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HomeMy WebLinkAbout0007 COACH LIGHT ROAD - Health 7 Coach Light Road Centerville P A = 172 101 i UPC 12543 a No...53..R HnSTINGS MN Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road - Property Address Bank of New York Mellon Owner Owner's Name / information is Centerville ✓ Ma 02632 3/12/2021 required for every State Zip Code Date of Inspection page City/Town 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. inspector Information filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmaii.com, SI4522 sean@smjonestitle5.com Ucense Number B. Certification I certify that:I am a DEP approved system inspector in full compliance with Section 15.340 of Titie 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed.based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails �.�...:._ 3/12/2021 Inspector's Signatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7I2812018 Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owners Name information is Centerville Ma 02632 3/12/2021 required for every page CityfTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The property located at 7 Coach Light Rd Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank and 2 1000 gallon precast leach pit. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain: The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•my.7J282018 Title 5 official inspection Form:Subsurface Sewage Disposal System'Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's Name information is Centerville Ma 02632 3/12/2021 required for every State Zip Code Date of Inspection page Cityrrown C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): I 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: l5insp.doc•rev.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road - Property Address Bank of New York Mellon Owner Owner's Name information is Centerville Ma 02632 3/12/2021 required for every page. City/Town State Zip Code Date of inspedion C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: I **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.71260018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form IVY" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's Name information is Centerville Ma 02632 3/12/2021 required for every State Zip Code Date of Inspection page City/Town C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 El ® 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. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ® The system fails.I have determined that one or more of the above failure El criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doo•rev.712612018 Trite 5 Official inspection form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's Name information is Centerville Ma 02632 3/12/2021 required for every State Zip Code Date of Inspection page Citylrown C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ® 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)] t5insp.doc•rev.712612018 We 5 Official inspection Fom Subswfaoe Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owners Flame information is Centerville Ma 02632 3/12/2021 required for every State Zip Code Date of Inspection page Cityrrown D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes M No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No unknown Last date of occupancy; Date isinsp.dOC•rev.71282018 Title s official inspection Form:Subsulaoe Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owners Name information is Centerville Ma 02632 3/1212021 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7rN=18 Title 5 Official Inspection Form:subsurface Sewage Disposal system Page 8 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's Name information is Centerville Ma 02632 3/12/2021 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Tank and one pit original second pit added 1993 _ Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.712 Oi 11 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's Name information is Centerville Ma 02632 3/12/2021 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 6. Septic Tank(locate on site plan): 1 Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000 gallons Dimensions: 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' 2" Scum thickness 7" Distance from top of scum to top of outlet tee or baffle -- Distance from bottom of scum to bottom of outlet tee or baffle 10" Opened covers and took How were dimensions determined? measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank needs to be pumped now and again every 2 years for proper maintenance. water level was even with outlet,tank was not leaking and was structurally sound. 15insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's Name information is Centerville Ma 02632 3/12/2021 required for every State Zip Code Date of Inspection page City/Town D. System information (coat.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp doc•rev.712612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's Flame information is Centerville Ma 02632 3/12/2021 required for every page City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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_): t5insp.doc-rev,71262018 Tale 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 12 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon _ Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2021 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ teaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: t5insp.doc•rev.7/2612018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(coot.