2021
The owners of the above-described premises hereby enter into the following
Covenant/Deed Restriction with the Barnstable Board of Health.
1. The owners each agree that the premises shall contain no more than five (5)
bedroom(s).
2. The owners hereby agree to incorporate this Covenant/Deed Restriction,in full or
by reference, into all deeds, easements, mortgages, leases, licenses, occupancy
agreements or any other instrument of transfer by which an interest in and/or a
right to use the Property,or any portion thereof is conveyed. This Covenant/Deed
Restriction shall be binding on or heirs,devisees and assigns.
3. This Covenant/Deed Restriction shall run in perpetuity and is intended to conform
to M.G.L.e. 1.84,subchapter 26,as amended.
4. The parties agree that this Covenant/Deed Restriction shall conform to 310 CMR
15.000 (Title V) and may be amended or released only upon approval by the
Local Approving Authority or DER Any such amendment or release shall be
recorded and/or registered with the appropriate Registry of Deeds and/or Land
Registration Office.
5. The Board of Health or .its appointed. agent shall have the right to enter said
premises, with reasonable cause to be determined by the Board of Health
members and with reasonable notice to the owner, to inspect and confirm
compliance with this restriction.
6. The property shall be connected to pubic sewer when and/or if it becomes
available in the future.
Bk 33664 Pg20 #1793
7. For our title, see Deed dated June 18, 2008, and recorded on July 18, 2008, with
the Barnstable Registry of Deeds,Book 23052,Page 294.
Executed this__tday of January,2021.
Boris Shapeton VIrina Shapeton
COMMONWEALTH OF MASSACHUSETTS
Barnstable,ss.
On this day of January,2021, before me,the undersigned notary public,
personally appeared Boris Shapeton and Irina S a eton, proved to me through
satisfactory evidence of identification, which was Iff1 _to be the persons
whose names are signed on the preceding or attache document,and acknowledged to me
that they signed it voluntarily for its stated purpose and who swore or armed to me that
the contents of the document are truthful and accurate to the best of their knowledge and
belief.
Notary Public 12-
My Commission Expires: 3 - 7
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JOHN F. 11EME, REGISTER
BARNSTABLE COUNTY REGISTRY OF DEEr
RF.ORTVRn F RRCORORn RT.X"PRONTMLTA
118 Clifton Lane FIRE SYSTEM &HOUSE PLAN
Centerville
Notes, 15T FLOOR
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I AA dimmOgm @r@ @pprommme 5!
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9 §4:ww@m
22! 29
FAMILY 99W
4
MYR46 q9@m MR90m#1 13Y
FRONT
§.MgKf PffLff@R
2ND FLOOR
PORCH 13,yW7,
I F-
§-TA11 V PI N§TO
SECOND 20
FLOOR ART 5-,T U 0 10 CSDA
ADDITION FAMILY ROOM
ff9q99mf3 §W-499M#4
PORCH BASEMENT
F11
WI ERER
GARAGE FAMILY ROOM
MEL
fi�i�§k 9f fi9�l������' 29 so 14 112,V
22
No. "A Fee
Meg wll/t4 Zu
VYeTHE COMMONWEALTH OF MASSACHUSETTSEntered in computeriPUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Z[ppYication for �Bigpogal 6p.5tem Congtruction Permit
Application for a Permit to Construct Repair Upgrade Abandon( ) ❑.Complete System L"J Individual Components
Location Address or Lot No.I��Cl PTO,✓LJ'• Owner's Name,Address,and Tel.No.
o7-.f
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building CepX. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) rro gpd Design flow provided 5 ? 3' gpd
Plan Date Number of sheets X Revision Date
Title
Size of Septic Tank c�`X�1'T�.ve; 1;1s-o9 j2. fC. Type of S.A.S. '" -z 3` X <1'-�X
Description of Soil cam" ®S`� � Z 0 G sy.�.v�Be610.
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signe ate �"� 900
Application Approved by ate
Application Disapproved by: Date
for the following reasons
�.»
