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Home My WebLink About0025 CROCKER STREET - Health 25 CROCKER STREET, CENTERVILLE A = 210 157 4 UPC 12534 No. 2_5_ HASTINGS, MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the 1 ) computer,use 1. Inspector: ll//only the tab key to move your Robert paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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: `Y ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority o 'a am 10/19/2010 ` Inspi Date The system inspector shall submit a copy of this inspection report to the Approving Authority( rd of Health or DEP)within 30 days of completing this inspection. If the system is a shared Oster r. has a design flow of 10,000 gpd or greater, the inspector and the system owne shall st.fPnit tfm report to the appropriate regional office of the DEP. The original should be sent to the sys em 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. V v t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sew4Dispostem•Pa e 1 of 17 z Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The spetic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a,surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: r **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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No - ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 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. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 25 Crocker St. _ Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of anc occu /use: p y Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.system vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 5" t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and ooutlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official,Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line observed 30" below invert Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately r3� C__ k . 3o�L iUUV t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 z Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar. ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 20' 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges od groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 25 Crocker St. Property Address Bank Owned Owner Owner's Name information is required for Centerville Ma. 02632 10/19/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I 216 TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION / Property Address: 9 S C e10 L Ka r $�. Name of Owner C7 e -m—a A,/cL 4 e_ � S Cej' 7 t v V IA-- Address of Owner- 7 6 C— 0 rZ c-4 r L Date of Inspection:,`//0 /9 �� tN t'crVi ��rt N(G. v2E3z Name of Inspector:(Please Print) Troy Williams � I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company.Name: Troy Williamt Septic Inspections Mailing Address: 15 Hummel'Drive, So. Dennis MA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails ILspector's Signature S.tom` �Z W ee&t� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to ttte system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department 1 Environmenta(Protection,certification is not to be construed as a guarantee of future work" .9 of system, piping or components. This inspection represents the conditions of the system ate of Inspection noted above. 10 d 11 d ,� 1999 � 1 Z revised 9/2 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continrwd) PropOwner: Address. 25 Crocker Street, Centerville,MA Date of Inspection: Gemma Mathews February 10, 1999 INSPECTION SUMMARY: Check A. B, C, or D: A../SYSTEM PASSES: V 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDMONALLY PASSES: A1119 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. Indicate yes, no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If "not determined explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced — The system required pumping more than four 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 '-evised 9/2/98 ra�c : ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirxwed) Prop"Address: 25 Crocker Street, Centerville,MA Owrxx: Gerarna Mathews Date.of Irupection: February 10, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /vl'9 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the Public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WTTH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well., The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 1 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 25 Crocker Street, Centerville,MA Property Address: Gernma Mathews Ownef: February 10, 1999 Date of Inspection: D. SYSTEM FAILS: You must indicate either 'Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due-to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: /t' //9 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. 