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 2 leach pits. Both pits had approx. 1'standing water at time of inspection. Original pit#4 on as-built has signs of past failure. Pit#3 on as-built has a stain line approx 12"below inlet invert. System is nearing the end of its usefuil lifespan. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•rev.7t26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owners Name information is required for every Centerville Ma _02632 3/12/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7f W018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Owner Owner's Name information is Centerville Ma 02632 3/12/2021 required for every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r;�` 0 1 E� 33 A7 23 39 *2 L/ t5insp.doc•rev.7lZ6*018 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's(dame information is required for every Centerville Ma 02632 3/12/2021 page. C4frown state Zip Code Date of Inspection D. System Information (coat.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth g g th to high round water. 1 fee et Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc rev.72812o18 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Uo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Coach Light Road Property Address Bank of New York Mellon Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2021 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed &Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,2; 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.MUM 8 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 18 of 18 RECEIVED MP OCT 252004 PARCEL j TOWN OF BARNSTABLE HEALTH DEPT. ;. DATE 1 o/1 /o4 PROPERTY ADDRESS 7 Coachlight Road Centerville Mass 02632 On the above date, the..aeptic system at the address above was Inspected. This system consists of the following: 1 . 1 -1000 gallon tank 2. 1 - Distribution Box 3. 2-1000 gallon leaching pits. Based on inspection, I certify the following conditions: This is a Title Five Septic system ( 78Code) The septic system is in proper working order atthe present time. SIGNATUR Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. O. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 (. JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-333.8 775-6412 • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIR,©NM"PNTAL AFFAIRS r" DEPARTMENT OF +NVIRON�ViEN'1`AL pRO�1TICTION d • y TITLE 5 OFFICIAL INSPECTION FORM—•NOT"F I., TARSYSTEM FORM SUBSURFACE SEWAGE DI PART•A CERTIFICATION Property Address•• 7 Coa 6h i ; nh t Roar] r pnt-ervi 1 1 P Ma Owner's Name: James Kraskouskas Owner's Address: 12 Pear o 02440 Date of Inspection: 1 0/1 /0 4 Name of Inspector:(please print) Robert Paolini. Company Name:�a. % I�c�come2 & .SAn Mailing.Address: en e2v c e, ab a. 026 3,Z Telephone Number: 5 0 8—7 7 :3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system.at this address and that the.infotmation 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 o on qite 31 GNiagdisposal ispo al systems.sys I am a DEP approved system inspector pursuant tu•Section.1�5c340 f XXXPasses Conditionally Passes N Further Evaluation.by the Local Approving,Authority F s Inspector's Signatmres Dater l� /l a The system inspector shall submit a copy of this inspection report-to the.Appmving Authority.(Boars of Health or 000 DEP)within 30 days of completing thisinspection.sll submit the report to f the systeM'Isa.shared.thetem or has a agp opnate regionaesign floffice oow of f the gpd or greater, the inspector and the system DEP.The original should be sent to the system owneY and copies sent to the buyer,if spp[icable,and the approving authority. Dotes and Comments �. ****This report only describes conditions at the time of inspectioir 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. A/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTIONYORM--.NOT FOR VOLUNTARY ASSESSME°'NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PARTA CERTIFICATION(continued) Property Address: 7 Coachlight Road c'�Nnterviiie_ Ma Owner:lames Kraskouskas Date of Inspection: 1 0/1 /0 4 Inspection Summary: .Chi& A;B C,D or.E/ALWJAY'S�complete all of Section.D A. System Passes: I have not found any information which indiCates`t'haf�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: septic system is in porper working- order at the present time B. System Conditionally Passes: NO One or more system components.as described in the"Conditional'Pass"lsection�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. NO •.The septic tank is metal.and.over 20 years old*or the septic-tank(whether metal.or:not)is structurally unsound,exhibits substantial!infiltratim or exfiltration or tank failure is.imminent: System.will pass inspection if the existing tank is replaced with'a complying septic Vnk.asapprvved by.theZoard 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: NO 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. . obstrudtion is removed distribution box is leveled orreplaced ND explain: NO 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 pipes)are replaced obstruction is removed ND explain: Page 3 of 11 INSPECTION EORIVI-NOT,VOR V.OL. NTA.Ry ASSESSMENTS OFFICIAL I s : CTION.