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HomeMy WebLinkAbout1314 CRAIGVILLE BEACH ROAD - Health 314 Cralgville Beech Rd Centerville P A 207 072002 i I UPC 12543 �a No.5�,OR ��s7.coasa� HASTINGS,MN .{ Massachusetts Department of Environmental Protection Bureau of Waste Prevention—Air Quality Decal Number F Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 ImpoftnWhen A. FacilityLocation When filling out forms on the HOWARD FRY computot9r,u9p Only the tsb key 1.Name of Facility to move your 1314 CRAIGVILLE BEACH cursor-do not trees Address use key. 9 return IMA 3,city 4.State _ .. S.Zip Code r ti.Telephohe Number INSTRUCTIONS B. Project Cancelled 1. Thls•form Is only availahte for Check here if this project islwas cancelled. online filing of proJed date revisions. 2. Enter project _....---...__..—._.._..�._...--— .... — - .. ....._..._. .._....,....-- . docbl number_ C. Project Dates 3. proect Validatethat the project 0410512M 3 04/05/2013 the location is correct 1.Orlc]net Start Date mm/dd/ m iur uRt tonumu decal. 3.Latest Revised Start Date(mm/d(Yyyyy) 4.Latest Revised End Date(mm/dd/yyyy) 4. Enter your new projet dates. 5. Certify your notification, D. Revised Project Dates Submit date changes 04/M013 04/pBJ2Q13 1.Rovisod Start Date(mm/ddlyyyy) 2.Rav ood End Date Date(mm/da_/ y) E. Other Project Revisions F. Revision History AnfOEpdm,doc-rev.215/04 Z'd t,02906L80ST 01 :WDH_:l S2:2T ZT02-b-&JIJ f Commonwealth of Massachusetts _ 10017"62 Asbestos Notification Form ANF-001 Decal Number Important: When fllling out A.Asbestos Abatement Description famre to the 1. a.is this facility fee exempt-city,town,district, municipal housing authority,owner-occupied computer,use tY• g Y. only the tab key residence of four units or less?d Yes ❑No to more your cursor-do not b.Provide blanket decal number if applicable: $IBrtket¢gC81 Number una the return key. 2. Facility Location: HOWARD FRY 11314 CRAIGVILLE BEACH A Neme of sacili _ b Street Addres n.R •c.CitylTown d.5�tr9 e.Zip code f Telephone Number 1Ns7nucrt0Ms 3. Workske Location: 1.All secWne opt this SAME E== form mugt be a.Building N& BWWing Location b.Building# c,V1tng d.Floor e.Room completed in order to corr"with 4. Is the facility occupied? Yes ❑No DEP notification requimmermt of 310 CMR 7.15 5. Asbestos Contractor: end Nre Divillon of Occupatkml JAIR SAFE INC -.W W..-.. 61 ENDICO'1T STREET SaW(DOS) a.Name b.Addq nufloauire lgn NORWOOD 0206x 7817623390 rmquiromwib of 450 CMR 6.12 a CityfTown dd.7� o.Telephone Number f.AC000464 6QSTuMn5e Number g.Cor imcl Type. Z Written ❑Verbal h. ntW eraoe J.Conte Parzori's Title 6, JAIME E AMAYA �AS060947 a Name of On-Site SueRnMg1lForeman b;y`u r orE3rnan 9 rt r ion Numt�r 7 NA a Flame q#1�R •A b.Pry ct Monitor DOS Certification Number NA toss, n!adcall L�ib b.AdbestogAnglylipal Lot Cglifigg&M N m r ®q 9 04l051x013 M0512013 w-PMect Stara Date mmlddf b.raid Data mnifd ®a 7AM-5PM �N G Work trout¢Mp d. 41.Work houm Solvun. a 10. a. What type of project is this? ❑Demolition ❑Renovation r r❑Repair ❑Other,please specify: b Describe 11. a.Chuck abatement procedures; ° p Glove bag Encapsulation �o ❑Enclosure H Disposal only —W ❑Cleanup f-1 Other, specify: _ --- 2 ❑Full containment b Describe < 12. Is the job being conducted; Q Indoors? ❑Outdoors? 2nf00lap doc•10102 Asbestos Nondcation Form•Puge 1 of 3 2'd t10M906L90ST:01 :WDHA 22:2T 2T02-t7-'JdJ r . Commonwealth of Massachusetts }� 100174452 Asbestos Notification Form ANF-001 i Number A. Asbestos Abatement Description (cost,) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated- i B tJ a Iota[pipes or uc s linear liTcdar�W guFN U �lquare Wrface coating8c.Behar, ing,duct,tank � { 19.insulating cement St. e.Corrugated or layered paper 18----- '��I" "" f.TrowaVSprayer ooaNngs lieu pipe Inwattm Lin.1L sQ;ft q.Spray-on fireproofing � h.Transite board,wall board (,In,h, `5q.tt LIn.rl q. i.Clothe,woven fabrim l� u i.Otlrer,please specify: Lin.ft. ft L�in.r� IL k Thermal,solid Core pipe {1 Insulation Lin_8 i it—" I.Spoci yi�r -- 14. Describe the decontamination system(s)to be used: 2 CHAMBER DECON ---._._.W..... .,.. .-.. 15. Describe the containerization/disposal methods to comply with 310 CMR 7,15 and 463 CMR 6A4(2)O: B MIL POLY SAGE - .—..�. ... .. � 10. For Ernergency Asbestos Oprx•aUons,the DEP and 005 officials who evaluated the emergency: 9.Name Of DEP OWMI - -- C.Date(rt,,,,,lddiy` .)of•Aurhan�alron d:Dip�I+)a�ver�_._._`— e. ame Sri D ael itie N g.Date(rrntt/ddlyyyy)of AUthorl2af14n h.D S Waiver# �. ®Q 17. Do prevailing wage rates as per M,G-L.c. 149, §25,27 or 27A—F apply to this project?CJ Yes d No 0 B. Facility Description �N RESIDENTIAL � y o 1. Current or prior use of facility: 2. Is the facility owner-occupied residential with 4 units or less? (E Yes ©No SAME m.lIbUilty Own1a Nkulm�--- ------ F AdiLmus _._�._---- ---- �a c.Ci !Town d.Z' Code a.Telephone Number(ama cods and extention 4' a Herne Qf KOclll pwnrJr's on-she manager b.On-Site Man er Address 4 C citylrown d.Zip Code e.Telephone Number(area code alto extension) WOO 100.doe•1OM2 Asbestos Nottncatlon Form•P. a Z oT 3 N Vd t70£906Z80ST 01 :WOad 9£:2T £TO2-t7-&IJ I Commonwealth of Massachusetts 100174452 •, Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cant.) 5' a.Name of General Contractor b.Address c.C' crown d.Zjv Code e.re! hone Numb& area code and extension f.Gmtrac W s Workers Comp.Insurer g.Policy Number h.