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HomeMy WebLinkAbout0025 COLLINS AVENUE - Health 25 Collins Avenue Centerville . A = 190 143 ' No. 4210 1/0 ORA 10% 0 0 0 0 ' Apr '09 2017 2220 Jim The Inspector Man 5085349919 page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Collins Ave. 4 Property Address r> Alicia Anderson Owner Owner's Name R Information is `A" . required for every Centerville MA 02632 4-7-17 4c� page. CityfTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important:When A. General Information s/ y /a�30L- filling out forms ``a`„p1H1II�llrrrrUp��i'' MA on the computer, o`� ......... use only the tab 1. Inspector: o�;' :4. key to move your JAMES :m= cursor-do not James D.Sears =use the return Name of Inspector =y m �* key. Capewide Enterprises Company Name '�,�� �e•5. ....�G `S 153 Commercial Street Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-7-17 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. t5ins.doe•rev.6r16 Title 5 Official Inspection Form:Subsurface Sewage Diwosa,System•Page 1 of 17 Apr 09 2017 2220 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owner's Name information is MA 02632 4-7-17 required for every Centerville page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal Tank D Box and two chambers. _ B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes","no" or"not determined" (Y, N, N D) 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): t5tns.doc-rev.6116 Title 5 Official Inspection Farm.6ubsurface Sewage Disposal System Page 2 of 17 i ' Apr 09 2017 2221 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Collins Ave, Property address Alicia Anderson Owner owners Name information is required for every Centerville MA 02632 4-7-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Requlred by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins.doc•rev.6)16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 117 ` Apr'09 2017 2221 Jim The Inspector Man 5085349919 page 21 I c Commonwealth of Massachusetts Romp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner owner's Name information is Centerville MA 02632 4-7-17 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑. ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 9MMIN is less than 6" below invert or available volume is less than day flow I.EAe//1N6 t5ins.Acc•rev.6116 Title 5 Official hspection Form:subsulace Sewage Disposal System•Page 4 o117 Apr '09 2017 2222 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Collins Ave. —— Property Address Alicia Anderson Owner Owners Name information is Centerville MA 02632 4-7-17 required for every State Zip Code Date of Inspection page. Citylrown B. Certification (cont.) Yes No 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal collform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10.000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E► Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system 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. 154ns.doc•rev.6119 Tide 5 Dual Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ' Apr '09 2017 2222 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson owner Owners Name information is required for every Centerville MA 02632 4-7-17 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)1 D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15ins.doc•rev.61% - Tide 5Offidel Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Apr 09 2017 2222 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 25 Collins Ave. Property Address Alicia Anderson Owner Owner's Name information is required for every Centerville MA 02632 4-7-17 page_ Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal Tank D Box and two chambers. 4 Number of current residents.- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No 2015-61,OOOGals Water meter readings, if available(last 2 years usage(gpd)): 2016-41,OOOGaVs Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seatsl person s/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present'? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 50flicial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r Apr, 09 2017 2223 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 4 ' 25 Collins Ave, Property Address Alicia Anderson Owner Owner's Name information is required for every Centerville MA 02632 4-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont,) Last date of occupancy/use: Dace Other(describe below): General Informadon Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the'I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6116 Title 5 Official Inapection Form Subsurface Sewage Disposal System Pape 8 of 17 Apr -09 2017 2223 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owner's Name information is required for every Centerville MA 02632 4-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2002 Permit # 2002 - 303. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" 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.): Pipeing is 4" PVC SCH -40 Septic Tank(locate on site plan): 10" 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 1500 Gal. Precast H- 10 Dimensions: 1" Sludge depth. t5ins.doc•rev.W16 Title 5Official InspeoWn Form:Subsurface Sewage oisposel System•Page 9 of 17 Apr •09 2017 2224 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owner's Name information is Centerville MA 02632 4-7-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" Asbuilt-Plan-Tape How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 10" below grade w/inlet cover at 4". In and outlet tee's No sign of leakage or over loading 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 t5ins.doc•rev.6116 Title 5 Official inspetlion Form:SuoWace Sewage Disposal System•Page 10 of 17 Apr 09 2017 2224 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owners Name information equirat for Centerville MA 02632 4-7-17 required for every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): I 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 Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required), Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.8116 Title 5 Official Inspection Form:Subsurfece Sewage Disposal System-Page 11 of 17 Apr- 09 2017 2224 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form RNM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owner's Name information is Centerville MA 02632 4-7-17 required for every page. City/TDwn State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-16"below grade w/two line's out. Box is solid. No sign of over loading. 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. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: 15ine.dx•rev.6f16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 o117 Apr '09 2017 2224 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owners Name information is required for every Centerville MA 02632 4-7-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Leaching is two 500 Gal. dry well chambers w/4' stone. Chambers are 34"below grade w/cover at 16". Chambers are wet on bottom w/clean like new wall's No sign of over loading. 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 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Apr,09 2017 2225 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owner's Name information is required for every Centerville MA 02632 4-7-17 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I5ins.doc-rev.6l16 Title 5 Official Inspection Form:Subsurface Sewage Dlsposal SYSIem Pape 14 of 17 Apr-09 2017 2225 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owners Name information is required for every Centerville MA 02632 4-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont,) Sketch of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately R EAR 3 U t7F K 11I f3-3 i 0 0 t5irrs.doc•ray.6116 Title 5 Official Inspection Form:Subsurface Sewage DSP0301 Syalam•Page 1s of 17 ' Apr,09 2017 2225 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owner's Name information is required for every Centerville MA 02632 4-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope' ❑ Surface water ❑ Check cellar ❑ Shallow wells N0 Estimated depth to(h—igh ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11-21-01 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: T.H. on Design plan 11-21-01-10'no G.W.. Bottom of chambers at 5' below grade. Bottom of chambers at 5' above T.H. Depth, Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6ins.doc•rev.8/16 Title 5 Official inspecuon Form:Subsurface Sewage Disposal System-Page 16 of 57 Apr' 09 2017 2226 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Collins Ave. Property Address Alicia Anderson Owner Owner's Name information is required for every Centerville MA 02632 4-7-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Tife 5 Official Inspeclion Form:Subsurface Sewage Disposal System Pape 17 0117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1, Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name tab 189 Cammett Road Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508.428.1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C, November 18 2010 Job# 10-275 Ins ector's i ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 +s . = i -1 V�t� :t �?pe 5FOfricia`I Inspection; Form Subsurface SewagejDssal System• 1 of 17 Commonwealth of Massachus etts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. Cltyrrown State Zip Code Date of Inspection B. Certification (cost.) 