�`O� SLTgS1�7RFACE SEW�I:OE O'ISROSAL SYSTEM INS.P'E PART°A CERTH ICA ION(6ontinued) ddres s; hli ht. Road Property A no„tArvill e Ma Owner:. r skouskas 1 94 Date of Inspection: 1 . C. Further Evaluation-is.Requfred by the Board of Health: _ Conditions.exist which require further.,evaluation-by.theBoard:of�Health=in•order;to:detertriine ifthesystem. � is failing to protect public health,safety or the environment. 1. System will pass unless Board-ofd-of Healh a matt ertwhi he.wmlll protect publicnheace lth,safety and the environment the system is-not functioning in. �g 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. Supplier ),determinesahatthe •if an 2. System will fail unless the Board:of Health(and Public Water 1 Y Su pp system is.functioning in a mariner.that protects the public health,safety and environment: NOThe system has a septic tank and soil absorption system(SA-S)..and the SAS is within 100 feet-of a surface water supply or-tributary to a.surfface water supply. • NOThe system has a septic tank and SAS and the:SAS is�within a Zone 1 of a'public watersupply. NOThe system has a septic tank and.§AS:and-the-SAS is within,.50 feet of a private water,supply well. NOThe system has a septic tank and SAS and the7SAS is less than 1Measured feet or:niore 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 at ac lity and bacteria and volatile organic compounds indicates that the well is free from-pollution from ovidhd tf atino other the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,p failure criteria are triggered.'A copy of the analysis must be attached to-this form. 3. Other: Page 4 of 11 OFFICIAL"INSP.ECTION FORM•-NOTTOR;VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOMFORM PART A CERTIFICATION(pontinued) Property Address: 7 Coachliaht Road C'r�ntcpryi 1 1 P Owner:James Kraskouskas Date of Inspection. 1 © 1 (M D. System Failure Criteria applicable to all systems:. You must indicate-"yes"or"no"to.each.of the:following,for all.inspections: Yes No I Backup of sewago:iuto-fatAiry.or system:component.due_to overloaded,oi clogged SAS..or.cesspool Discharge,or-ponding of effluent to ft 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 ' Liquid depth in-cesspool is less thank"below invert or,available volume is less than Wday 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. _ X Any.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion,of a cesspool-or privy is within a;Zone 1,ofa:public.well.. x 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 pollutioq:fr..om: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 attache&to this foriq.] No (Yes/No).The system falls.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.afacility,with a design flow of 10,00.0 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 x the-system is within 400 feet of a surface drinking water supply the s stem.is within 200 feet of a tributary to a surface drinking water su 1 — ._ .X Y �'Y g. PP Y 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 gLiRSURFACE-SEWAGE DISPOSAE:°SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 CoachliQht Road Centerville Owner0ames Kraskou kas Date of Inspections; '1 0 04 ' Check'if the following have been done.You must indicate"yes"or"no"unto each.of the following: Yes No X Pumping infoftnation was provided-by the 6wner,occupant,or Board.of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as-part of thkinspoction? Were as built plans of-Abe system•obtained and examined?(If they were not available�hote is N/A) X 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,i4ludingthe 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? X..— Was.the facility owner(and occupants if diff6rent.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 detemthaed based on: Yes no , — __X. Existing information:For example,.a plan at the Board of.Health. " X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation.-of distanc is unacceptable)[310 CMR 15.302(3)(b)] w 5 w Page 6 of 11 OFFpCIAL INSPECTION:-f rQRM'! 1NO'T FOR VOU NTARY ASSESSMENT'S SIBSU-RFACE-SW- AGE DISPOSAL SYSTUM,INSPEETION:FORM ' PART.0 SYSTEM INFORMATION PropeMAddress:7 Coach-light Road Centerville Ma Owner:James j(raskouskas. " Date of Inspection: 1® 1 0 4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):aA Number of bedrooms{actual): 4 DESIGN'how based on-310 C1GIE 15.�03':(for example:•110 god ii#-ofbedroomsy--4X1.1 0=4 4 0gpd. Number of current residents: .:3 Mes-,residence have a garbage grinder(yes br no):no is laundry on a separate sewage.sysiem-(yes or-no)no [if yes separate inspection required] Laundry system inspected(yes or no): no , Seasonal use?(yes orno):Yes 02_18, 000 gallons G.P.D=49.32 Water meter readings,if available(last 2 years usage(gpd)): 0 33 l l o n s G.P.D.=3 5. 6 2 Sump pum (yes or no): no Last date o�occupancy: season a 1 COMMERCIUSTRIAL - Type of estala kh • h t: NA Design flaw W on 310 CMR.15.203)% NA mod' Basis.of dig i flow(seats/persons/sgtetc.): NA Grease trappresent(yes or no): 8 industrial waste holding tank present.