�g,.Date mm/dd/YYYY G. What Is the size of this facility? a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary); AIRSAFE Note:Tranft a Ne a of T ne or1 r I� b.Address Stobw must Comply with the G cityrrown d.Zip Code a.T elephonu Number Solid Waste Division 2, Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 --� a Name of Trans afar b.Address c.City/Town d.Zip Code e.Toleohorie Number a Refuse Trarig%r Staticn and Owner (' b.Address L — Q Ciberrown d.Z Code e,Tafthane Number _ 4. IMINERVA ENTERPRISES INC a.Final Dispoeei Site Location Name b.Final Disposal Site Loration Owner's Name 19000 MINERVA ROAD -- WAYNESBURG� r�Elm I 21te Udwad.Cit/!own OH 44688 e.state t Zip Code 9 Tetepnane Number �O D. Certification N The underslgnea hereby states,under the DF WALSW o penalties of perjury,that he/she has reed the N m ti.AuU'iofIz&J S.I nature c Commonwealth of Massachusetts mgutations VP for the Removal.Containment or psi d t d Encapsulation of Asbestos,453 CMR 6 00 and a ` q�fff)---.--.. 310 CMR 7,15,and that the information 781 762.3390 JAS containW in this notification Is true and correct e,-Tolophone Number �_f,Raprecan4rt�___ to the best of his/her knowledge and belief. 61 6NDICOTT -o .Address �,� NORWOOD �� Q20B2 -__-- h.CltylTown i.Zip Code ■ anUlap-doc-10/02 Asbestos Notification Form,Pape 3 of 3■ it S'CI b0£906Z809T:01 :WDHJ 92:21 ZT02-t7-dclb Commonwealth of Massachusetts Q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 ry 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 the computer, r,use 1. Inspector: • '�� C/l/ (((i((,,,,1111 only the tab key V to move your MARK L WHITE cursor-do not Name of Inspector use the return key. NEIGHBORHOOD WASTE WATER Company Name 350 RT 28 Company Address WEST YARMOUTH MA 02673 City/Town State Zip Code 508-775-2820 S113381 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 maintenanckof on--site sewage disposal systems. I am a DEP approved system inspector pursuant to'Section 15.340 of Title 5 (310 CMR 15.000).The system: FX1 El OF Passes Conditionally Passes Faj, 4, jN ❑ o`'••' MARK ;yc Needs Further Evaluation by the Local Approving Authority _ WHITE No.S13381 t v, RTlf������`` NOVEMBER 6, 2012 nspe tor's Signature Date �iprnn��ttn�p�� 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E L always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 20 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): . ❑ , 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 20 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name reuired for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 Citylrown State Zip Code 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 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form �6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 Citylrown State Zip Code Date of Inspection 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 ❑ ❑x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow B. Certification (cont.) Yes No ❑ x❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary.to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. 11 FX-1 Any portion of a cesspool or privy is within 50 feet of a private water supply well. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 20 f y Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 Citylrown State Zip Code Date of Inspection ❑ ❑x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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. ❑ ❑R 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. C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ M Were any of the system components pumped out in the previous two weeks? ❑x ❑ Has the system received normal flows in the previous two week period? t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 Citylrown State Zip Code Date of Inspection ❑ 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)N/A ❑x ❑ Was the facility or dwelling inspected for signs of sewage back up?. ❑O ❑ Was the site inspected for signs of break out? ❑x ❑ Were all system components, excluding the SAS, located on site? M, ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑x ❑ Was the facility owner(and occupants if 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: ❑x ❑ 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 Information 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): 440 D. System Information t5ins-11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 7 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 . NOVEMBER 6,2012 City/Town State Zip Code Date of Inspection Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑x No Islaund on a separate sewage system? If es separate inspection required] Yes ❑ rY p 9 Y �� Y p p q ] No Laundry system inspected? ❑ Yes ❑ No Seasonal use? M Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2011-111,000 2010-150,000 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 City/Town State Zip Code Date of Inspection Sump pump? ❑x Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) 0 Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No ❑ Yes ❑ Industrial waste holding tank present? No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ i No Water meter readings, if available: D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: B.O.H. NEIGHBORHOOD WASTE WATER Was system pumped as part of the inspection? ❑ Yes ❑x No If yes, volume pumped: gallons t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 20 Commonwealth of.Massachusetts ' r Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for CENTERVILLE every page. MA 02632 NOVEMBER 6,2012 Cityrrown State Zip Code Date of Inspection How was quantity pumped determined? Reason for pumping: Type of System: ❑x Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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): D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 7/9/93 Were sewage odors detected when arriving at the site? ❑ Yes x❑ No Building Sewer(locate on site plan): Depth below grade: 48 INCHES feet Material of construction: El cast iron. ❑x 40 PVC ❑other(explain): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 20 Commonwealth of Massachusetts