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HomeMy WebLinkAbout0038 COVE ISLAND ROAD - Health 38 COVE ISLAND RD. , CENTERVILLE A= 187- 060 J1 1 llll UPC 17534 No.2-153COR `;fir kASTINOS.UN t, ep 1514 04:52p p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ' 38 Cove Island Road Property Address William Belden Owner Owner's Name information is required for every Centerville MA 02632 9-12-14 page. Cityrrown 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 ng outforms A. General Information filling out forms \``tttttturlrupryii� on the computer, �! \����� `��1 OFF l'ly use only the tab 9C, 1. Inspector: y key to move your cursor-do not James D.SearS __' JAMES :�, use the return Name of Inspector =�; ;r„ key. CapewideEnterprises,LLC o„ o Company Name 153 Commercial Street ''��iF,s wc�``��. Company Address mwt 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. 1 am a DEP approved system"inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: r i ® Passes ❑ Conditionally Passes ❑ F ❑ Needs Further Evaluation by the Local Approving Authority 9-15-14 nspector's Signature Datea The system inspector shall submit a copy of this inspection report to the Approving Autho ity(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. I� I t51ns-3,113 Trtle 5 official keF : dace Sewage Disposal Sy tam•Page 1 of 17 Y Sep 1514 04:53p p.2 Commonwealth of Mawachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -- A 38 Cove Island Road Property Address William Belden Owner owner's Name information is required for every Centerville MA 02632 9-12-14 page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal.Tank D Box and three 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, 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): t51ns-3f13 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 I Sep 1514 04:53p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 38 Cove Island Road Property Address William Belden Owner Owner's Name information Is required for every Centerville MA 02632 9-12-14 page. CityfTown 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 breakout 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 t5i�s•3rl 3 Title 5 Official Inspection Form Subsurlace Sewage Disposal System.Page 3 of 17 Sep 1514 04:53p p.4 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Cove Island Road Property Address William Belden Owner Owner's Name information is required for every Centerville MA 02632 9-12-14 page. Citylrown 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- 0 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 ❑ Z liquid depth in aww"O is less than 6' below invert or available volume is less than Yz day flow.4 1=,4 P/1.i.v e t5ins,•3113 Title 5 official Irnpec lion Form:Subsurrace Sewage Disposal Syslem.Page 4 of 17 Sep 151404:54p p,5 Commonwealth of Massachusetts Title 5 Official Inspection Form 1� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cove Island Road Property Address William Belden Owner owner's Name information is required for every Centerville MA 02632 9-12-14 page. Cityrrown 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 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone I I 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. 15ins-3113 Tnie 5 omal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Sep 1514 04:54p p.6 Commonwealth of Massachusetts U. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments_ 38 Cove Island Road Property Address William Belden Owner Owner's Name information is d for every Centerville MA 02632 9-12-14 require page_ Citylrown 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? El ® 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: ® ❑ Ekisting 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): 4 Number of bedrooms(actual): 4 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3113 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 d 17 Sep 1514 04:54p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form C� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cove Island Road Property Address William Belden Owner owner's Name information is Centerville _ _ MA 02632 9-12-14 required for every — page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 tank, D Box and three chambers. Number of current residents: 2 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 NA 9 ( Y 9 (9P ))� Detail; Sump pump? ❑ Yes ❑ No Last date of occupancy: Present Date CommerciaVindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(90) 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: 15 ns-3113 Title 5 Official Inspection Form:Subsurface Sewage Dlsposal System Page 7 of 17 Sep 1514 04:55p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cove Island Road Property Address William Belden Owner Owner's Name information is required for every Centerville MA 02632 9-12-14 page. cityfrown 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: 2010 12014 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): 15ins-3113 Title 5 Official Ensiled ion Form:Subsurrace Sa'aage Dlspasal System-Pap 8 of 17 Sep 1514 04:55p p.9 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cove Island Road Property Address William Belden Owner Owner's Name information is Centerville MA 02632 9-12-14 required for every _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank around 19771 D Box and chambers 1998 permit#98-42. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 6' 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): Depth below grade: 5'-6"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: 1500 Gal. Precast Sludge depth: 2" t5ins-31 3 Title 5 Official Inspection Form-S6swface Sewage Disposal System-Page 9 of 17 Sep 1514 04:55p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cove Island Road Property Address William Belden Owner Owner's Name information is Centerville re aired for every MA 02632 9-12-14 page. City/Town 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 28" Scum thickness 01. Distance from top of scum to top of outlet tee or baffle 91 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape 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 at 5'-6"below grade in black top drive way. In cover paved over. Out let cover steel at grade. inlet baffle,outlet tee 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•3113 Title 5 Offilolal Inspection Form.Subsurface 3ftWo Disposal System•Page 10 of 17 Sep 1514 04:56p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cove Island Road Property Address William Belden Owner Owners Name information is required for ery Centerville MA 02632 9-12-14 ev page. Cityrrown 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 ❑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 15ins-3113 Title 5 Offitiial Inspection Form:Subsume Sewage Disposal System•Page 11 of 17 Sep 1514 04:56p p.12 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Cove Island Road _ Property Address William Belden Owner Owners Name information is Centerville MA 02632 9-12-14 required for every page. Cityrrown 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 t} 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 5' below grade.Camera box and located box on site. 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: t5ins•3113 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System•Page 12 of 17 Sep 15 14 04:56p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Cove Island Road _ Property Address William Belden Owner Owner's Name information is required for every Centerville. MA 02632 9-12-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ® leaching chambers number 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: --- ❑ overflow cesspool number: ❑ innovative/aitemative 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 three 500 Gai. dry well chambers. T stone around and in between. Chambers are 52" below grade wlcover at 25". Chambers are wet, clean walls. 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 t5ins•31113 Tittle 5Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Sep 1514 04:57p p.14 Commonwealth of Massachusetts --- Title 5 Official Inspection Form �- Subsurface Sewage Disposal System form-Not for Voluntary Assessments a 36 Cove Island Road _ Property Address - William Belden Owner Owner's Nameinfor required ation is Centerville MA 02632 9-12-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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•W3 Title 5 0f6dal Inspection Form:SubsuAaw Sewage Disposal System•Page 14 of 17 Sep 1514 04:57p p.15 Commonwealth of Massachusetts IN Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cove Island Road Property Address -- _ William Belden Owner Owner's Name information is required for every Centerville MA 02632 9-12-14 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 I 13 -1 Z �, C � - = 3rl ti ! L 0 ''. 3 1 � f I 1 /i 1 15ins-W13 Title 5 Official InsoecHon Foam Subsurface Sege Oisposat System-Page 15 of 17 Sep 1514 04:57p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cove Island Road Property Address William Belden _ Owner Owner's Name information is required for every Centerville MA 02632 9-12-14 page_ City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells YO 12' Estimated depth to high ground water_ 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. 1977 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 1977 no G.W. at 12'. Bottom of pit around 10' below grade. Bottom of pit at 2' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3h3 Title 5 Otrical Inspection Fom1:subsurface S"s oisposai system-page 16 of 17 Sep 1514 04:58p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Cove Island Road _ Property Address William Belden Owner Owner's Name information is required for every Centerville MA 02632 8-12-14 page. Citylrown 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-3N 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 10 No. I-AV r ✓® Fee THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for Migooar 6potem Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) O Complete System E Individual Co nents Location Address or Lot No. d G®j1e ;5 � Owner's Name,Address and