(yes or no)1QA Non-sanitary waste discharged to the Title 5 system•(yes or no):_ Water..meter readings,if available: NA Lase.date of occupancy/use: . NA OTIIER(describe):. N V . UNERA,L INFORMATION h Pumping Records Source of information: 6/9/0 3 pumped-by J _ Ma cnmher & son Inc Was system pumped as part of the inspection(yes or no):LU If yes,volume pumped: gallons--How was quantity pumped determined? _ Reason for Pumping: TYPE OF SYSTEM • X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Priory _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: 30 + years Were sewage odors detected when arriving at the site(yes or no):nQ- 6 - Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A PART C SYSTEM INFORMATION(continued) Property Address: 7 Coachlight Road Centerville Ma Owner: James Kraskouskas Date of Inspection: 10 110 4 A BUILDING SEWER(locate on site plan) Depth below grade:1 6" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply_wel�—or suction line: 10 0=f e e Comments(on condition of j oinW,venting,evidence of leakage,etc.): All joints are tight No signs- of leakacre. Vented through house vent. ' SEPTIC TANK:v e g(locate on site plan)1000 gallon Depth below grade: 2 4" Material of construction:X concrete_metal _fiberglass_polyethylene _other(expIain) If tank is-metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: . 5 ' 8" H X 4 ' 1 0"W X 8' 6" L Sludge depth: trace Distance from top of sludge to bottom of outlet tee or baffle: 0, Scum thickness:trace Distance from top of scum to top of outlet tee or baffle: 0 Distance from bottom of scum to bottom of outlet tee or baffle: 0 How were dimensions determined; measured . Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): P'Umptank every 2 years. Inlet & outlet tees are in ,place. Tank is structurally sound.No signs of leakagizi. GREASE TRAP: NWocate on site plan) Depth below grade: NA ' Material of construction:_concrete metal_fiberglass_polyethylene_other (explain): NA Dimensions: NA Scum thickness: NA Distance from top of scum to top,of outlet tee or baffle': NA Distance from bottom of scum to bottom of outlet tee or-baffl— e:-ITA Date of last pumping: NA Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc):. Grease trpa is not present.. Title S Tnan4M4nn 17nrm Ail a,)nnn 7 Page 8 of I 1 OFFICIAL INSPPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continues}) Property Address: 7 ad rCentervIlle Ma 02632 Owner:-James Kra k I Date of I•ispection: 1 0 1 TIGHT or HO1rDING TANK: NO(tank must be pumped at time of inspeotion)(locate on site plan) Depth below grade:NA Material of construction: concrete metal fiberglass--polyethylene other(explain): NA Dimensions: NA Capacity: NA• gallons Design Flow: NA gallons/day Alarm present(yes or no): NA Alarm level: .NA Alarm In working.order(yes or no): Date of last pumping: NA Comments(condition of alarm and float•switches,etc,): Tight or holding tank.-; arp nnt-, pgPCPnt _ DISTRIBUTION BOX: os (if present must bs opetted)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc,): Distribution -box is level. Has 2' laterals. No signs of .solids carry over or leakage. PUMP CHAMBER: NO (locate on sife.plan) Pumps in working order(yes or.no): NA Alarms in work4 ng order(yes or no): NA Comments(note condition of pump,chamber,condition of pumps and appurtenances,ett:.); Pump chamber is no prgsent_ 8 . - Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.I?ISPOSAL.SYS'FEM INSPECTION FORM PART=C SYSTEM INFORMATION(continued). Property Address:7 Coachlight Road Centerville . Owner.James KraskoLGkas Date of Inspection: 1 0/1 /0 4 M SOIL ABSORPTION SYSTEM(SAS): {locate on,site plan,excavation nqt required) If SAS not located explain why: See page 10 Type X leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Loamy t-n merli ,im sand No ci cinG of } ydzaiil i re fai l me o.r ponding Soils are dry 'Vecretation is normal CESSPOOLS:o(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: NA Depth—top of liquid to inlet invert: NA Depth of solids layer: NA Depth of scum layer: NA Dimensions of cesspool: NA Materials of construction: NA Indication of groundwater. inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Cesspools are not present PRIVY:�Q_(locate on site plan) Materials of construction: NA Dimensions: NA Depth of solids:NA j. Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Privy is not present Page 10 of 11 p'p'nCL4L.TNSPF' '�TQN) 'OR1VI NO'F-1�OI �VOI11{JNTA�SON 1F'QR SSESSMENTS ' STSSUMACE'SEWAGEM14SP R tS �?EEAT.IN PA SYSTEM P-MRMATI.ON(ic®ntifived)' Property Address:Z d Centervil e owner; James Kr skas Date of Inspection: 94" SKETCH OF SEWAGOISPOSA,L SYSTEM Provide a sketch of the sewage disposal system in neSubl to aitc lwa,teeastr supply ento stthe bu lding flr benchmarks•Locate all wells within }00 feet.Locate where p », 4 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOL 'TINSPECTION FORM ASSESSMENTSARY SUBSURFACE SEWAGE DISPOSAL SYSTEM PART C SYSTEM INFORMATION(continued) Property Address: 7 Coachlight Road Centerville Owneniames Kraskouskas Date of Inspection: 1 0/14 4 SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 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 Mviewed: Observed site(abutting property/observation hole within 150 feet of.SAS) Checked with local Board of Health-explain: Checked:with local excavators,installers-(attach documentation) Accessed USGS database:explain: —. You must describe how you established.the high ground water elevation: an s used,•Gahert & Miller model 12 1 used•USGS observation w wm�used- :'Technical bull - — wa er a eva ions. Leaching Q Pit , : 'eet Groundwater: Feet Below Bottom of Pit Hi&h Groundwater Adjustment 1.8 ft prj F inptejMethod g Therefore,the.vertical•separation distance between the bottom J of the leact ing pit and the adjusted groundwater table is feet. • tt �a•nnr\T•—ni•f�•rr•♦rrlr nit'P1Trn��TesrEr.