pil, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �e 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name reuired for every page. CENTERVILLE MA 02632 ,NOVEMBER 6,2012 City[Town State Zip Code Date of Inspection Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): INSPECTED MAIN LINE WITH SEWER CAMERA, LINE IS CLEAR Septic Tank(locate on site plan): Depth below grade 40 INCHES feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) RISERS IN PLACE BRINGING COVERS TO 8" DEEP If tank is metal, list age: years Is age confirmed by a.Certificate of Compliance? (attach a copy of certificate). El Yes El No Dimensions: Sludge depth: 2„ D. System Information (cont.) t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 - NOVEMBER 6,2012 City/Town State Zip Code Date of Inspection Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2 Distance from top of scum to top of outlet tee,or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) INLET AND OUTLET TEES IN PLACE,NO SIGNS OF LEAKAGE 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 20 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 Cityrrown State Zip Code Date of Inspection Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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.): t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 20 r Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for CENTERVILLE MA 02632 NOVEMBER 6,2012 every page. Cityrrown State Zip Code Date of Inspection *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert AT INVERT Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX IS IN GOOD SHAPE Pump Chamber(locate on site plan):. Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 20 �y Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 CitylTown State Zip Code Date of Inspection 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: D. System Information (cant.) Type: ❑ leaching pits number: 0 leaching chambers number:4 INFILTRATORS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name ° required for every page. CENTERVILLE MA 02632 NOVEMBER 6 2012 City/Town State Zip Code Date of Inspection ❑ 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.) NO SIGN OF HYDRAULIC FAILURE, NO PONDING 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 D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 20 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 Cityrrown State Zip Code Date of Inspection 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ra 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 Cityrrown 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 ❑x drawing attached separately t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r _ 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for CENTERVILLE MA 02632 NOVEMBER 6 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 0 Check Slope 0 Surface water 0 Check cellar 0 Shallow wells Estimated depth to high ground water: 12 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 ❑x Observed site (abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) 0 Accessed USGS database -explain: WELL MIW-29 ZONE B-2.00-2.99 LEVEL 7.7 ADJUSTMENT 2.0 X12 =24" t5ins•11/10 Title 5 Official Inspection Form:Subsurface •Sewage Disposal System Page 19 of 20 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 1314 CRAIGVILLE BEACH RD Property Address Owner VALERIE FRY information is Owner's Name required for every page. CENTERVILLE MA 02632 NOVEMBER 6,2012 City/Town State Zip Code Date of Inspection You must describe how you established the high ground water elevation: BOTTOM OF LEACHING IS AT 40" W/24"ADJUSTMENT BRINGS TOTAL TO 64", NO GROUNDWATER FOUND'AT 144" ( 144"-64") LEAVES 80" OF SEPERATION Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist ❑x Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information— Estimated depth to high groundwater ❑x Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 20 of 20 f Al- - -9+ PS Io" Q� - 2q'6 � �� " 3 �� 3y • a.5� Fry T-&Wo•one Tole S OfIeW Inspecoon Fain.SubmWaco Sew"v Lh-4=0 Syeleto•Pap 14 of 15 V Commonwealth of Massachusetts Z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 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. Important:When filling out A. General Information forms on the r computer,use 1. Inspector: only the tab key to move your Brad J. White = cursor-do not Name of Inspector use the return key. Bluewater Company Name 350 Main Street Company Address West Yarmouth MA 02673 Citylrown State Zip Tde (508)775-2800 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 CMR 15.000). The system: --1p ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/28/08 Inspector's Sig ur Date The system ' pector 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. Fry T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. Cityfrown 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: System fully meets pass criteria. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by- the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following staternents. if"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Fry T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28108 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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 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. Fry T-5.cloc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System^Page 3 of 15 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Fry T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 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. Fry T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. Cityrrown 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: ® ❑ 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)] Fry