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Home My WebLink About0162 COTTONWOOD LANE - Health 162 COTTONWUMDEAKNE CENTERVILLE A = i UPC 12534 No.2 153LOR � NASTING8,UN Commonwealth of Massachusetts - W Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Cottonwood Lane '{ 1M Property Address - Susan Landon Owner Owner's Name — -- information is required for every Centerville ✓ MA 02632 _April 6, 2016 boo page. City/Town State Zip Code Date of Inspection 1W 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 forms `� A. General Information /lJ/# $ on the computer, (Y , use only the tab 1. Inspector: key to move your l cursor-do not Michael DeCosta Jr. t use the return key. Name of Inspector Wind River Environmental --- — � Company Name, ---- ._------------------ 577 Main Street, Suite 110 Company Address Hudson _ - _ MA 01749_ City/Town State --- Zip Code - (800)499- 1682 13230 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 15.340 of Title 5(310 CMR15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation bKLocaol ing Authority l` I April 6, 2016 spector's SignatureDate The system in sp ctor shall subspection report to the Approving Authority(Board of Health or DE )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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �ow Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Cottonwood_ Lane Property Address --- - _.__._._------------__._--- Susan Landon Owner - -- - - --- ---- - --- -- Owner's Name - information is Centerville MA 02632 Aril 6, 2016 required for every __ _ 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: Outlet cover 2' below grade. No filter installed. Highly recommend installing filter___ 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 FIND (Explain below): 151ns•3/13 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 162 Cottonwood Lane Property Address -- Susan Landon Owner — --—_---— Owner's Name ---- --- ---- - information is Centerville MA 02632 A rll�-.-_-6, 2016 required for every _-- -----____-- --- --- -------__.__.._ 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 (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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "M 162 Cottonwood Lane Property Address -- Susan Landon _ Owner Owner's Name -- information is Centerville MA 02632 April 6 _required for every p �il , 2016 page. City/Town 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 ❑ F] 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 ❑ E 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 'h day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Cottonwood Lane Property Address ---�----------------------- Susan Landon Owner Owner's Name information is required for every Centerville MA 02632 April 6, 2016 _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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. ❑ E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ z 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 ❑ E, 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ,\ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'M 162 Cottonwood Lane____ Property Address Susan Landon Owner Owner's Name information is Centerville MA 02632 Aril 6, 2016 _ required for every page. CityfTown 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 ❑ Z. Were any of the system components pumped out in the previous two weeks? ® Ell 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? ® 0 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. ® 0 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 lnformation Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 --- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 4409 i i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 162 Cottonwood Lane Property Address — Susan Landon _ Owner Owner's Name ^-- -- ------ ----- information is Centerville _MA 02632 A rlI 6 required for every � , 2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: 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 Water meter readings, if available last 2 ears usage d 87.5 gpd -- _ _ 9 ( Y 9 (gP ))� Detail: 2014 = 31,00;0; 2015=32,000. Total use 63,000/24 months =2625gpm /30 days =87.5 gpd. Information from water department. Sump pump? ❑ Yes ® No Last date of occupancy: November 2015 Date Commercial/Industrial Flow Conditions: Type of Establishment: - --- — ------------ i 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-sanitarywaste discharged to the Title 5 system? ❑ Yes ❑ No Water meter'readings, if available: --- -- t5ins•3i13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Cottonwood Lane Property Address Susan Landon _ Owner Owner's Name ^ . information is every Centerville MA 02632 Aril 6 2016 required for eve _� page. City/Town 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: Wind River Environmental Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,000 _ gallons How was quantity pumped determined? Previous pump records Reason for pumping: Check structural integrity.of septic tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy i ❑ 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): s t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts _ F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .0 162 Cottonwood Lane Property Address Susan Landon Owner Owner's Name _ information is required for every Centerville MA 02632 Aril 6, 2016 _ — �--_----.._-_--_-- ------- 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: Approximately 17years er plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet feet Material of construction: ❑ cast iron -- ---- ---- ------ _® 40 PVC El other(explain): Distance from private water supply well or suction line: 0"/ N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): All dints sealed. No leaks. Vent on roof. Septic Tank(locate on site plan): Depth below grade: 18 inches feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years v --- Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 8'x5'x4' Dimensions:Sludge depth --- --------- 6 inches : ---- t5ins•3i13 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 �.H 162 Cottonwood Lane Property Address Susan Landon _ Owner Owner's Name — information is required for every _Centerville _ _ _ _ _ MA 02632 _ April 6, 2016 page. CityFrown 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 32 inches Scum thickness 4 inches Distance from top of scum to top of outlet tee or baffle 6 inches Distance from bottom of scum to bottom of outlet tee or baffle 15 inches How were dimensions determined. tape measure--- ------ - - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both covers 18" below grade.Tee's in good condition. No filter installed on outlet. Liquid level normal, moderate solids and sludge.Tank is structurally sound, not leaking. Highly recommend installing 1' riser on cover with the use of a filter. Pump tank annual._ _ 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•3/13 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 ' .W 162 Cottonwoo_d'Lane Property Address - --- Susan Landon Owner Owner's Name --- ----- information is required for every Centerville MA 02632 Aril 6, 2016 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.): t 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 -- -------------- ------ i ons Design Flow:; — --- —— ---- -- --- -- gallons per day 1 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.): 4 Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 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 162 Cottonwood Lane Property Address Susan Landon _ Owner Owner's Name information is Centerville MA 02632 Aril 6, 2 required for every P 016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): E t Depth of liquid level above outlet invert 0 inches Comments (noote 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 30" below grade. Box size is 16"x20". Box has 2 outlets, accepting equal flow. Liquid level normal, moderate carryover into box. Box is showing signs of deterioration. Box is in good structural condition, water tight and not leaking. Pump Chamber(locate on site plan): Pumps in wor:.king order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump and alarm in good working condition. Alarm box just replaced. * If pumps or, alarms are not in working order, system is a conditional pass. i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts _ y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M —5 162 Cottonwood Lane Property Address -- -- Susan Landon Owner O —- wner's Name _.__.._.._. __.....__._..__..___ information is _p Centerville MA 02632 April 6 2016 required for every —_ — � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: --- --- ❑ leaching chambers number: -- ------ ® leaching galleries number: 5 4'x 4' ❑ 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.): Galleries aretempty. No evidence of high stains. Showing no signs of hydraulic failure. Vegetation normal. 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 i Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts F� Title 5 Official Inspection Form iR Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 162 Cottonwood Lane Property Address Susan Landon Owner Owner's Name -------- ------------------ information is 6 Centerville MA 02632 A rll 6 201 required for every i�_.__..-_.—_._.____—_________ 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.): t5ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 162 Cottonwood!Lane Property Address — — ---- Susan Landon _ Owner Owner's Name - --- - - ---- information is required for every Centerville _ MA 0263_2 _April 6, 2016 _ 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 publicwater supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately i i i i i i t5ins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 1 i Commonwealth of Massachusetts WTitle 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,H 162 Cottonwood Lane _ Property Address --- - _---" Susan Landon_ Owner Owner's Name information is ril 016 _p Centerville MA 02632 _ A 6, 2 required for 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: 6 feet + 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: Dug small hole off side of leaching. Hole was approximately 6' below grade no signs of ground water inflow. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3r13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ` Commonwealth of Massachusetts W Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 162 Cottonwood Lane Property Address — — Susan Landon Owner — --._.. ----Owner's Name information is required for every Centerville _ MA 02632 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 A , TOWN OF BARN -ARI DOCAMN .C� .r��,�a o f1 /'b�� VILLAGE_ Ce to e j dk ASSESSOR'S MAP &'LCT INSTALLER'S'SAME&PHONE N0. 