•ra(rnrT+r4rrl+rrT�^r 1fRTly r+V'�r'r�n�+ 11'014N OF Barnstable BOARV OF HEALTH S1I)9UIZFACF 9ENAOR I)ISF'OSAL�SY9TEM IN911FCTION FORM - PART D - CERTI F1 CATI ON f..•are•r••.•... -r• n-.rrn:nr.+n•nmr rwrr ms•rrrn+'n�'t—•.��mr.stenwr-n'*T". rrw"=r.F"WW" -T`pt OR PRINT CLEARLY- PIWERTY INSPEC7'ED STREET ADDRESS 7 Coachlight Road ASSESSORS MAP , z) QCK AND PARCEL # 1 72-1 01 James Kraskouskas OWNER•' s NAME PART U - CERTIFICATION NAME OF INSPECTOR Robert Paolini COMPANY NAME Joseph P. Macomber • &- Son Inc COMPANY ADDRESS ^ Box 66' Centerville Mass 02632 Street Tovn or C ty State lip COMPANY TELEPIiONE ( 508 ) 775-3338 FAX ( 508 ) 790-1.578 CERTI HCAT•ION. STATEMENT I certify that I .. have personally inspected the se.wage ' dieposal system 1 ;this address and that the information reported is true., accurate, and ,.,this as of the time of �inspectior�, The Inspection was performed and any 'recommendations regarding upgrade , maintenance , anti repair are consistent witli my' training and experience in the proper function and maintenance of of site sewage disposal systems . .Check one : XXXXSysteai .PASSED ' The inspection which I have conducted has not found any information which indicates that th.e system fails to adequately protect public he.R1Cll or, the environment, as defined i.-n 310 CMR 16 . 303 . Any . failure criteria not evaluated are as stated in the FAILURE CRITERIA section o this form . System FAILED* The inspection which I have cQnatloted has found that the system fails Protect the Eitlb.lic health and the environment in accordance with Title 5 , 3.10 CMR 15 , 3Q3 , and as specifically noted on PART C FAILURE CRITERIA of this in pect ' o fo � Y` v • - Date Inspector Signature . f. one copy of this cp-rc.t.fication must be provided to the OWNER, the BUYER ( where applicable ) and the I30nRQ of HEAlr7`It, * If the inspection FAILED , th*e• owner orIop.erator. shall tapgrado ' the vyetem within one year oP the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 , 3,06 , partd . d ,, s `i ,€ r,f tom✓ 4b.<, f x) #� d r a sx y c v rs `t�'y r 1 ,g,;z g r- s r x 'a v s -a i3,§-a.�''� <4-ac u.�r' r +,r�x rr ,r`'" �'' > ar 4 d +`' .. 1 S,: t Wit' uN`„y,�L T"TaL .,"' 'k„' �a ?,ti• 3k r7f f L `'+'"9 2 d 3, R } t "r"r a x7 "s3.i �z a t-'�' f i �,r� -L �t ..e� 5'?M.- U„-s�`sn .'+''i _ .r C� 'zv" a r <x n., 4 y�;. 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Y + µ t-n 4 '�> '-?.,.�.�'`C?ol,",. - e1/a -r a> *'2j ''" -{'.A.z :�z ,p'f: �N r _..I .� a��t$ x ''�#' s., t�r4; F;.r ` vd. - ,✓e.,tr.,,�. y� .s f 4.9'y�`.'f§c '' i' "a 6 =y y`,x .' -t ti F, +' 'H� i x^�c C 4,l�;J. �''y" �'�`_-' ,.:. j`' '� �:+� ^ym,�,a,- Y W ? 'k � j.` � s^ �+E,;., tom€ 'e�Yr ,s�, � r {kr y,�j s raft W .I h / v ; 132 .. # .s°'..4 g is'S`, f>tz :r, J- ar> i. `+,t,_. 41 "� sa 3,� 3a .-__,' S!T"�5 4 �r � ''F� 'fi ''"�'-i�"'`�' ''zs -.�]� 8)v z � 14t Pw ,� 4. .h cc s { �` f7�q��,,r ��i.'�� — �• z 3`{,4jy'-}ir*�. nrE .. t ' rx r.;t e ..,i _ I -.��:�m� �. 1. . _- > s �S, Yr<y,. 3 {ro r"; ^tb i✓ i a•`t `~�' f v 1y r Yay .i p E TOWN OF BA STABLE LOCATION SEWAGE #(:73 VILLAG ? JiL�� ASSESSOR'S MAP & LOT - Q INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ��1"iA'9- "-` (Size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERQ� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes N v;sT"-. ,L-m elf � i aao Bch Q�� Lf CT E e-,, -'' TOWN OF BA ISTABLE LOCATION (!&dv(aA( SEWAGE VILLAG ASSESSOR'S MAP & LOT Q INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY L`( LEACHING FACILITY:(type)�C 1 U` (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Kf( S ' DATE PERMIT ISSUED: a R DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No� ' 1 d `7 X1'ro iew No....B • Fs$ THE COM O EALTH OF MASSACHUSETTS R® � HEALTH .................OF....... .. Cil��1 .._..._........._._..._...... Appliration for Disposal Works Tonstrurtinn Fami# �lApplication is hereby made for a Permit to Construct (, or Repair ( ) an Individual Sewage Disposal Sys}em at- 61* .........7 ---------- --- - - Location-Address --• or.. Lot No. ---------- wner _----•----_-_-•.-•-•--•-.-------Address ller Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........ ...........................Expansion Attic ( ) Garbage Grinder ---),�v ' aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtur ---- ----------------------•----------------------------------------------------•••-••-•••-•----------------------••----••--•- W Design Flow___...._............ ________________gallons per person of Oy. Total daij�Y'/flew... _______....._________.galpns. WSeptic Tank—Liquid capacity�l���gallons Lfngth�Z______ Width._�f__7___. Diameter________________ De th�_�.. __._____._.. x Disposal Trench—No......../.......... Width..../L%......... Total Length___,e.�....... Total leaching area__�sF�____sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area................. q. f . Z Other Distribution box ( ) Dosing to ) �./_ / q '-' Percolation Test Results Performed by..... ._C?_f �PA1._../ e- Date_ __g �l 7j------------------ Test Pit No. 1.... ._ __minutes per inch Depth of Test Pit_.�Z•O_��____ Depth to ground water.___ .__.. ...... f=, Test Pit No. 2.... _minutes per inch Depth of Test Pit.../le_ .... Depth to ground water....1,4._�y....... w 3 z 110 K.... .._..._y......�1.. ... 