Permit No. Date Issued
No. '■Fl x w, r, Fee
T _E COMM6*NW!'ALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye
y 0(ppYication for �Die;ponl *pgtemr Cons;tructton Permit
Application for a Permit to Construct O Repair( ) Upgrade( Abandon( ) `Complete System LJ'Individual Components
Location Address or Lot No. l 4-``7, Owner's Name,Address,and Tel.No.
R
t 07>f
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
��� L��.1-limit- 99s=o>o)' O�o'liip ,6r?/ti�,1'o•�,�.1,; d�3.� ��>J
Type of Building:
Dwelling No.of Bedrooms S Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building G�t`1`, No.of Persons Showers( ) Cafeteria
:-•- Other Fixtures
Design Flow(min.required) ' �fo gpd Design flow provided r» gpd
Plan Date 3 o—oi Number of sheets I/ Revision Date 'y
Title
Size of Septic Tank ccX�l'Ti.v� Js—oo �.11. Type of S.A.S. Ta'''—CAV ./.Z •-2 T k,
j Description of Soil �- 3 01`o if/,L o C,y���F�
Nature of Repairs or Alterations(Answer when applicable)
s
Date last inspected:
Agreement: ,
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system,in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signe c ate �— -O�
Application Approved by ` ate - - -
Application Disapproved by: r+ e,,_ ° Date
for the following reasons
t .
Permit No. A-0-6-10
..� Date Issued
x
THE COMMONWEALTH OF MASSACHUSETTS -
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded
Abandoned( )by
at ��� CG/FTv� 2 �-• cE-•�T. ha been c structe i ac rdance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer 177�,,W L�•�OcCY/F Designer Q�dli/p r� w(,rG✓� �/'.
bedrooms ,S� Approved desi n flow s-Zr7• d' gpd
The issuan of is F rmit shall : be co tr �d as a guarantee that the system I`l tion as designe�f 1e J�
i
Date � 0 _ Inspector 1 ll�� r
C.. /
---------- .-------------- ----------_- -
No. ` Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS'
1=i!gpool *pgtem Construction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( A01 Abandon ( )
System located at -OOS/ cQ G 1
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction ust a com feted within three years of the date of th's�1it.
Date � Approved by
l� �r i
Town of Barnstable
WE Tp� Regulatory Services
Thomas F.Geiler,Director
snaivsrAs E,09. +`
Q a Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-8�2,4644 Fax: 508-790-6304
Installer &Designer Certification Form
Date: POE) rWq �- l �d Z()o e)
� � �
Designer: 1 1 �a M45-oK.] Installer: 8�C
Address: . Address: 1�� _
On '� K4 � �� u� was issued a permit to install a
(date) (installer)
septic system at 61-•-1 F7_XX1 "i .�(address) based on a design drawn by
��t �• 1��d dated 30
V <Icertifythat the septic system referenced above was installea, stants ally according to
the design, which may include minor approved changes such as4ateral.relocation of the
distribution box and/or septic tank.
l L,.J47 4t-L,►drR 0-d
I certify that the septic system referenced above was installed with ma}ol%chariges (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any"comp'onent
of the septic system)but in accordance with State&Local Regulations. Plan recision or
certified as-built by designer to follow.