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: Tank is not in need of pumping at this time leaching system had no standing water or sidewall stains. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 . every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has 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 asses system if the w Y p well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be: attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppml, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No , ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water,supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 • Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • 25 Collins Ave.` Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. Cltyfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as pall of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 — !Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. CityfTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments ents 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date: 8/5/02 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1' 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.): Septic Tank (locate on site plan): Depth below grade: 1' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5' long x 5.8'wide- 1500 gal Sludge depth: 2 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 every page. city/Town November 18, 2010 State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 1„ Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank is not in need of pumping at this time. 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 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. Cltyrfown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): No solids or high stains present. Liquid level was found at bottom of outlet invert. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Two 500 gal drywells. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool num ber: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, tation, etc.): ) Chambers had no standing water or sidewall stains 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 t5ins•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,� •''- 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is Centerville required for MA 02632 November 18, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14�f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Collins Ave. Property Address David Nevins Owner __._... --- ---— ------------ -------Owner's Name - --- information is - required for Centerville _ MA 02632 November 18, 2010 -- _..... __ --------- --------------- every page. ity/Town State Zip Code Date of Inspection D. System Information (cont) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately i t r / J ! YQ� y/^/+• r / J r / J / / / r / 28 28 36 3 44 45 r • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 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: Perc test performed prior to repair found no water at 12 feet Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 25 Collins Ave. Property Address David Nevins Owner Owner's Name information is required for Centerville MA 02632 November 18, 2010 every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE t 1 LOCATION AVE— #—,nSp V(LLAGE fief Q <Le ASSESSOR'S MAP&PARCEL INKS NAME&PHONE NO. c L�zVr,'(Jc_ ai�_OAV,_W --0L9-1-n q SEPTIC TANK CAPACITY 1560 PJ LEACHING FACILITY: (type) (size) SbO NO. OF BEDROOMS OWNER Vic-, PERMIT DATE: C - - ATE7.J 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 we ds exist within 300 feet of leaching facility) Feet FURNISHED BY v \ •4• •4• •4• .t• .t.\• .4.4.4• .v•1 f ? f f J ? J l ! ? f ? f 1 f f f f f \'\ \ \ 4 4 \ \ 4 4 4 1 \ 4 \ ♦ v. 1 4 \ \ 1. ' \ 4 \ 4 \ t 4 \ 4 t \ 4 \ \ \ \ t 4 k J ? f f f J f ! f f I f J f \ 4 4 4 \ \ 4 \ 4 \ t \ 4 \ \ \ 4 \ \ 4 v \ 4 \ 4 \ \ \ J f f ? f f f f f f f f 4 4 4 4 4 4 4 \ \ 4 \ \ k 28 28 36 3 q' 45 44 \ —O�ITIO-NTWEALTH:OF NLASSACHUSETTS EXECUTIVE OFFICE OF ENVIRON-NIENT_AL AFFAIRS I)EPAFLTNIE?�T OF ENVIRONiYIENTAL PROTECTION TITLE 5 OFFICL-AL INSPECTION FORT I,-NOT FOR VOLUNTARY ASSESSMENTS S �.EcITRF_ACE SEWAGE DISPOSAL SYSTEM FORM: PART A CERTIFICATIOIVT P 1� Pro erty:Addres_: � . Ire Owner's Name: . .r7 . n✓: Owner's-Address: s � ; Date of Inspection: _ C Name of Inspec#o--- (pieasa Company NaMA;, .s>� c Mailing.Address 7- Telephone Number: « CERTIFICATION STATEMENT i certify, that I have personally inspected the sewage disposal system at this address and that the Lormation reported below is true, accurate and complete as.of.the time of the inspection. The inspection was performed based on my training and e perience in the proper function and maintenance of on site sewage:disposal.systems;.