T-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown Number of current residents: 2 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 ears usage d 06-109.58gpd 9 ( Y 9 (gpd)): 07-224.65gpd Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: a 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: Last date of occupancy/use: Date Other(describe): Fry T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: 1 year per owner 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 ❑ (No) Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: System was installed in 1993 per as built plan of septic system. Were sewage odors detected when arriving at the site? ❑ Yes ® No Fry T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3-7 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): --p Building sewer is in good condition. No evidence of leakage. Septic Tank (locate on site plan): 3' 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 -------------------------------------------------------------------------------------------------------------------------- Dimensions: 10'-6" x 5'-8" x 5'-8" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 6„ 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured -Fry T-5.doc'•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 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.): ---w Inlet tee and outlet baffle are in good condition. Liquid level is normal. No evidence of leakage in or out of tank. Inlet cover has riser 6" below grade. Recommend build up on outlet and installation of filter. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): Fry T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1314 Craigville Beach Road Property Address .Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 . every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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.): —®$ Distribution box is level. No evidence of leakage in or out of box. No evidence of solids carryover. Distribution box is 27" below grade. Box only has one outlet leaving it. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Fry T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): ---�� Soil is dry, No signs of hydraulic failure. Vegetation is normal. No ponding. Leaching consists of 4 infiltrators in a 7'x 29' area. There was only 1/2"of liquid in infiltrator. Top of infiltrator 29" below grade and bottom of infiltrator is at 40" below grade. Fry T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): Fry T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. City/Town State Zip Code Date of Inspection D. System I liformation (cont.) Sketch Of Se age Disposal System: Provide a sketch of the sewage disposal system including ties to at least tw permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 0 131U A �� Q� y � U I t A2 2C G? ' 2.4 t A3 ' Z3) G2 - 24' Fry T-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 u i Commonwealth of Massachusetts p Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 1314 Craigville Beach Road Property Address Valerie Fry Owner Owner's Name information is required for Centerville MA 02632 4/28/08 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: I ® Check Slope ® Surface water ® Check cellar ® Shallow wells I�y + 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.: 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: Well MIW-29 Zone B -2.00-2.99 Level 7.7 Adjustment 2.0 x 12 = 24" You must describe how you established the high ground water elevation: --� There is a significant slope off in the rear of the property. Used laser level to shoot elevations. Bottom of the infiltrator is @ 40". Add the required adjustment of 24", brings the total to 64". No groundwater encountered at 12'+. 144"-64" leaves the remaining balance of 80"with no groundwater present. Fry T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 I � I I -- i--.. {-- - - - - - -- - - ---- - --f----- -------- - r 10 03 I f I I � ' • I I I 2 In I I i : I ' 1 . 4L h ; 1 I i i t i I , : I ! o , I_ Y ; I { - _ - I � I P !47 , 1 { 1 i I i ' _ 1 1 G I i ' I : : t 1 i I 1 ' I , , I - i Town of Barnstable OF 7HE Tp� Regulatory Services BARNSfABM ; Thomas F. Geiler,Director v buss .$ `��pfnr�,�A Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division:does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic ,System Inspector who conducted the inspection. COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �y y�s`� pp,-,mF•�(�+rt"��1Q��4i F�4�o �y/fir - TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: C" Owner's Name Owner's Addre s: g" �o (RECEIVED . Date of Inspection: �,� %7 3 ' JUN 2 6 2003 Name of Inspec or (plea a print �CN TOWN OF BARNSTABLE .Company Nam C, HEALTH-ODPT. Mailing Address:. Telephone Number: -7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the.time of 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.CMR 15.000). The system: jPasses Conditionally Passes Needs Further Evaluation by the Local.Approving Authority ails Inspector'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 is a.shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments /�1i1�j !?l _.. %J��i+c /!e � ****This report only describes conditions at.the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/20.00 page I .Page 2 of 11 ciy i OFFICIAL INSPECTION:FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: N&/47.0 &,ae, . '000�� Owner: Date o ,nspection Inspection Summary: Check A,B,C;D or E/ALWAYS complete.all of Section D A.jystem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.�Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair; as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septictank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltratiori or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or 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 boy. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is.leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 . Page 3 of 11 OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: - ' _ Owner: GCL� Date of spection: e 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. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to,or less than 5 ppm,provided that.no other failure criteria are triggered. A copy of he analysis must be attached to this form. 4 3. Other: 3. Page 4 of 11 OFFICIAL INSPECTION.FORM=-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART A CERTIFICATION(continued) Property-Address: • 7 ` � 0,A �� Owner• Date o nspection: aOO—�2 A System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N�j ✓ 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 i/ , Liquid depth in cesspool is Iess than 6"below invert or available volume is less than 1/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped V Any portion of the SAS,cesspool or privy is below high ground water elevation. t/ Any portion of cesspool or privy is within 100 feet of a surface water supply or.tributary to a surface water supply. lAny 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. ortion of a cess ool greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence.of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,:provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system.fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E: Large 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the'system is within 400 feet of a.surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II:of a public water supply well . If you have answered"yes"to any questibn in Section E the system is considered a significant threat, or answered- "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed.under Section D shall upgrade the system in accordance with 310.CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5ofj1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property.Address: Owner p Date o nspection: 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 v_ Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? L/ _ 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? V 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: Yes no Existing information.For example,aplan-at the Board of Health. — Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance = is unacceptable)'[310 CMR 15.302(3)(b)] 5 Page 6 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: / Owner: Date .f. spection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 15.203(for example: 11.0 gpd x#of bedrooms): Number of current residents�e----�t Does residence have a garbage grinder(yes or no) Is laundry on a separate sewage system ( es or no);/ if yes separate inspection required] Laundry system inspected yes or no✓�/� Seasonal use: (yes or no Water meter readings, i av iIable(last 2 years usage(gpd)):d 7i Z/nr00 �l Sump pump(yes or no Last date of occupancy: COMMERCIAL/INDUSTRIAI�/�' Type of establishment:.. Design flow'(based on 310 CMR.15.203): gpd Basis of design.flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records /1 e Source of information: l`(J Was system pumped as part of t4 finspectiotf(yes'cO o If yes,volume pumped: gallons--How was qua titfi y pumped determined? Reason'for pumping: TYF�OF SYSTEM Septic tank,distribution box,soil absorption system � Y Single cesspool _Overflow cesspool :Privy _Shared system (yes or no)(if yes, attach previous inspection records, if any) _Innovative/A Item ative technology.Attach a copy of the,current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval Other'(describe): Zximate age o all corn ents, ate inst led(i own)-and sour e of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART-C SYSTEM.INFORMATION(continued) Property Address: Owner.:OAA Date of nspection: / O BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 4.0 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:�. ncrete_metal_fiberglass polyethylene _other(explain). If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /0. .� ' Sludge depth:-,;�0, Distance from top of sludge to bottom of outlet tee.or baffle: 20 Scum thickness:-/ r Distance from top of scum to.top of outlet tee or baffle: . 2,,� Distance.from bottom of scum to bottom oK outlet tee or baffle: How were dimensions determined: Comments(on pumping recommen ' tions, in et and outlet ee or baffle condition,structural integrity; liquid levels related to outlet invert,e i ence of leakage, c.): l � �. oy GREASE TRA✓/1 I'ocate 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 baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,_etc.):. r Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: eCI�G� Owner: Date of nspection: -7,aCO3 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 L Uolyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches; etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet inve •: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of aka`ge into or o t of bo te.): PUMP CHAMBER:ZOL&Iocate on site plan) Pumps in working order(yes or no): Alarms'in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Ad dress: � �" Owner Date nspection: C G3 SOIL ABSORPTION SYSTEM (SAS),:�,,�(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ 1 aching chambers,number: aching galleries, number: leaching trenches,number,'length: leaching fields,number, dimensions: 'overflow cesspool,number:' _innovative/altemative system. Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, 3P �f 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.or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIV�Y. ocate on site plan) Materials of construction:. Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owne : 2,e19 Date Inspection: ,000 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the.sewage disposal system including ties to at least two permanent reference,landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. O �\ 10 Page l l of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION(continued) Property Address: / 3 1 - Owner:aAGZ/hLPi9 Date of Inspection: J Al 7 03 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water�feet Please indicate(check).all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: 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) --y iI_Accessed USGS database-explain: You must describe how.you established the high ground water elevation: �91 5 I1 Permit Number: Date: Completed by: %/ K HIGH GROUND-WATER LEVEL COMPUTATION Site Location: j 3/ ��/ /�GL, � � 4z/ Lot No. .Owner: 0/1 r1112# /�fC:i�— Address: Contractor:._V�, lr (2W,S7, Address: Notes: /l STEP 1 Measure depth to water table tonearest 1/10 ft. ............................................................................:.... .Date month/day/Year STEP 2 Using Water-Level Range Zone and 'Index Wel1'Map locate I site and determine: l OAppropriate index well........:....:.:.................��`�.�... OWater-level range zone .......................................:........::...... N STEP 3 Using monthly report."Current Water Resources Conditions" determine'current depth to water level for index well .......::................ '9� month/year STEP 4 Llsing ,Table of.Water-Ievel.Adjustments. for index well (STEP 2A), current depth to water level for index.well (STEP 3)., and water-level zone(STEP 2B) determine water-level adjustment•....'.......................:......:....................................................... ( I '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) ............................................•.:.........................,....................................... 1/ Figure 11--Reproducible computatim form. E t a` �5 T. a : 4 i fog t � k4 F a 9 w } Y • F ( t S THE COMMONWEALTH OF MASSACHUSETTS` APPROVED BOARD OF HEALTH Barnstable Conservation D8p8is .-7? .bTOWN OF BARNSTABLE ,11pp iraNm r Ui'ipmi l Wi orkii Towitrurtturi Frrmit Application is hereby made for a Permit to Construct ( ) or Repair 0< an Individual Sewage Disposal System at: .......1c3/�- �...2.¢ �.//!mac � CIFN J�ICAO, wner /LG�'tC/ c�G2 ���/ � f '✓/�`�r - !7 U�! ...................... -�----------------" ------•- ................ ------............................... Address Installer Address Type of Building Size Lot............................Sq. feet ,.., Dwelling—No. of Bedrooms...............��_�________--_--____-__-.-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------• No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ._.. �.......................... . W Design Flow................... _•-----____gallons per person per day. Total daily flow_.-_---__--. --- g g� P P P Y Y Q gallons. 1:4 Septic Tank—Liquid capacitvh,ad.gallons Length---------------- Width---------------- Diameter................ Depth................ Disposal Trench--No. ---------/...-__. Width........ Total Length-------c�_-_ Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed bY-------- -------------------------••-••.............•-•••-....---••-•---•- Date........................................ ,,.a Test Pit No. 1................Ininutes per inch Depth of Test Pit.................... Depth to ground water........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................ Pr -----------------------------------•----------------------------•-••----------------......_...............•--•--•--.......-•••••......-----..........--•----- 0 Description of Soil........................................................................................................................................................................ W U Nature of Repairs or Alterations—Answer wh n applicable.-_/!U ___ ... U .. �yc._...Z.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance be iss a by the rd of health. Signed . �' .. . . % . Application Approved By ......... ..... �� .3 Dace Application Disapproved for the following reasons: .......... ............................... .... . . -- ..................................... ......... .......................................................... ................................................................ .............................................. ........................................ Permit No. ........ g Date ....... .. Issued /...-.. ........ Date —————— 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ TOWN OF BARNSTABLE Xpp iratiun for Diripuiu1 Wnrkri Cnunitrur#tun Farm# Application is hereby made for a Permit to Construct ( ) or Repair ( !) an Individual Sewage Disposal System at ....................i..�/- E f ../ ///.....� =--� .� �''� -------•---•-------------------------------------------- --- --- Locat'ion-Address or LOt,NO. ( / c ��� ��ryi '��L c.z 11`= /,� Glj L ......................„........................................................____._______.___ __ ..................__. Owner �. Address W G L 10777 i Installer Address Type of Building Size Lot.............:..............Sq. feet Dwelling—No. of Bedrooms.--_._._•.....y ----------------_----Expansion Attic ( ) Garbage Grinder,,( ) p,I Other—Type of Building ---------------------------- No. of persons-------__------•._-----.--- Showers ( ) — Cafeteria ( ) 4' Other fixtures ---=--------------------- ............................Design Flow.....................S. ............gallons per person per day. Total daily flow............ ` --_._..--_.-_ ....... R: Septic Tank—Liquid capacity Z. .gallons Length-,-------------- Width.---_--_-----_ Diameter.- ------ Depth................ 