. j
OF MasS�
DAVID y
o 0 B. C `a,
(Installer's Si tore) MASON rn -
No.1066 a �;
GISTS
sgN/TAR\Q�
(Designer's.Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTII, BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Qi Health/Septic/Designer Certification Form
a
`•, TOWN OF BARNSTABLE
LOCATION /'l 1p C �� �o�" �-. SEWAGE#
1�t'LLAGE G�'Y� ASSESSOR'S MAP&PARCEL-2
INSTALLERS NAME&PHONE NO. -J%W
SEPTIC TANK CAPACITY '1'�'"'S
LEACHING FACILITY:(type) (size) A
NO.OF BEDROOMS
OWNER 074
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility / Feet
Private Water Supply Well and Leaching Facility.(If any wells exist
on site or within 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
f07owT ®/�/flo�.f'F 8
o �
y o
TOWN OF BARNSTABLE
LOCATION C(L� n 'AAL SEWAGE#
VILLAGE tA�i c:fv,4 ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
E'PTIC TANK CAPACITY t S )
LEACHING FACILITY:(type) C'NNAM�d (size)
'%NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 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 �ZIwwrlgn
A �roni Q�
[�° 3 O
aq 131
3 a3 �3
TOWN OF BARNSTABLE
LOCATION AI a SEWAGE #
V LLAGE ' ASSESSOR'S MAP
INSTALLER'S NAME&ZNE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
?'0.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 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
� A
13
b ,
r
5
�1 l3
91
Town of.Barnstable P#
Department of Regulatory Services
//�2/0
o`.t+e►o, Public Health Division Date
Q„ 200 Main Street,Hyannis MA 02601
e,►nHST,►eM
bJ�q. 1a�
ae t„ar" Date Scheduled WTime Fee Pd.
Soil Suitability Assess4nentfor Sewage Disposal
DAV`C> 6. VI — Witnessed B : ` I �zmLOPPerformed By. Y
,.!.... ,,,.!.:.....:..............!-!a,'::!,:!.�:.!.r. ..... ... inn .. :.. EN ...,ir.,,.! ! !.aryl .;r.61.L4.
.I..,........!.. .! ' ':
....:!...................I�.E ,r
,
Location Address ANC���- Owner's Name
Address
Assessor's Map/Parcel: 7 7 / Engineer's Name a •d/��D �' f
NEW CONSTRUCTION REPAIR V Telephone#
Land Use � ���"'��`1 Slopes(%) b Surface Stones
Distances from: Open Water Body Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line,;l d ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
I
I
I �J r_4
/ G1
C)
Parent material(geologic) by 1 W Depth to Bedrock t /00
Depth to Groundwater: Standing Water in Hole: /11- Weeping from Pit Face 1114
4
Estimated Seasonal High Groundwater �0 /
. .._....._._..R,........r.,!x..__.,...,.._.T-11.111..,._............5_,.._..............................__n...._..._....i_..................,.._:_......P._.:.;:...................:....;...h_.. ... .!..._r_.................e....... .....
A... �..; �!.. .:. .,. .,: ,, I - "!i..rr..
::
Method Used:
Depth Observed stanhing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_
.................................
.....,i........:........:.......................................a...:..,....I:......._................................................_.. OWN
.: r....
._.. ., .. ..I,...,.i.:.r...:...... :...:.:4...,...............,.,n.....,....n.........,yN�.. i .. .. .. .... �i,.:a:...,...t.I!i�ie:i!inri�:::i!:.`�lrrti~::!!:!is�:::!::::::.:...a:.::.:'�'�!I
....,1:::..:.:.....:1.!.�:v..4.:..L:a i..e.:c!..,.........._r,.......:.I...:..a i..L.....0:.................._v.,..a......!.:,,Jn.r i . �����:,T
...nn_.,:....,.r_v...,.I.,...L......y.......L,... .,.......9 �::::,::: !:a::::::,::::::c::::::::::�::.�................
Observation
Hole# Time at 9"tF
s
Depth of Perc I !/ Time at 6"
Start Pre-soak Time @ Time(9"-6") 41
End Pre-soak r'1
Rate Min./Inch �;All
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/I)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----�---
Q:HEALTH/WP/PERCFORM
Depth from Soil Horizon Soil Texturt Soil Color Soil Other
Surface(in.) (USDA) (Munseil) Mottling (Structure,Stones,Boulderes.
Consislencya%Gravell
-8� -�t C
< ::::»:>:::<:>:»::>::r>:>::>;;:DEEP:.;QBSERVA.. .: �l�i....i�:74 ...L�.�.........................II.o e..#.......... ......................................