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3:10 CMR 15:600). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving-Authority Fails Inspectors SiEnatu e- a e:. The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)witl_in 330 days of completing this.inspeciion. If the.system is.a shared system or has a design flow of 10,000 gpa or greater, the inspector a dthe system owner shall submit.the report 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. Motes and Comments r at This report only describes..ondit�ons at the time of inspection and under the conditions of use at that time..This inspection does not address how the system wiII perform in the future under the name or different conditions of use. Title.5 Inspection Form 61"5/20.00 page 1 Page 2 of I 1 OFFICIAti INS.PECTIO.N FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEI.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ip—lZ e-- f' a• Owner:. Date of Inspection: /; .' Inspection Summary: CheckfB,C,.D of E/ALWAYS complete all of Section.D A. System Passes: I I have not found any information which.indicates that any of the failure criteria described"in 310.CMR �l5.303 or in 310'CNIR 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 Healthwill pass. Answer yes,no or not determined(Y,N;ND)`in the for the following statements. If"not determined"please explain. The septic tack s-metal and over 2.0 years old* or the septic tank(whether metal or not)is structurally unsound' exhibits substantial.infiltrati on or exfiltratzon or.tank failure is imminent:System will pass inspection if the existing tank is replaced with a complying septic tank:as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound; not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. . ND explain: N. }. . Observation of sewage backup or break out or high static water level irz 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: Paee 3 of I I OFFICIAL INSPECTION FORI'r1 -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORIM PART A CERTIFICATION(continued) Property Address. 261. PCB -m 'rw�,, Zia LA-1 4 Owner Date of'Inspection / / ��. C. Further Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the.Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15'303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment. Cesspool or privy is within SO feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Z. 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 absor tion 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 withima Zone 1 of a:public water supply. The system has a septic tanl: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 fifth e well water analysis,performed ataDEP 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 thatno other failure criteria are fria-ered. A copy o f the analysis must be attached to this form. 3. Other: 3. Page 4 of.11 OFFICIAL.INSPECTI-OiV FORM.—.:NOT.FOR VOLUTjdTARYASSESSMENTS SUB SURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION.FORA PART A. CERTIFICATION(continued) Property.Address „ .� ✓" ' e1fl1V = 'Owner- Date of Inspection: k , .g Yj�4 D:. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each.of the following for all inspections: Yes No _ Backup of sewage into:facility. or system component due to overloaded or ciosaed 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 Xcesspool` . Liquid depth in cesspool is less.than 6"below invert or available volume is less than %day flow - 7 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 surface:water supply or tributary to a.surface water supply. Any portion of cesspool.or.privy is within.a.Zone 1 ofa'.public well. _ rJ� Any portion of a:cesspool.or privy is within 50 feet of Lprivate water,supply well. Any-portion of a cesspool or•privyis.less than 1.00 feet out greater.than.50:feet.ftom 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 colifor.m.ba.cteria'and=volatile organic compounds indicates that the.well.is free from pollution from that.facility-and the..