0Vw r 4./i 4-1 ►t fir ) �Descrton o So• - - - ------ ------ -------------------� ''/ 1444�,V:- p - �9QR /�......_U Nature of Repairs or Alterations—Answer when applicable.......... _{a 4l T_.SUPEr", •------••---- ---- FSIGNING Eh(GIc� �TIF`� Ild NTFr w its a Agreement: N!TALLATION A13% _ ,.s.( rr-Nn \VAS INSTALLED IN b The undersigned agrees to install the aforedescrib Nidual•Sewage Disposal S m i' accordance with the provisions of i I - 5 of the S e S -tary C h ersi ed further agree(not place the system i operation until a Certificate of Compliance s en su t oar ea Sin --- ---------- ......... ----... ate Application Approved By......................___________ __Gl... ._ . Date Application Disapproved for the following reasons________________________________________________________________________________________________________________ ...................••--------.._...._...-.--------...--------...-•------------._.._.._...--•---------•--------•----.._......--------------------------------------------•----------------••-----.... -2 -7 e Date PermitNo....... ................................... Issued_..................................................... -- Date V n �3�'� THE COMMONWEALTH OF MASSACHUSETTS lA BOARD F HEALTH Tn#if iratr of Zomplianrr THIS IS O RTIF , That the n ividual Se a isposal System constructed or Repaired ( ) by..-- .... - � - ••--••. - -----••-------------•------------------------------------------------•--------------------- / 1, 4- C ... ................................................................ has been installed in accordance with the provisions of T ,?fZ'7—; 5 of The St to Sanitary Code s d�jscribed in the application for Disposal Works Construction Permit No._ __�_2. .. dated I ��Z•-`--�-��............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... 101 No... . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE f -pp ir iiul Works Cnomitrnrtinn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (l,)"an Individual Sewage Disposal System at: ocation-:\ ress or Lot No. J.....�.....�......�...................�... .............. -___._______-. __----`' cc .......................... .____....._._.. .......p Ad es i Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.--. ....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons___-__-__--___------_._.-- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- - - Design Flow------ .......----••--• ��E- Ions. W g gallons per person per day. Total daily flow....._r .___ gal WSeptic Tank f-Liquid capacit�j�_TV_.gallons Length---1:0------ Width_- ....... Diameter................ Depth................ x Disposal Trench--No. .................... Width-------------------- -Total Length.................... Total leaching area....................sq. ft. � t Seepage Pit No.......�....-_._._. Diameter._._./'0. ._t__..._ Depth below Inlet... ............... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-__-_-___-___---_.._ Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit............._...... Depth to ground water........................ P4 ....•------•...................••-....--••-•••-•-•-•-•-••-•••••-••-•••-••-•-•-•--•--•---------...•--......................................................... 0 Description of Soil........................................................................................................................................................................ w ------------------•--------------•----•--•--........--••--•------- ---•---•--•-------••---•---•--•---•--•••••----------•--•--•----••-•--•••-•••-•---•--•---••••-•-••--•-••--------•••......---........ U Nature of Repairs or Alterations—Answer when applicable----� 5- ...... �5!'77..s-G ?. ................ ..---•--....----..c -' :�Y..............& &A-4.�a-`-�`1_ ..... ..._--------------•----•-------------------•----•-------...---•--•-•-•---•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with .the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Co s been is e the board - health. Signed .......... - ...........................:...... Date Application Approved B ...................... . . ....... . . .--. PP PP Y �. Date Application Disapproved for the following reasons: ..................... ............... . ....................... .......................................................... .............................................................................................................................................................................................................. ........................................ Dat C� e Permit No. ....../.. -..-... 7. ................... Issued -_--------.7��..7.-..5.2> ................ Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a TOWN OF BARNSTABLE 7 . Appiiratil�n for Diripuiul Work,6 Tomitrurtinn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair (Li)an Individual Sewage Disposal System at: " thT - vt � `t cr t'�=L Location-Adtliess or Lot No. • ---•--•--•-•-------------------- ................................ .......-'..................................................... Owner Addre s ; ....-•-•-•-•... --------- .....1 ---•• ------••-•-.-•---------••-••--• Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms---.,.�. ....................................Expansion Attic Garbage Grinder aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QOther fixtures -------------------------------------------------------------------------------------------------------------•---------------...