Consistency, Gravel)
;::.: ::•;:.; :.::• Soille< to Depth from Soil"Horizon ."" S xture Soil Co r soil Other
Surface(in.) (USDA) (Munseil) Mottling (Structure,Stones,Boulderes.
%
77/ Y1
lI ,
1),
1 '
ri:`.';:2:;?:is?<:C::«:::::;i:•::k::::;::...:.:,,....: ..................... .... ...:....... :..............,.,..:...;.. .. :f: ....: ,:........ ::::
.. S: .. >................... .. ... ..:•:>i:::$S:'ri::::2v}:::(S:':•i:•iii:b:•i:{i::+i:".:<4:•:
t' ::.......... ::.::.:.
t ' ! ' Depth from Soil Horizon Soil Texture Soil Color Soil Other
~� Surface(in.) (USDA) (Munseil) Mottling (Structure,Stones,Boulderes.
�+ r ° Gravel) -
i _
�1'I' O HALE EF»OBER... . . LQ.G.:..:................HMIs.#..............................:..:... .. ..:......
Depth from Soil Horizon Soil Texture . Soil Color Soil Other
Surface(in.) (USDA) (Munseil) Mottling (Stricture,Stones,Boulderes.
%Gravel)
I
l
Flood Insurance Rate Man:
Above 500 year flood boundary NO— Yes ?/
Within 500 year boundary No ` Yes -
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?'
Certification
1 certify that on 1091, (date)I have passed the soil evaluator examination approved by the
Department of Envir nmental Protection"and that the above analysis was performed by me consistent with
the.required training,expertise an 11 d eri a lbe in 310 CMR 15.017. /y
Si'gnature Date Z�`-CJ
i
Wadlington, Ellen
From: Miorandi, Donna
Sent: Friday, June 27, 2008 12:05 PM
To: HeathDeptMailbox
Cc: 'david mason'
Subject: 118 clifton Lane, Centerville
Just an FYI,. Did a perc test for a repair this morning and did a walk-thru on the house with Dave Mason. It is definitely 5
bedrooms and looks like it has always been that way. It is two bedrooms down and 3 bedrooms up. There is in the
basement what appears to be a new room with storage in it and a small casement window-not for egress. The room has a
door framed out with hinges on it but no actual door. I know the assessor's calls it as a four bedroom but most likely
didn't count one of the rooms due to lack of a closet. Thanks! Donna
• 1
Town ®f Barnstable Barnstable
P�Of SHE Tp�� I_
Regulatory Services Department NAmeficaChy
+ BARMWABLE.
M 39. ,�� Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
June 2, 2008
Torao Ota
118 Clifton Lane
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 118 Clifton Lane, Centerville, MA was last inspected on
March 23, 2008,by James M. Ford, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Back up of sewage into facility or system component due to overloaded or clogged SAS
or cesspool.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER THE BO OF HEALTH
a c ean, R.S., CHO
Agent of the Board of Health
CERTIFIED MAIL# 7006 2150 0002 1041 9686
� rtic:\SEPTIC\Letters Se Inspection Failures\TEMPLATEI.doc
COMMONWEALTH OF MASSACHUSETTS
A .
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
Property Address: 118 Clifton Lane. C�
Centerville, MA 02632 �
� o
t Owner's Name: Torao Ota
Owner's Address:
i
C i
Date of Inspection: March 23, 2008. (�
Name of Inspector: (Please Print) James M Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
2 - 4 Ostervdle.MA 0 655 00 9
Telephone Number:" (508) 862-9406
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the infortnation 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 functiop and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Ne s Further Evaluation by the Local Approving Authority
✓ Fai
Inspector's Signature: Date: May 27. 2008
The system inspector shall subm copy of thi inspection.report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.. If the system is a shared system or has a.design flow of.10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 118 Clifton.Lane
Centerville, MA
Owner: Torao Ota
Date of Inspection: May23. 2008 .