-presence of ammonia nitrogen and nitrate nitrogen is equal.to or less than 5 ppm, provided'that no other failure criteria are triggered.A copy-of the analysis,must be attached to this form.] (Yes/No)The system-fails. I have determined that one or more.of the above failure criteria exist as described in 310 CIMR 15303,therefore the system.fails.'The.system owner should contact the Board of Health to determine what will be necessary to correct'the failure: E. Large Systems: To be considered a large system the system must serve'.a facility with a design flow of 10,000-gpd to 1.5,000 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 n0 _ the system is within 400 feet-of a.surfac'e 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 signif cant threat under Section E or failed under Section D shall upgrade the system in accordance with 3,10 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 . Page 5 of I OFFICIAL INSPECTION YOR -NOT FOR VOLLri IM TARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSA.,SYSTEM INSPECTION FORYI PART B CHECKLIST /3 Property Address: o Owner:, Date ofTnspectio� � 74 , Do . Check if the following have-been done.You-must indicate`yes"or"no"as to each of the following; Yes ��To Pumping.information was-provide d by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks ? f/Has the system received normal flows in the previous two week period? t/ Have large volumes of water been introduced to the system recently or as part ofthis 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 baffies or tees, material of const-uction, dimensions, depth of Iiduid,.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 detertnined`based on: Yes no _ Existing information. For example, a plan at the Board of I-Iealth. L/`_ Determined in the field (if any oft failure criteria related to Part C is'at issue approximation of distance is unacceptable) (310 CitiIR 15.302(3)(b)I Page 6 of 11 OFFICIAL INSPECTION FORM.-NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM-INFORMATION ," Y Property Add,'ress� - �.�i_ �1 Owner: "7' ..4v 0- Date:of Inspection: ,y d;� 1,� FLOW CONDITIONS RESIDENTIAL r/ Number of bedrooms.(design). Number of bedrooms(actual).: DESIGN flow based on 310.CMR 1.5.203(for example: 11.0 spd x'of bedrooms): 230 Number of current residents:. Does residence have a garbage grinder(yes or no): �V Is laundry on ai separate sewage system (y5s or no):. )/ [if yes separate inspection required] Laundry systern inspected (y s:or no): 4 Seasonal use: (yes or no):NO Water meter readings; if available(last 2.years usage(gpd)): ovo 0 tr— 2-7oG�W Sump-pump (yes orno):d\/� Last date of occupancy: // 7 i � s`C� � / G (� t 'Lfy"' • COMMERCIALIINDUSTRIAL. i�� �J Type of,establishment:. Design flow(based on 310 CMR 15.203): gpd Basis of-desigr 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: 6Z Was system pumped as past of the inspection(yes or no): If yes, volume.pumped: gallons—How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM eptic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system (yes or no)(if yes, attach previous inspection records, if any) _IrmovativeYAlternative technology.Attach a copy of the,curent operation and maintenance contract(to be obtained from system owner) _Tight tank; _Attach a copy of the DEP approval -Other,(describe): Q 9 mate ag of all components date installed f know,n at�_s��prce of i formation:. V, Were sewage odors detected when arriving at the site(yes or no}: . _ 5 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR V T VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: .�' z. & e_ " Owner: � _ •� Date of Inspection: Z !. x 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: � Material of construction: 1,J6oncr ere rretal_fiberglass�oolyethylene —other(explain) y If tank is metal list age: is age:conftrmed by a Certificate-of Compliance(yes or no):_(attach z copy of certificate) �y Dimensions: Sludge depth:' Distance from top of sludge to bottom of outlet tee or,baffle: Scum thickness: d0 id Distance from top of scum to top of outlet.tee or battle.- Distance from bottom of scum to bottom c f outlet tee or baffle: �1 How were dimensions.determined: L Comments (on.pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of leakage, etc* GREASE TRAE �� e (iocat on site plan) Depth below grade: Material of construction:_concrete_metal fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or bafle:. Date of last.pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural inteygrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of I OFFICIAL INSPECTION.FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART C. SYSTEM INFORMATION(continued) Property Address: A1'4 Q� Owner: Date of Inspection: �.y.LZ TIGHT or HOLDING TANK:1' (tank must be pumped at time of inspection)(loc.ate.on.site plan) Depth,below grade: Material of construction: concrete metal fiberglass polyethylene. other(explain):. Dimensions` Capacity: gallons Design Flow: gallons/day Alain 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)(Iocate on site.plan) Depth of liquid level above outlet inver+iL � Comments(note if box is.level and distribution-to outlets"44ual,.any evidence of solids carryover, any evidence of ,Lezr age into or out of box, etc.): .,1to PUMP CHAMBER:: (locate on site plan). Pumps in working.order(yes or no): Alarms in working.order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 3 . Pate 9 of I I OFFICIAL INSPECTION FORIM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART,C SYSTEM INFORMATION (continued) Property Address: Owner / �_ �1'�� s Date of Inspection: SOIL ABSORPTION S`i'STEIbI (SAS ocate on site plan, excavation not required) If SAS`not located explain why: Type teaching pits, number: l e aching 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 �)f�/J may / :] .,,•"'.! ..3 '-!