1 Disposal Trench--No. .........,2........ Width........:ZZ... Total Length------- --_ Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter------_............. Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) {{ aPercolation Test Results Performed by........---............................................................... Date........................................ I Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water......-----...--....---. 44 Test Pit No. 2................minutes per inch Depth of Test Pit--------_........... Depth to ground water........................ Ix0 ....-•••--••-----•--•-------•.....................•-•••--..._._...................-----..._...............-•-•------------•--•---•...---=•--•------••--..-•-- Descriptionof Soil-----------------•----------------------------•-------•---•--------------•-••--------------------------------------•-•--•-------------•-----------------..............-- x w UNature of Repairs or Alterations—Answer wh n applicable-- N % - :--._ -._. ........... ......... J-! ....... n1c.--.............-------•---................----•-............--••.......--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-7been iss by the board of health. Signed /� r ...> ��� � --------- Application ..../., .... � � �- Dare ApprovedBy --- ...�... ----. .................................................................... re Application Disapproved for the following reasons: ...._.....-_....................._ ---------- ------- .............................. - ............................ . -- ... --...... -- - ... ... - --_..............-....-...-.................-........ Dire� ....................................... .. ........i...r.e...--..._.. - -- o. .....Permit N ... Issued .....7..-....... ...... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#tftrate of C�IImpliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �) by ......................... ................ - ..... ! ..__.... c G.,- iL c �9ruN --.-. .............. ........... Insr.Jicr at ................ .. ....... ......... .f�3/. --- ��� .�?/ -.�>>L-1:.� -_4 "/.............----------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No.,��r .... ,`. ........... datedr'..��'-'.�,�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE 77 '.a,3. . . ........... .... Inspector ,. . .. .. .. - ................. ..._... __.-_. _..............THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Z�6-7" 7�---- TOWN OF BARNSTABLE FEE.••••�56.. �i��u��t1 ur�u �un��r�r#iun �prmi� Permission is hereby granted....................... C. %7..Gi- --7 ..... to Construct ( ) or Repair (--/—) an Individual Sewage Disposal System at No................................................ � __. 1_ -c.l✓f 1- -------------�i-lG�� � ........................................ ------- strcet as shown on the application for Disposal Works Construction Permit ':__r_..�. ._ Dated_-_.��-'".-.���. ... � Board of Heath DATE------. ....••-•-• .......................................... 'FORM 3860E HOBBS&WARREN.INC..PUBLISHERS "�----ter TO41N,0F.-B-aRNSTABLE i1ON ATW SEWAGE # p VILLAGE G19eiyr,V)w- - ASSESSOR'S MAP 6i INSTALLER'S NAME & PHONE NO. CP1Wsr S&'TIC TANK CAPACITY Xb-0�4 LEACHING FACILITYAtype) (size) 7 �g f NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER = BUILDER GlK OWNERS- � DATE PERMIT ISSUED: 7 DATE COMPLIANCE ISSUED:���-/� VARIANCE GRANTED: Yes No� La - r � ciCA'TION SEWAGE PERMIT NO. 141 � VILLAGE 1 f, I.NSTALLER'S NAME A ADDRESS B U I L D E R OR OWNER q 4►'V�6nA SZ: D A T t PERMIT ISSUED DAT E COMPLIANCE ISSUED l(,U�rl �?Pvr. 5 t. 71 A ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH QCU ........------OF..... .......................................... Application for Disposal Worku Tomitrurtion rainit Application is hereby made for a Permit to Construct (X or Repair an Individual Sewage Disposal Sys em at• ......... ... ............ ...... Z......... :............................................... Address 100 or Et NO. ................................ Installer --------------- Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms_______.__ ........_______________Expansion Attic Garbage Grinder ( ) Other—Type of Buildin 04 g No. of persons..........(o.............. Showers Cafeteria ( ) Other fixtures ...............................................................................................................................*--------------------Design Flow................ f_6...................gallons per person per day. Total daily flow......'3� Q......................gallons. Septic Tank—Liquid capacity,/kW..gallons Length./10..A.... Widths.,-k'Z"*" Diameter________________ Depth_____.___.__.... Disposal Trench—No____________________ Width____._.__._.__._.___ Total Length....................Total leaching area__.__.______.__ ft. Seepage Pit No-------------I/------ Diameter.___...X-1_..... Depth below inlet.....7_13.if_ Total leaching area..,_______.___ Z Other Distribution box Dosing k Percolation Test Results Performed by..wo- ............. Date.... ........ Test Pit No. I................minutesperinch Depth of Test Pit.................... Depth to ground water GY4 Test Pit No. 2................minutes per inch Depth of Test Pit._._._.__.____._.__. Depth to ground water A./ P4 oil....C .................(... ..........**** .............................................................................................................. 