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or,
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass 'inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level.in the distribution box due to broken or
obstructed pipe(s)or due to a broken,-settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
i
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 118 Clifton Lane
Centerville, MA
Owner: Torao Ota
Date of Inspection: May 23, 2008
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 CNVIR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
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 colifon-n
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
i
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 118 Clifton Lane
Centerville, MA
Owner: Torao Ota
Date of Inspection: May 23, 2008
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes".or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400,feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D.above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or.failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 118 Clifton Lane
Centerville, MA
Owner: Torao Ota
Date of Inspection: May 23, 2008
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 thes:ystem obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ _ Were all system components, excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened;and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,.dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the,facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been deternined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)j.
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 118 Clifton Lane
Centerville, MA
Owner: Torao Ota
Date of Inspection: May 23, 2008
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): N/a Number of bedrooms(actual): S
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
Number of current residents: I
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a.separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type.of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.)`.
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unknown
Was system pumped as part of the inspection(yes or no): _
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
installed 6112186-per as-built
Were sewage odors detected.when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 Clifton Lane
Centerville. MA
Owner: Torao Ota
Date of Inspection: Mav 23, 2008
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain);
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 13"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: -
Distance from top of sludge to bottom of-outlet tee or baffle:
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: -
Distance from bottom of scum to bottom of outlet tee or baffle: -
How were dimensions determined: Measuring stick
Comm m
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with outlet invert
GREASE TRAP: .None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scuin to bottom of outlet tee or baffle:
Date of last pumping:
Connnents (on pumping recommendations,inlet and outlet tee or baffle condition,.structural integrity,liquid levels
as related to outlet invert,evidence of leakage,.etc.):
7
f
Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 Clifron Lane
Centerville, MA
Owner: Torao Ota
Date of Inspection: May 23, 2008
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alann 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: ✓ (if present.must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was clean
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address: 118 Clifton Lane
Centerville, MA
Owner: Torao Ota
Date of Inspection: May 23, 2008
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation-not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 2-chmnbers per as-built.?
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Connnents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The liquid level was up to the inlet ripe in the chambers.A cmnera was used for the inspection
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
Page.10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 Clifton Lane
Centerville, MA
Owner: Torao Ota
Date of Inspection: May 23,.2008
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.
A
0 3 p
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3 a3 Y3
10.
+ Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 118 Clifton Lane
Centerville, MA
Owner: Torao Ota
Date of Inspection: May 23 2008
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+/- feet
Please indicate(check)all methods used to.determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of-SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours neaps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours snaps the maps were showing approximately 20'+%to ground water at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected as of the date of.impection and failed. 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 septic
system, the inspection, this report andlor any components of the septic system which have not been located and inspected..
11
Town of Barnstable
�opYHe rpm
o Regulatory Services
Thomas F. Geiler, Director
9 2639.
,fig
`�ArEo1. Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax:.508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC
UNITED STATd•� R E;'? '':. �. .• ,,w it Ci sF4
• Sender: Please print your name, address, �d ZIP+44 in this box •
cr -
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cv
Town of Barnstable m
Public Health Division
`'.� •
6 200 Main Street
Hyannis,MA 02601
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��� Ilt�!!!!!1l=1f/13"Y1lillfdi113�tdl�ldislt!?3dl/:.Il�IiiltFF}tli�fl
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COMPLETE •
■ Complete items 1,2,and 3.Also complete A. Signature.
item 4 if Restricted Delivery is desired. Agent
■ Print your name and address on the reverse X ❑A dressee
so that we can return the card to you. rin ed Na C,D e XofieIi ry
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to: D. 16 delivery address difiere " item 1? Yes
If YES,enter delivery ad Tess below: ❑No
1 t i�� L&rUI_
1 �� 3. Service Type
[ ' � �I ❑Certified Mail ❑Express Mail �
0 e-11.,3� ❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number i 7 0 0'6 21s5 0 i 0 0 b 2 10 4'1( 9 6 8 6 1
(Transfer from service label)
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
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,9r 6T) tC
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Address of Owner: 93 OSSIPEE RD.SOMERVILLE MA.02144
Date of Inspection: 10/2/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 508-564-6813 FAX 508-564-7270
:r
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:
X Passes
_ Conditionally Passes
_ Needs Further Evaluati n By the Local Approving Authority
Fails
Inspector's Signature: !/ Date: 10/3/00
The System Inspector shall s bmit a copy of this,inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 16.303.My findings are of how the system is performing at the time of inspection.M,
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
• v €
revised 9/2/98 Paoe 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Date of Inspection: 10/2/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
i
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the
septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure
is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved
by the Board of Health.