--•---............... '' .......................gallons per person per day. Total daily flow ....................gallons. W Design Flow....... .....: .. g� P P P Y Y Pr Septic Tank;Liquid capacit !*+.!.gallons Length---1_.!...... Width... !__---. Diameter---_........... Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------/........... Diameter.....A. 7 ------ Depth below inlet...ln............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ --••-•----------•..........._•-••-•••-••--•------••--•••-----•--•-•••••...................•---------......................................................... 0 Description of Soil........................................................................................................................................................................ x w ----------•---------------------••----•-------•••. --------....-••-•••--...------------••-•-•••-----•--•---------•---------•----•-.....••--•--••---•--••-••-•-•••--•-......------......-••--•-•-•-- U Nature of Repairs or Alterations—Answer when applicable.--- r"U`-.=`N_iat--_____.1.`? .. � !!..�:.................. ...........................�.....::t!.....___...........�.`...... P ...__._...__......__.`'__:;r_...._._..... - .�:------------------------------------._._......_._.._....--------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-.with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate ofCqpliance_has been issued.by_the board of health. Signed --- / \ ....Gt"1- ... -_'-"s----- ..� .......-----'------------ ................................. Dace Application Approved B .............. ................................................. ...`;7.-.. .�..'.9-)7 PP PP Y .... Date Application Disapproved for the following reasons: ............. . . .................................................................................................. ...........'.......... ........ . . ............................................... .... . .......................................................... ........................................ Dare Permit No. � .-... ...1f...7 ----- ------------------- Date ............... .......... Issued .............7 .?. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE w6ler#ifiratre of (11vomplianee THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ........................................ _t I(�:. .. .1( ........ ........._.........................................................---------.......---------------------................ V 1-talle, at ............. _..._..................�........ ... `.................. .........................._... .. . ...................................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ....._-��3'._-.3 V-..7-_.. dated _........__.............._........___ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. I. I DATE.......................... ..._ .?._.. . % ........ Inspector ............ _�..._.,...�._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.---•��-`�.�� FEE_ �e.*2....'-::.... Uwpooal Works Tunitrurtion Urrntit Permission is herebyranted.............. IA�e L�A--j--`.7: I_-�--L__......._.......__.__..... g I• •••••------- to Construct ( ) or Repair (�_- —a6 Individual Sewage Di��jjposal System at No----------------------------------------------------- --�-!-1i-•L'--- Y— �•k-�--•--•----•-- r.._.....-.. _ ......................................•--.._..........._...... S�reet 7? 3 S 7 as shown on the application for Disposal Works Construction Permit No..._>\t_...______.. Dated-.__,.7. .7.-.7-3............ - �7_Z� _ r Board of Health DATE-----•--------------• --•---------��--------------•---._.......__...... ./ FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS ' Y -7 . Fizs........l.... THE fOONWEALTH E F MASSACHUSETTS j' BOAR® 9F HEALTH GL...... -------------;----OF.......-:,4Y"46_sir -�/C......................................... Appliration for Disposal Works Tonstrnrttnn jkrmit Application is hereby made for a Permit to Construct (,-ror Repair ( ) an Individual Sewage Disposal System at,:_ • - L=T. .. c' �------_Tf.................... ........................... --"- ................................................. ,.�Location-Address or Lot No. Address -------------- .r- !' k ._...__.... ' � r� .----------...----------------------.----.-------------------------------------- � Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........... .............................Expansion Attic ( ) Garbage Grinder ) c a Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtu --- -- - ---- - r W Design Flow...................:.._._.. ._._......._gallons per personper Oy. Total daily' fi�ow.......�f.% ......................gallons. W Septic Tank—Liquid*capacity4�ll�.gallons Length.%.. ...... Width.l�/ .._ Diameter................ Depth._ �_._... /f r x Disposal Trench—No..................... Width.... Total Length.-. ........ Total leaching area..=__...-__._-.._..sq. ft. Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sgq Z Other Distribution box ( ) Dosing tank ) '-' Percolation Test Results Performed by._.._Z......1....Z-...................... Date_ ..... i ,.-a Test Pit No. I....._...7.-. _minutes per inch Depth of Test Pit....fir_.. Depth to ground water.... ............. 44 Test Pit No. 2_._`_�._minutes per inch Depth of Test Pit... ���.��__: Depth to ground water.