0 Description of S ................... ­ --- --- - ------ ..........................................I........................................................ 1.14 - - --i�_ ---------- .......... ..... ....... .................................................................................................................... -------------------------- b ------- __ .. ;� .....j....72W-------- ... ..... ........... .................................................................................................................................... ........... . . U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal,System in accordance with the provisions of TI I TA12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ssued by the bD rd of Zhnl,.thn,.. �g . ... .. .................. 9 e/te� gned. ....... .. ....... '9........ D to Application Approved By......... ..... ...... .... ............... ...... ......... 7 Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF .HEALTH Appliration for Uhipolial Works TonstruIrtion Ilernfit Application is hereby made for a Permit to Construct (4 or Repair ( ) an Individual Sewage Disposal Ste: 't `_. .... -..... - ......................................... I ocatio Address r or Lot No. . .. _�'__ --- _.--_ �:--:_. � � Tom) ��� W -/% '- "Wner --_' _^___....----- -' G4;iyl'YYQdr�eSs'" "'............................... i a _____ .E/............................................................_..._.............. ...............__.....____........................................._......_._..__..........._..._. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms____.___:t �_______________________Expansion Attic ( ) Garbage Grindera Other—Type of Building,�9 2 -----.. No. of persons..........G.............. Showers ( ) — Cafeteria ( ) Otherfixtures --------•----------------------•---------------------------------•••----------•......•......_.........•------------ W Design Flow............... ...............gallons per person per day. Total daily flow-------330......................gallons. WSeptic Tank—Liquid capacity. Keallons Length_1L?"k/..__ Width_ r: Diameter________________ Depth................ xDisposal Trench—No_ ____________________ Width____.................... Total Length.................... Total leaching area..................,esq. ft. Seepage Pit No_____________ ----- Diameter....../__....... Depth below >nlet___ .. ___.. Total leaching area__.': ___ Z Other Distribution box ( �) Dosing �nk ( ) Percolation Test Results Performed by-_ //? --!a�_''7"--�--!«'"-- � " -•--•-• Date..... Test Pit No. I________________minutes per inch ,Depth of Test Pit.................... Depth to ground water_ _ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water. •-........ S✓ O Description of Soil___.._�� _lR c _�___:_ U ---------------------------------- U.... '�G.._ -.___...____-------- •----------------------------------------------- •------------ _-__...... _------------------------ UNature of Repairs or Alterations—Answer when applicable_________________________________________________________.................................... ..------•-••----------------•-------------------------------.......................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the jar of health. - ned__ ' ......✓%-- ............................................ -,)li �-- at /1 Application Approved By.......... -�- •- •-- .._••. •L-�--�!2 '`'�` � f, - Application Disapproved for the following reasons:..............................................................._......._.................. Date----••-----•-- -------------------------------------••---------------------...-----------•-----••-------------•-•---------••-•--•-----•-•------•--•------•-•---••-•••-•-•-•-•--•-•-•--••----••---•-•---••••••----._.... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF....... ����....... a;�4.............................. ......... ......... Trrtifiratr of Tontpli, urr THI IS TO C Y, Th the Indi :dual Sewage Disposal System constructed (X) or Repaired ( ) by......... =: ......, _.... .: '. ..... �...........................................T'............... e ------------------- -------- ------- Installer at Yed �.�-. ..-1GC... ...... has been instn accordance with the provisions of ' 5 of The State Sanitary Code as described i the d Y application for Disposal Works Construction Permit N _ ________t_ _:_��__.___ dated ...�--�.�_�"`" _.G�____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................... --•--•-•-----•-••----------------•----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HErw a ............OF....... �k'!Us.-....---- -•---......................... ,. C� No..........._„ __...... FEE.......:................ Disposal or�va2lrnr?an amit Permission is hereby granted._._ f- ______ __________ ______�u :_._._..____ !. to Construct (V) or Repair ) an Individual Sewa e Dis ,osal System at No................. s. /1 .w/T 'Jtreet as shown on the application.for Disposal Works Construction Permit �� _ _..•-•••- ........ _ p� Board of Health DATE.............-/ -•----•---------------4-i/------..•.-.----•------------.._..._. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ` , ON S E W A - E PERMIT NO. VILLAGE 4 1 1 INST" LER'S NAME L ADDRESS SUILDER OR OWNER M D a}-s SIG U IIL 6P �� /� Ca DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � ✓� ryv�Me- of F q OF �A` ......... 4� 'N' T 7 JOTE', Y, �i, e ...... 4 .5 -.1 A,tr -77 It U11, 4U 44 J�L!#t ... 50 co tr mi 77, z ZO A jo 9=2= v r '0 . ,, I ' -T, - I" -A YI. 01 IS� -4 jo pl N Jerre t> SA#J VrA Ij 4119 6 0 TIN, 10 0 tz Q. 6r r4C�, L %4)w- -A."t> 1660 0 :V 4 �J �P dim'; ��,A 2A , Ye C,I-Ib" Z5 C>1-1-0)`-I kj -T t I's E L45v. 4 A F Is tA ove its A� So Axa x -f zt --4p Zt/,�FV/4)/Y j"'I r c .4 AIZ) �,e r: �P,- OP NAL <= j lit -�-Is,-5o 10 r,;% IS v- 0 N IOL "46 V tic \,-/oA" 'A; V ts oe rseqvA 46 7-Ao PI CAII CID 7 'A C+�I '00 OIL t4 IE�A,t-7 A 7.z 267,F7 Of P6 �r j2 % lip E 47 O�f 6�1 "_4. NZ- PeeSOO f,4570- f>AY ikp e e '100 <;jA LLosj S PS Al GI 10011�1 Mi e Aee,&, CXF 5 C 35 4:)o�W I-Sb-7 P. V Z*'r.4 7- M J> -z>o,I�e*, f0e A, X4--Y-4 M PLAI" -P �C)R ,V�4 NORMAN AD .74 'GROS 2 JAI