Tel.No. Assessor'sMap/Parcel ,i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. UEZ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/60 Other Type of Building / No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank k5 i/!9 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7-/-1 e_ G 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 issue y .s Boar, f Heal Signed Date Application Approved b Date -/_Z F` Application Disapproved for the following reasons Permit No. Date Issued — --- ---------------------- 4, 77 No. t' rt Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,- Yes -PUBLIC HEALTH.DIVISION-.TOWN OF.BARNSTABLE, MASSACHUSETTS 2porication for Migogar Opgtem.Contruction 'Permit Application for a Permit to Construct{ )Repair(V)Upgrade( )Abandon( .)': O Complete System `Q Individual Co nents. Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel G. ey /5 f/�' Installer's Name,Address,and Tel.-No., Designer's Name,Address and Tel.No. Type of Building:', Dwelling No.of Bedrooms L' t'Size. Sq.ft. Garbage Grinder(10� Other Type of Building Tq of Persons Showers(; ). Cafeteria( ) Other Fixtures !J. ' Design Flow gallons per day."Calculated daily flow 7 gallons Plan Date Number of sheets Revision Date ' Title Size of Septic Tank. S7`/.1!9 Type of S.A.S.- '361 X 2 E: Description of Soil Nature of Repairs or Alterations(Answer when applicable) rJ r/e a o r Date.last.inspected Agreement: t 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 'r ' cate of Compliance has been issue y s Boar f Health " :Signed Date Application Approved by .. Date oeyy"" Appli:atiCn I�iiSat yr.Cved for uie jvliG'N1ilgYreasGnS - Permit No. , Date Issued 4-..r THE COMMONWEALTH OF MASSACHUSETTS /f 7l-Daj BARNSTABLE, MASSACHUSETTS r t: Certificate of Com riance ! , s -THIS IS.TO CE�T��,tha the Ott-site Sewage Disposal System Constructed( )Repaired(Upgraded(; ) Abandoned( . ).by at !/ Gbh j GG�y' I^!// l has been constructed in accorda e With the provisions of Title 5 and the for Disposal.System Construction Permit No. dated ..f Installer Designer The issuance of this permit shall not be construed as a guarantee that the syste will function as designed. Date µ�: _ Inspector y ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION.- BARNSTABLE MASSACHUSETTS igogal Opotem Congtruct on Permit Permission is hereby.granted to Construct( )Re air t/�)U grade, )Abandon( ) System located:at C�li!� L5 !'C�h ' 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 , t. Date: �R""' �� ^- T Approved b C Pra•posccL sGp41c UP9rcxcdc. � Ncw ,O BOX Lcachinq 'U-)idc x 38 ' Long X a 'dccp 3-Soo a 9 1 Lcach charrtbcrS Svrrondcot 5y 3 's-lonc ci it around in 5c-lwcr P f ct,vla O f1c+ L # COL)c SS LAND R�- G Lcaeh Q��} ,pomp O �roposcd --� Lcach;ng 11 xasx;2 GJa.Acr Scru',c CL �c be SiccucaL cacti S,dc off' proposcd IccLch;N 1019/97 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 ENGINEERED PLANS) /-)--A/'2®!4 hereby certify that the application for disposal works construction permit signed by me dated /6iz X , concerning the located at 3'9 CFl(.� lQ� '" meets all of the property _ following criteria: here are no wetlands located within 100 feet of the proposed leaching facility ere are no private wells within 150 feet of the proposed septic system flow and/or than in /• There is no Increase In change use Proposed :/,ht ere are no variances requested or needed. Ifhe proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will psi be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) ` l B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.art TOWN OF BsAARNSTABLE LOCATION ZJ � �(Q �"` SEWAGE# 9 �y VILLAGE G�� � � ASSESSOR'S MAP & LOT Zi A:�a INSTALLER'S NAME&PHONE NO. o®� ��' �C��S� 771—,0 )Pe SEPTIC TANK CAPACITY I 1 LEACHING FACILITY: (type) ` ��} � � C I,NAK (size) NO.OF BEDROOMS BUILDER OR(� - ?ell c, PERMIT DATE: I COMPLIANCE DATE: — h----- Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by A Pr3 - Asa r 3C 3 B� 01-13-1998 04 22PM CENT OST FIREDEPT 5087902385A P.021, matte appucauon to tocaj rare ueparrmenT. `/4,. Fire Department retains original application and issues duprk2te as Permit. �`LLr/1J/392892G� L7!/!r2�Brle?Jf.Cr,6— ✓UOQYJ�Qr 01 ✓ � yZ�� APPLICATION and PERMIT Fee: 10 for storage tank remcl.-W and transportation to approved tank disposal yard in accorda wtlh the-:provisions of M.G.L. Chapter 74& Section 38A, 527 CMR 9.00, application is hereby node by: Tank Owner Name(pie print) Jane 0`Neil x agnaluro a ap mQ to,Mold- Address 38 Cove Island Road Centerville, MA Street 04Y Stare Zip ` - . • • Company Name Advanced Environmental Co.or Individual Advanced Environmental - Pant Print Address F.O. Box 472, S. Dennis, MA Address Pi,»t Prwfr Signatu i pl a ftr= Signature (if applying-,cc=errn t) C IFCI Certifier Other _I�_ = IFCI Certified = , _ Other M= Tank Location 38 Cove Island Road, Centerville, MA 02632 • SroerAdaress �_, Tank Capacity(gallons; 1,000 Substance Last Storar #2 Fuel Oil Tank Dimensions(diar.>Er.�x length) Remarks:KIN O •.. .• n • Firm transporting waste Advanced Environmental State Lic. # MV5083856100 Hazardous waste marl =• E.P.A.