----`n._1 G ��=-----------------'-- -=-------.--.----------- ---jam----------- �0�1 De�s/cription of So� ` Z -.................................................. ......-i � ------•- j ` /l� --- W �•'7 l z �< - �1 .,. ' ( -- /�C , �I/,- _�F/,r,� fir/' e ;ram �5 Cc 'Z, Z T c.� .......................r ��..........iC .._ -`--•�rJA: e2........_�' �- VNature of Repairs or Alterations—Answer when applicable............................................ ......_.._........_......................_........_. ..................-..................................................................................................................................................................................... Agreement: I , The undersigned agrees to install the aforedescribe ividual Sewage Disposal Sy em in,accordance with the provisions of TITIE 5 of the Stat nit y Code`' e u der ' wed- urtl rees of t place th/syst /iinoperation until a Certificate of Compliance ha e is ed e rd eaSigned ... _. :_ ....... ..................'------.__----..__ ......-'---- ,, Application Approved By------------------------•--••----------...........-----._. Date Application Disapproved for the following reasons:......................................_.............................................................--•'•••••- ---......-•---•--------------•-------.....------------------•------------'------------•--...--------•--------------"••-'•••-------•••------------'--•---'•-•----------------------................... Date Permit No. ��-.. ---..•-'-----�......._.... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARQ--OF HEALTH OF.. .................................................................... Trriifiratr of Tiamplianrr THIS IS T.0 C IT =hat the Indiadual ew ,' .osal System constructed (A or Repaired . ! by L._. �._... �'�_ »�. -- --- -----------------•---- f / I� l / --- has been installed in accordance with the provisions of TI o 4'ge Sanitary Code s_de*cribed in the application for Disposal Works Construction Permit No......................................... dated_..... .0 _.__--___..cam...&_._-------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...----•-....--'••--•..............................................."-'----•... Inspector...............................-----------..........----------'-------•--•••-•-•--. THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH - r 2 ......................................OF...../..,.......................... ................................... FEE........................ Disposal Works Tonstrwflott Vantit Permissionis hereby granted.............................................................................................................................................. to Construct ( or Repair ) an Individual Sewage Disposal System _ at No... - �,- Street / as shown on the application for Disposal Works Construction Permit No »...1� ............ yated7. ... Z�-...... _ ..........................................•--- _ DATE_ Board of Health ----- - ------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TD Tye dCST OG M Y /.v1�E.QT E'LE'✓� �ESGF�', - /pl/G"02MA T/a�./� /��l/Oi�(/L�U�' fl �T YET Cl//sE"GEo ovT �L/E/= T-�E EGEV,q 77oti/,s ,B /oa,se %v sE� rA,uK TtiE Exis-Ti�,� sYSr&M .I� C /02,/S OUT S, T, 5 S;Yo K/ti/ hV T1415 /,v ro D, -,clo t' ,g r Z-eoc-Z-T I 1 I L.0 T 3 C) LO r0 • R N 8$• �J ,od ' --- L0 i 4 _ate• r • ,,�''�� LOT T A � 4 OLD STAGE ROAD IS ALSO KNOWN AS CE NTs '�,RY-I- LE ---WEST BARNS TABLE RD. t - ,i.y�^n7poaHI. " 1S " C �. ; OT PLAN prppp 1 :.: BUILT PL TO THE'- BEST OF MY INFORMATION';"`" lt�C/��"T t' MASS. KNOWLEDGE, AND BELIEF THE GO T ,eD, SY5?E/1 SHO o ss9 IS PLAN HAS BEEN LOC n' E R. a/. OHEAR/V /IVC. GROUND AS INDICATE Z RICH N SWAN RIVER A o' 35 ROUTE 134 UNIT 2 HEARN 71 o SOUTH DENNIS, MASS. 02660 No. DATE : _ 12-2y SCALE " JOB N0. G,3526 CLIENT: cc�;/�ec�/fA, TE EGISTERED AN RVEYOR DR. BY: .SOB SHEET _1_OF i r- ' L U ( ram ► 'v�� _ 1 S' 1®Ez i U r/� __._ .__ __e. tom C (ki 1:TW S u '`�L (ZO�JG H _ 0(Z rind 1+y c-.I --Cl —t''yj C c 0 LO _ 0^'1y1� 'Tc� r k-'-fa t a T 1-} C 1-:-V TAG'i.V�V .�, lw CCLbr�C, A)L=(A,) CO L1_A/� l C �._.._—..A'��_ _T P C L� Pki'M e v r - ALL o�. Pl- f C.-__/l)�=Zy �_ � C��J )N Cc.t✓�C-1 �}c 1 txJ�71,-'Yi. �t.`�J _ 1 N ► t N\-"� l� i�} l U f TO i llilt, i IC, � c�l�� � f Viwv- •trz i.: 4 .n _3� �. -. .q., a,✓.c F '���.,�,�€'��,ep,, „fit '.�� � 6 I-� N t A- f4,+ b fvOWO r—tQu2J L�•-1 'T te ki I 1 to NJ -- ry e) t l av C C u O i o,� C �`N ILI �\?d2 v� � c C R - .� .�rlh�- it j✓rJ. �=�J�. 3 j C> Nj r,� 0 a V� - _ c �v4 Ir ------ ON ...._r, PRO,IEC � "' ComPensation# T WILL BE TgXS TO a f'. ID 4�.^L t V g y ya Z i r� fR oil 7 f .� Y � ;r. F `s Z7 ITT ` J r- c Y. — T HI S pRO,IECT WILL rs Compensation BETq K`? E N TO WN TO LOCI C� NS�TAyB�LE� 2 LOCATION �j � hO�U SWAGE # 1279 VILLAGE LL ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.Cl SEPTIC TANK CAPACITY ZQQQ C 4 Li- pAJ�S LEACHING FACILITY:(type) ,2- :Ekoci) Dri=v-„ (size) NO. OF BEDROOMS :7 PRIVATE WELL OR PUBLIC WATER Plc .BUILDER OR OWNER Cl 3 `C 0- rzAqr-—m�D DATE PERMIT ISSUED: / 2- ! 6 -6C DATE COMPLIANCE ISSUED: - I :z- �? VARIANCE GRANTED: Yes No Y 1 Y I 3 '4 3 SEWAGE INSPECTIONS LC` rl I(i"N , c 1 DATE VILLAGE C� l' ASSES OR MAP & LOT �~7� •INSPECTOR n + m 5fl SEPTIC TPNK CAPACM LEACHNG FACILITY: (type) t�Z--� (size) 0 10 NO. OF BEDROOMS BUILDER OR OWNER OWNER MAILING ADDRESS a9`� 3