24- fJ SEPTIC TANK CAPACITY ad / LEACHING FACILITY: (type) (size) J 21 L NO. OF BEDROOMS-- ROWNER �4 i DATE: PEFc.UTDATE: 2 �% ... �CO .PL CE75 � L4N Separatioa.IDistancc Between Lie. Maximum Adiusted Groundwater Table to the Bottom of Lea_ ing Fax i_M- Feet Private Water Supply Well and Leaching facility ,(if any wtils e7 on site or-within 200 feet of leaching fagtlity) Feet Edge of Wetland and Leaching Facility(If any wetlands e.,,st within 300 feet of hing,facility) Feet .. Furnished by N+� 1 ` CS x a _ � 1 TOWN OF BARNSTABLE LOCATION < e�,�fchAil�sa cellSEWAGE # 6' ✓ VILLAGE f e Amore t y[(k ASSESSOR'S MAP INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / a d LEACHING FACIL=: (type) 1,VZ!W7 ®iZS (size) Jr zI 2- NO. OF BEDROOMS__ BOR OWNER4 �c PERMITDATE: COMPLIANCE DATE: " Separation Distance Between the: - Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility - Feet Private Water Supply Well and Leaching Facility='(If any wells exist on site or within 200 feet of leaching facility) Feet . Edge of Wetland and Leaching;Facility(If any wetlands exist within 300 feet of ching,facility) Feet .�-- Furnished by vaT I � p t3 3 u 7 Y1 I C lyn IL 170 } PR �. wrA K. i�1 �w►c -� c'� �"C- �L�� t,.��y��c�.,.. c i F c s v4r�-C. q S"R7L� c f 7 1 . LV I n 36 J�\.� C��,n✓A-cc,cJ' fin'--e y �, 1 / ^F ((2� ✓fi� 2�� ' �� Fin31� No. ` w Fee r / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpphration for i0t5pool *pgtem Congtructton Vermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No./ c;;i Cc-1-1 f�45F_1 D Owner's Name,Address and Tel.No. C` 7- Assessor's Map/Parcel Od_� Installer's Name,Address,and To.No. Designer's Name,Address and Tel.No. e4V 0_C 64Ve,2_>eOTkc 1-5 tou4s-5r-, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ® gallons per day. Calculated daily flow 'I `�( gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank II SO-D �n�n1o� T"ype" off S.A.S. Description of Soil 1`die_ ' W uV Nature of Repairs or Al rations(Answer when applicable) CqJAC`t c� 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 ha a Signed Date Application Approved by 4 _ Date —2 3 Application Disapproved for the following reasons ',r r �Y Permit No. Date Issued "' ' N �! �J �b � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes 9pphcation for Mgoml *pgtem Con!5truction Vern-pit Application fora Permit to Construct( )Repair( )Upgrade( )Abandon( ) `Complete System ❑Individual Components Location Address or Lot No. Cc-!f r/�--000e`f` PJ Owner's Name,Address and Tel.No. Evt�( Q Assessor's Map/Parcel Installer's Name,Address,and Tel.No. d 1E! Designer's Name,Address and Tel.No. ,. i 0-.c Q .._19IT � Type of Building: J/ _ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building T No. of Persons Showers( ) Cafeteria( ) Other Fixtures C Design Flow Q gallons per day. Calculated daily flow '7 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 S� S'Q` . Type of S.A.S. 1, 4 G`T� TccT= Description of Soil f.2,CZ I t,� 14 c� Nature of Repairs or Alterations(Answer when applicable) " t � ct 7 h 5 1." TCti—4- . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system s 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 -is a Signed �^ , Date IV Application Approved by C. Date Application Disapproved for the following reasons a k i Permit No. Date Issued 3 — —————————— —— _ ----——— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(k ; Abandoned( )by . - at UUC? ea�R_. �.�4.Tt= � has been constited in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 36 dated_ Z 3—g / Installer Designer The issuance of this permit shall not be construed as a guarantee that the ill function asf* njed) ,Date Inspectd g �1 ------------------ -- �'No. Fee THE COMMONWEALTH OF MASSACHUSETTS, PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi5po5ar *pgtem (Construction Vermit Permission is hereby granted to Construct( Repair( )Upgrade( )Aba don( ) System located at ki < , 4 7 / 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 e completed within three years of the date of this permit. O /0 / Q Date: 3 / Approved b J� �`' f' 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. _ CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) L� -N w hereby certify that the application for disposal works construction permit signed by me dated_ �'��-�� concerning the property located at I �v ��« � meets all of the following criteria: "e failed system is connected to a residential dwelling only. There are no commercial or business �es associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ere are no wetlands within 100 feet of the proposed septic system !� There are no private wells within 150 feet of the proposed system septic stem P is no increase in flow and/or change in use proposed /"";ere here are no variances requested or needed. �• /T!-/I he bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximu a usted md groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevations(J+the MAX. High G.W. Adjustment. DIFFERENCE BETWEEN A and B Q SIGNE7- � DATE: [Sketch proposed plan o system on back]. q:health folder,cert G �d r TOWN OF BARNSTABLE LOCATION Cc 7-1 U, d c�n- 4:L- SEWAGE # i VILLAGE Ce_"-re/% YdAc ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO. /&In C,4 - P,0 c- 7_2e SEPTIC TANK CAPACITY f d d LEACHING FACILITY: (type) 1 tJlTi ® C (size) 2 NO. OF BEDROOMS__ BOR OWNER �4 c PERMITDATE: COMPLIANCE DATE: ` .Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility. (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching-Facility(If any wetlands exist within 300 feet of]eaching.facility) Feet Furnished by .tea ) i ' � 9� � d