\...✓ d A L..'!ss S ✓'1. �. 1 -d/)<l S'�'I.34•o•'�,yrt'�'" - �I"7 L+(,s'"7J C' CESSPOOLS: . (cesspool must be pumped as part of inspection)(locate on site plan) Number and con iQuration: Depths—top of liquid to inlet invert: Depth`of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication.ofgroundwater inflow(yes or no): , Comments (note condition ofsoii, signs of hydraulic failure; level ofponding, condition ofve,,etation, etc:): . PRIVY: Itl,,�(locaze on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil; suns of hydraulic failure, level of ponding, condition of vegetation, etc.):. 9 Page 10 of 1.1 OFFICIAL; INSPECTIOiv FORM=.NOT FOR VOL TNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE_IN INSPECTION FORIM PART-C. SYSTEM II!iFORMATION(continued) Property Address: Owner. . Date of Inspection:. SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the.sewage disposal system inc permanent luding ties to at least two eanent reference landmarks or r benchmarks. Locate all wells within 100 ee o - � t.Locate where public water supply enters the building --------------------- Ole �, Sc Paae 11 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFOPUMATION (continued) Property Address: 449,11yjAorlptl'U'� Owner: Date of Insp-ection: <ZY1,11 P . SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Wfeet 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: Checked with.local excavators; instaIl_ers-(attach documentation) VAccessed USGS database-explain: You must describe how you established the high ground water elevation. ,� IJ- 11 Permit Number: Date: Completed by: w, HIGH GROUND-WATER LEVEL COMPUTATION. Site Location: �� ��°'�� k: /// Lot No. Owner: °e,V%. .�� CO AMes Address: y Contractor: Address: Notes: STEP 1 Measure depth to water table / � tonearest 1/10 ft. ............................................:...:............................. .Date ! d month/day/year STEP 2 Using Water-Level Range Zone: and Index Well Map.l.ocate site and determine O.Appropr.iate mdex.weil ................... '............ OWater level range zone ................................................ STEP 3 Using monthly.reporf''Current Water'.:Resources Conditions -' -,determine current depth to � water eve.l for.rndex,well• ! month/year STEP 4 Using Table-of0ater-level'Adjustments for index we.Il-=(ST.EF,,2A),-.cur-rent depth to water:'le.v.el,for.index-well (STEP 3), and water level zone (STEP 213) determine waterr IeveL.adJustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting.the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1► .:.......................................... Figure 13.-Reproducible computation form. 15 __ i �. � 1 � Y �ti :� .�' �--�' ��, - �. ..� .- - . �- � #. � I f ► � €. � _. t ;� • �� .. . .. �� .. .. --- r �. � _ .- . � �. . � � _ �: . . � - ��- __ �� . . � . � � _ _ _ �� �_ _ -,.,� �' � �. �:. �. � � � � . � ; � _ - -�.� �� �� a _�. � � � .. �� i TOWN OF BARNSTABLE C LOCATION 2f- SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 9 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /SDo ao-r LEACHING FACIL=:.(type) 5bQ mRt Clr�,�,? eL (size) 0V NO.OF BEDROOM 3 BUILDER 9KIZWNER C{o A/ PERMTT DATE: COMPLIANCE DATE: U 2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Sf 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 RAY 3G` 0 3� f/ ' No. f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipphratton for aioaaf *raem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) L�rComplete System ❑Individual Components Location Address or Lot No. Cell) �'l� Owner' ame,,A9dress and Tel.No. Z� 6`'�i17�1�1 Assessor's Ma /Par el Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/ 3 ' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/0 Other Type of Building and-ONo.of Persons -Showers( ) Cafeteria( ) Other Fixtures Design Flow / gallons per day. Calculated daily flow 33e�, gallons. Plan Date 1 Z Z Z6?4 Number of sheets Revis'on Date Title cS7iGl� 11y� O C4 ! s Size of Septic Tank /,�0� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by =BdH941th. Signed Date l!J C Z Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued X Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es v.PUBLIC HEALTH DIVISION -..TOWN OF BARNSTABLE, MASSACHUSETTS " I' r ZIppYication for his*oar *pgtem Construction Permit Application for a Permit to Construct(- )Repair( )'Upg ade(✓)Abandon( ) 1�t omplete System ❑Individual Components Location Address or Lot No. r Owner's ame,Address and Tel.No. 01 Assessor's KE � IkA-z" G2y /ll lefblle Installer's ame,Address,and Tel.No. - Designer's Name,Address and Tel.No. 7 71- Type of Building: Dwelling No.of Bedrooms A3 s Lot Size sq.ft. Garbage Grinder( d ` -- �4 °No.of Persons Showers( ) Cafeteria( )Other Type of Building Other Fixtures //7 �ry Design Flow Me, gallons per day. Calculated daily flow 336 gallons. Plan Date , Number of sheets Revision Date Title S l 5z"Lv �4'/I © ' ce l S Uvc- Size of Septic Tank Type of S.A.S. Description of Soil S:J �T(�►,�Ql ^ ��(l Nature of Repairs or Alterations(Answer when applicable) Date last inspected: r Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by phis B and of H Ith. Signed r r .c—�-% n Date ,/!J r�''Z Application Approved by _ Y Date / r Application Disapproved for the following reasons I! Permit No. ­Z �' �~� Date Issued n O -------------------------------------- ' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ` Certificate of Compliance THIS IS TO CER , that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(✓) t Abandoned( )by lwPS�, at C-/ N r� �� has been constructed 'n accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. C - �dated Installer Designer The issuance 01 this) ermit shall not be construed as a guarantee that the sysDi"11 ill funcct�onlas de g fed. Date / Inspector �t '" No. ��� -------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=igpo9;a1 *pztem Construction Permit Permission is hereby granted to Construct )Repair( )Upgrade(i�Abandon( ) System located at 7 �4 �//Y 5 f�'d/`G Ir owl>e '// and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this Date: n C�� Approved b �_ I PP Y 1 TOWN OF BARNSTABLE , C X LC-cATION 2r BOA, �y,c SEWAGE # o`llSDa 3Q� Y!'�,LAGE z 41111111t ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /Sdo 6Age, LEACHING FACIL=:_(type) 3-Pa C,.< C44i (size) dV NO.OF BEDROOM 3 BUILDER. OWNER �{o PERMTTDATE: `7-//0 0� COMPLIANCE DATE: 2 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 l ri et ✓ k.;0V RF.y x • �/ - O R 36 O YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). 'A business certificate ONLY REGISTERS YOUR NAME in town(which you t; must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form.at 200, Main St., Hyannis. , ,; Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St.-, Hyannis, MA.02601 (Town Hall) and get the Business Certificate that is -!: required by law. �a DATE: L 0 Fill in please: M. T�AIXM'L��``k�'am�f��P'"`�'`�• � APPLICANT'S YOUR NAME/S• n� r� g6ti��t' 3P P� g a �� t�r�; BUSINESS YOUR HOME ADDRESS: 5 C� I I i (1 S N'l)� AC__ C .P.10 Ane r'�,II��`P) I• MA k _TELEPHONE # Home Telephone Number �r,".• ;i1:.aadbfii� !: �'If�'' 1. EIN.'.'or, Email Address: NAME;OF'CORPORAT.ION:' NAME OFNEW'BUSINESS �- YE •TYPE OF BUSINESS IS THIS A HOME.00CUPATION?. NO C¢pL GoE ADDRESS OF BUSINESS" t MAP/PARCEL NUMBER C) _ ( �� (Assessing) oab3 When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is'intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COM S ION R' . FF This individu I b iRfo ed an er i rpquire nts that p rtain to this type of business._ MUST COMPLY WITH HOME OCCUPATION RULES AND REGULATIONS, FAILURE TO A th rized i u � COMPLY MAY RESULT IN FINES.. M _ ENTS. 1 _ ' n 2. BOARD OF HE TH This individual has be the permit requirements that pertain to this type of business. MUST COMPLY WITH ALL HAZARDOUS MATERIALS REGULATIONS u riz tune* COMMENTS: �(�r✓2 — K6 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual-has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: j c I ASSESSORS MAP : ��� TEST HOLE L.-OCS PARCEL : CaUa�! SOILEVALUATOR : ► C r FLOOD ZONE: WITNESS : LA REFERENCE: A2 bC� D TE I IAJ 0cu<..- 7/*4 PERCOLATION RATE. s �.-- . _ T (..�1"fI65 99M r. TH- I TH-2 per, , _ MAP oat ' _ rbQS2. LI1 -� Tl °C + t LOCAT I`ON � � a j 9 1 � I a- 3, __ ./ tea' P� ► ! i j 12 j SEPT I C SYSTEM DES` I GN I FLOW ES-IMATE BEW,OOMS A7 � GAL/DAY/BEDROOM �30GAL/DAY � SEPTIC °,ANK GAI';/DAY x 2 DAYS - �I GAL ; USE GALLON SEPTIC TANK SOIL AB>ORPTION SYSTEM oL4 U .,, .'i SIDE AREA. yC. 1. -I �C X L Bf'TTOM :AREA: I - -' 1 o I �. SEPT I C SYSTEM SECTION N n , ►w� vu►w t _u ....._.._ ,,- f? ` � A _. k Fj `�; -sax P o � ° �► GAL �� SEPTIC TANK �bVL_UF1 - �— !. b�J�JI� ✓ � - - 7?7t1 _ ANk o� o7T O Y ,_.. MAZONSITE AND SEWAGE PLAN � s _ n �. ---- - "--r i f _ _ • . 4" , LOCATION : - . _ a _..,r PREPARED FOR a / 3 LJ:• .:u..... SCALE: DAV I D B . MASONI 5 DATE :/ Z o - DBC ENVIRONMENTAL DESIGNS EAST SANDWICH MA DATE HEALTH AGENT ( SOB ) 833- 2I77 j