# Approved tank disposrJ;raid J.G. grant Tank yard# 03501 , Type of inert gas / Tank yard address Readville, MA Centerville 01920 City or Town FDlOff Permit# Date of issue January.l3, 1998 January 27, 1998 Date of expiration Dig safe approval nurntxr. 980100946 Dig Safe Toil F:�To?. Number-800-322-4844 Signature/Title of Offi--y wanting permit .after removal(s)sand Fcr-r?.290P signed by Local Fire Dept. to UST Regulatory Compliarx-a Unit. One Ashburton Place, Room 1a10. Boston, MA �703 1618. FP.pg2 rrsvi-npd"o; TOTAL P.02 of BA�.s BARNSTABLE COUNTY �$; f . DEPARTMENT OF HEALTH AND THE ENVIRONMENT O SUPERIOR COURT HOUSE V F: tZ POST OFFICE BOX 427 S5 BARNSTABLE, MASSACHUSETTS 02630 Phone:(508)362-2511(JS Public Health Administration tration Ext. CH 333 ' Environmental Health 383 Water Quality Analysis 337 FAX(508)362-4136 UNnF.R(�RnllNn TANK TEST RF..CULT.4 TDD(508)362-5885 NAME: JANE O'NEIL TEST DATE: 12/19/97 TANK LOCATION: 38 COVE ISLAND RD, CENTERVILLE MAP/PARCEL: 187 060 TAG#: 575 YEAR INSTALLED: 1978 CAPACITY: 1000 The recent check of the vapor monitoring well(s) near your underground storage tank (UST) did not detect any significant contamination. Because the use of soil vapor monitoring for UST leak detection is a recent and limited technology we cannot,however,guarantee that your tank has not leaked. You should also realize that a "good" result from our test is no indication of how long the tank will remain sound. Due to fiscal constraints, the Barnstable County Health and Environmental Department has instituted a nominal test fee of$30 for one well and$10 for each additional well at a site. Accordingly, would you please send a check for made payable to BARNSTABLE CO INTY to: Charlotte Stiefel Barnstable County Health&Environmental Department Superior Court House, Route 6A. Barnstable, MA 02630 The following items, if checked, also apply to your UST: __X_We encourage the removal of older tanks before the expected leak(s)develop. _We encourage removal of tanks under 300 gallons as they were not designed to be underground. _Your UST doesn't appear to be registered and tagged as required by your Board of Health. _It would be advisable to mark your monitoring well to prevent accidental usage. _The soil conditions surrounding your tank are nid ideal and may accelerate tank leakage. A copy of this letter has been sent to your Board of Health and the records reflect the results of this tank test. If you have any questions please contact Charlotte Stiefel at(508)-362-2511 extension 334. cc: Board of Health: BARNSTABLE Whereas,the escape of fuel from an underground storage tank may result in civil and/or criminal liability of the owner,lessee,licensee, licensor,and/or other persons in control of the premises; Whereas,the use of vapor monitoring procedures is only one of several procedures that may be used to detect leaking or escaping fuel; Whereas,the reliability and experience of the testing procedure is limited;and Whereas,from location to location and soil to soil test results may vary due to a number of factors; The County of Barnstable and the,Barnstable County Department of Health&the Environment represent that while the test results give a fairly accurate reading of the vapor content in the well sites at the place and time of the testing,the soil conditions and condition of the tank and connections may be such that leaks could occur at the time of testing or shortly thereafter without detection. Similarly,the equipment is sufficiently sensitive as to detect fumes when,in fact, no actual tank or piping leaks have occurred at all. Therefore,no party shall rely exclusively on the results of the vapor monitoring test. Neither the County of Barnstable nor the Barnstable County Department,of Health& the Environment shall be liable to any person either for the failure of the test to detect a leak when such a leak has,in fact,occurred or for the detection of readings which may indicate that vapors are present in the soil when,in fact,no leak has occurred. Neither the County nor any department thereof shall be liable for any faulty or overly sensitive readings resulting from the taking of such test. TOWN OF BARNSTABLE V LOCATION J ,�hoAl SEWAGE # VILLAGE eeWX3 V11Z6' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 90r�OCf SEPTIC TANK CAPACITY �/0,W ` LEACHING FACIL=: (type) �`// ` l� , C(/ AMba 5(size) rK l h X cl�0 NO. OF BEDROOMS 7 BUILDER OR-(�_ /eE // PERMITDATE: �l COMPLIANCE DATE:_I ` Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 Al (e-* 63 - 48 ; z a � 3 `� 30 8-f9- 77 f - P.-AUK M 'PR"gv, �N 5F-0CToR ,�� 74`t { -r 39. 7 t `7 . Pilb �. •�'��•�'•'�'I4., l`. . .f4' {� � �i J�,(��...ff���� '• �,�ti/ �ma`s •� •+• �-` �y - cei tie V - . D' lc) R ElJOs�Ft'3'E '. fl pb. N � . . - . .. s 5., AVAIL A$f E1 ' t] ,. T3 u7LD/arG S TBAC :. 6Q�✓ �- Ie• X:5 FQ QiV 7' D i Z7E' 20,�0 QED 1 SEP7-IC' 5y57E!N CoAk5:?-/2, 'cr ny G OiVFQA M TQ E ' M 7 Ai TSL.t,E �-: x V E RAL: O / s3 � 74/GENVieovMNAI'7AZ.7 5/MCA" HEALT / � 0F M,ST Jc—�•t`j� 2 �G PEA •ST�JNLS' ,. 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