q
nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
`iii
due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
_obstru"cfion is removed
_distribution box is levelled or replaced
nla 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
a,
l.i
la
a
revised 9/2/98 Paae 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 118 CLIFTON`LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Date of Inspection: 10/2100
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I;
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER,THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
A.
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 septAc,tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
f
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance n/A (approximation not valid).
3) OTHER
nla
LS.
i
3
E
1 ''f
revised 9/2/98 Paoe 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Date of Inspection: 1012/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n1a.
X Any portion of the Soil Absorption'System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health
and safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a`surface drinking water supply
,14
X the system is within 200 feet of a tributary to a surface drinking water supply
�;
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply
well) y
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of
the Department for further information.
r
f}
irk
et
revised 9/2/98 Paae 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner: CHRISTE CHRISTO
Date of Inspection: 10/2/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X - The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material
of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site
has been determined based on:
X _ Existing information, For example, Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)j
X - The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
,t
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Date of Inspection: 10/2/00
FLOW CONDITIONS
RERIDFNTIA ;I '
Design flow: 110 g.p.d.lbedroom
Number of bedrooms(design): 5 Number of bedrooms(actual): n/a
Total DESIGN flow: 550 gpd
Number of current residents:2
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): YES
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
C O M M E RC IAL/I N D U STRIAL
Type of establishment: n/a
Design flow: nla gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no): NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no): NO
If yes,volume pumped n/a gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy
_ Shared system(yes or no)(if yes.attach previous inspection records,if any)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all componerits!date installed(if known)and source of information:
1988
Sewage odors detected when arriving at the site:(yes or no): NO
revised 912/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Date of Inspection: 10/2/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 12"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
TOWN WATER
t
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 6"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 5'7"W 4'10""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet`tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
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
Date of last pumping: n/a
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.)
n/a
C
revised 9/2198 Pane 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Date of Inspection: 10I2I00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: nla
Capacity: n/a gallons
Design flow: nla gallons/day
Alarm present: NO
Alarm level:NIA Alarm in working order: NO
Date of previous pumping: nla
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nla
DISTRIBUTION BOX:X
(locate on site plan) `3 ;
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nla
:I
4
L revised 9/2/98 Paqe 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Date of Inspection: 10/2/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits, number:(n/a)n/a
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (1)LEACH FIELD
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY.
CESSPOOLS: _
(locate on site plan) ^ti
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a u;.
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
E
revised 9/2/98 Paae 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Date of Inspection: 1012100
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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revised 9/2/98 Paae 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 CLIFTON LANE WEST HYANNISPORT, MA 02672
Name of Owner CHRISTE CHRISTO
Date of Inspection: 10/2/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: nla
USGS Date website visited: nla
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 10 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
UGSS MAPS AND CHARTS-10+FEET
revised 912/98 Paae 11 of 11
Fims.$ .5.00
O THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH .
e � ............. Town...........OF.....R&M$1able... .................................................
�Appliration for Uhqvviial Blorkii Cfnn,olrnrtinn ramit
' i hereby made for a Permit to Construct or Repair x an Individual Sewage Disposal
Applications e y O p O g p
System at:
..Clifton Land..........G '1 ��xvil ,c.,..Ma.... ----•---#---2,6--------------------------------------------------------------------------------
.._....
Location-Address or Lot No.
--Chri s to-_Ch R ........ ................................ ....... (a..C�.i,f tort...L�ane-.--•-•----•--•----•-------------------------------
Owner Address
WA&BCanco _350--MainST.....---..W....Yax.E oUtb,.--Ma- .................---•..............................................•---..._....
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............_ .Expansion Attic ( ) Garbage Grinder (YO)
'4 Other—Type of Building No. of persons...... _______________ Showers — Cafeteria
a YP g P ( ) ( )
Q+ 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—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 ( ) 4-
Percolation Test Results Performed by................................................-•-----•-•-------_------ Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test-Pit..................... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ra'
0 Description of Soil.............................................................................-----------------------------------------------------•--------------------.-------•-.-----
x
-------------------------------------------------------------------------- ------------•-•----------------------- - .........................
U Nature of Repairs or Alterations—Answer when applicable._.._15QII---gal lion--- ^--tan .-t4i-th--D-9e3e--
= -------
Agreement: fl'z-L Is+,OY1
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL i 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed �_7ta. -------------------------------
Date
ApplicationApproved BY................-------••--�-Q-..... ---- .... ---- -----•--------•-------•--•------- --•-----
Date
Application Disapproved for the following reasons---------------------------------------------------------------•-------------------------------------------------
-----------------------------------••-------•----------------•---•---------------•-----...------------....---•----•-------------------------............................................................
Date
7RCU" O
PermitNo......................................................... Issued.......................................................
Date
No."`..: ..: :. .. FxA15,Od..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................zwn...........OF....BAMG.tab..0........................................................
, pplirtttion for %gpoottl Vorko Tonotrnrtion thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
..C1iEto_v.. e.......-.cexxterviues__l+ia.............. .......t#--26--------------------------------------------------------------------------------
Location-Address or Lot No.
Ghz ---------------------------------------------------------
_.CuftJOTI__J.4ane...................................................
Owner Address
a A&BCanco 350 Main6T..---__..► ... ? l ou.,tJ4.
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder P)
Other—Type of Building No. of persons............................ Showers — Cafeteria
Q' 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—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........................................
aTest 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........................
--•-•---••-•-•--------------••-•-•••----••------•--•--•••-••---•---••._..__...................-••-••.........................................................
ODescription of Soil..................................--------------------••-----•--•------•---------------------------------------------------•-•-------------------------•-••--••--__----
x
c,
x ------------------------------------------------------------------------------ ------------------------------------------------------•------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.___.1500--gallon___ a �ti(,.-..t&7At .�7Lt1`l
J
Agreement: t z 1t `�, '` '{"�D�1 fir,,.,
The undersigned agrees to ins all the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
— Signed---------------'----•-----•----•---......------------....__.......•-••-••-••-•-•----•. ••-•••••-•..:...........__...._
)� Date
Application Approved By.._..-------••-•-- ..-- 1.i t �1==`=------------------------•----------•---•-- ---------.---....... �==-!'-----.
Date
Application Disapproved for the following reasons:•-------------------•--------------------------------•--------•-----._...----------------------•--•----•.._...--
.............................................................................................................._...._....__._.____...______.__....._....._________._.______..____....___......_..._..._.._
Date
PermitNo........ ca C -----•--M�.......................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................Tin..........OF......13arn s tab le..............................-•-................
�rrfifirtt#le of f�onttittnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (x)
by -A& B C.anco ..._... .Maim. .._........W....yat Qmthl._Jft......................................................................
Installer
at.....2b-_Clifton__Lane............. enterville.*_..Ma..-- ------Chrxste_Chp sto•-------•..................•------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code Rs described in the
application for Disposal Works Construction Permit No.___.._.e'-:_.S _-:____--==�____. dated----------- ..�._�./__L'_�_------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTES THAT THE
SYSTEM WILL F NC ION SA�IS �ORY.
DATE.-•----••-••••• ------------------------------- inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Christe Cbristo
TE'>W�.............OF........Ba tt:�.ale.........--"--•--•---.........._............_..
NoC ....::a FEE...!3 Ap ......
Disposal Worko Tonotr ion . amit
Permission is hereby granted-------------------------------------------•--.---••-•----------------------
•---------
-----------------------------------------
.........._._.. "
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No C__-. v__ Dated___J .........................
~ :....:{.............••--•----•----------------------------------------•••-•----•-..._•-•--_...._
Board of Health
DATE......... =�!�- .............................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS t
ASSESSOR'S MAP NO. PARCEL
LOCATION LUT Z(,-) CC/ SEWAGE PERMIT NO. $
V I L L A G E C _Kj-r CP_v ILL c_
N S T A LLER'S NAME i ADDRESS
�' UILDER OR OWNER
DATE PERMIT ISSUED 1
DATi' E COMPLIANCE ISSUED
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ASSESSORS MAP : 2-/7 LOGS
TEST NCLE
PARCEL : — NOTES:
f FLOOD ZONE G✓ Al_ E—!G SOIL EVALUATnR : D ✓�
WITNESS : r >� € � I C��.�
� 1) The installation shall comply with Title V and Town of Barnstable Board of
-0 REFERENCE : ,3 ,�` -- /�� 9 15 DATE : V Ems, (DC"�c�
� � � _�� Health Regulations.
p 1 PERCOLATION RATE : "Z k d 2) The installer shall verify the location of utilities, sewer inverts and septic
1r - -- - _- - Z components prior to installation and setting base elevations.
/ 3"Qd ` --- �� { ,� �g TH- 1 TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
" two feet out of the d-box to the leaching shall be level.
0� " t �l L,L- 4) This plan is not to be utilized for property line determination nor any other
ell purpose other than the proposed system installation.
V>twe 6N ( I,[> ��- ��° lt' 5) All septic components must meet Title V specifications.
k( D �1,, 2� 6) Parking shall not be constructed over H10 septic components.
L 0 CA T I ON MAP�� k I Z 7) The property is bounded by property corners and property lines.
� i 8) The property owner shall review design considerations to approve of total
design flow and number of bedrooms to be considered for design. Receipt
of payment for the plan and installation based on the plan shall be deemed
I approval of the design flow by the owner.
�j 9) The existing leaching or cesspools shall be pumped and filled with material
per Title V abandonment procedures. Those within the proposed SAS shall
be removed along with contaminated soil and replaced with clean sand per
Title V specs.
,X ; 10)System components to be 10 feet from water line. Sewer lines crossing the
water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
SEPT I C SYSTEM DES I GN
applicable. The proposed SAS is being installed below the water service
x f line. The line is to be sleeved as aforementioned and maintained in place.
f' 11 If a garbage grinder exists it is to be removed and is the responsibility of the
FLOW ESTIMATE MATE ) g g
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..� owner to ensure such.
� "ENE ', BEDROOMS AT 110 GAL/DAY/BEDROOM -EFO3AL/DAY 12)The installer is to take caution in excavation around the gas line.
13)The installer shall verify the location, quantity and elevation of the sewer
► lines exiting the dwelling prior to the installation.
SEPTIC TANK
14)Excavate 5 feet around the SAS and below to a depth of approx. 112" (to
-
-"'� GAL/DAY x 2 DAYS - ��� GAL med. Sand ) and fill with clean sand per Title V specs. Excavation depth
US!' 6WGALLON SEPTIC TANK X_11j; 11%4('C may vary.
J
"fo I _ABSOF;;PT I ON -SYSTEM
1. I�_
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► -- -� 'n s 1 DE AREA: I Z Z + 4 x ' . ."
1 BOTTOM AREA: IZ � -
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SEPT I C TANK
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S I TE AND SEWAGE PLAN
°) \ -- _UH �f-#rr¢As�1 fi�.f< LOCATION :
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PREPARED FOR :
4
ZF-I� SCALE :
C,T ,�
— �. DAV I D B . MASON DATE :
o DBC ENVIRONMEN AL DESIGNS
EAST SANDWICH . MA
w DATE HEALTH AGENT ( 508 ) 833_ 2 1 77
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