1-Pv 1 S d 9/2/98 Pu Cr 4 of i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Crocker Street, Centerville,MA Owner: Gemma Mathews Date of Inspection: February 10, 1999 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye; No Pumping information was provided by the owner, occupant,or Board of Health. Y " _ stem co ✓ram=�-��y Y components have been pumped forat least two weeks and-the system has been•recei rates during that period. Large volumes of water have not been introduced into the system recently or as Part ofmTth s None of the s flow / inspection. V As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. J _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes.were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: !L _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation pproximation of distance is unacceptable( The facility owner (and occupants,if different from owner) were.provided with information on the.properxnaintanaace�f Subsurface Disposal Systems. revised 9/2/98 Page 5 0( I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: 25 Crocker Street, Centerville,MA Date of Inspection: Gemnla Mathews February 10, 1999 RESIDENTIAL: FLOW CONDITIONS Design flow: //U g.p,d./bedroom. Number of bedrooms (design): Number of bedrooms(actual): Total DESIGN flow 22z y — Number of current residents:--Jo— Garbage grinder(yes or no):_(/_o Laundry(separate system) (yes or no):�u If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):_L/o. Water meter readings,if available(last two year's usage(gpd):7/1 8 _ ,5-8 .00w Sump Pump (yes or no): &O Last date of occupancy: 04. 8 COMMERCIAL/INDUSTRIAL: A/1/q Type of establishment: Design flow: qpd (Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: X. System pumped as part of Inspection.(yes or no)LV0 �., °~'` v w vt��, If yes, volume pumped: gallons Reason for pumping: TYPE F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) A10 revised 9/?/98 Page 6 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: owner: 25 Crocker Street, Centerville,MA Date of Inspection: Gemma Mathews February 10, 1999 BUILDING SEWER: (Locate on site plan) Depth below grade: /8 Material of construction: lie/cast iron t/40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age ls.age confirmed by Certificate of Compliance—(Yes/No) Dimensions: S �x `/ �� 6 /DUO Sludge depth: IR Distance from top of sludge to bottom of outlet tee or baffle:// Scum thickness: IVaA/C Distance from top of scum to top of outlet tee or baffle: A16 S ✓v� Distance from bottom of scum to bottom of outlet tee or baffle: it,/, $ c ,k�% How dimensions were determined: A-V la e Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet'nvert, structurstintegrity, evidence of leakage,etc.) p✓Gcar r ova if c HU i 1, A,G O GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(ezplain) 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Pagr7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Address: 25 Crocker Street, Centerville,MA Date of Irupection• Gemma Mathews . February 10, 1999 TIGHT OR HOLDING TANK:&"%(Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order:Yes No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:j/ (locate on site plan) Depth of liquid level above outlet invert: L" J v( Comments: (note-if level and distribution is equal, evidence.of solids carryover, evidence of leakage into or out of box; etc.)_ PUMP CHAMBER: Al (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) O nef: A SS 25 Crocker Street,Centenille,MA Date of Inspection: Gemma Mathews February 10, 1999 SOIL AESORPTION SYSTEM(SAS). (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: _&t�_ 7 /X( c G-L� (� t,,, r 1 `S yt'a, L leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) 5—" V �r :�' a./cx- v a J cj 4 �r r /V� _fn L- ✓�r� r� e r t_P y --5 c CESSPOOL$ZLj/jj (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.(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 " PaQ, a..I ii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 25 Crocker Street, Centerville,MA Date of Inspection: Gemma Mathews February 10, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3� /000 �w 11 SLpfi `�� w 'X� L4,-,A p� revised 9/2/98 Ngc 10 0l I I f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(conf. d) Oner: Address. 25 Crocker Street, Centerville,MA Date of Inspection- Gemma Mathews February 10, 1999 NRCS Report name �/� Soil Type_ Typical depth to groundwater USGS Date website visited '50i /ZS a 97. 8 Observation Wells checked ZwV,E C 8 " Groundwater depth: Shallow Moderate Deep V SITE EXAM Slope Surface water Check Cellar ✓ Shallow wells Estimated Depth to Groundwater/5+Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record ✓Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 4A a.j y c r.e CA 1 U 45 LIJ u y c ! l� t K c r f h: A-z) I.,v(r✓r,_�o-- /c 4j e-( , revised 9/2/98 Page 11 0! I I No. v t Fee ,f� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Migpool *p5tem Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.Q Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. _ Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow -33 d gallons per day. Calculated daily flow � � gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil `e- Nature of Repairs or Alterations(Answer when applicable S YSt� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code d not to place the system in operation until a Certifi- cate of Compliance has been ' of igne� d Date Application Approved by Date Application Disapproved for the fol ing sons t Permit No.� ` ;�V Date Issued No.L 6 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS Ziuurication for Migozal *pgtem Construction Permit Application for a Permit to Construct( )Repair Grade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. a S YOB Li „r`J�' Owner's Name,Address and Tel.No. Assessor's Map/Parcel � V N I Installer's Name,Address,and(Tel.No. Designer's Name,Address and Tel.No. i Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons .Showers( ) Cafeteria( ) Other Fixtures r� Design Flow 33 gallons per day. Calculated daily flow 33 �• gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. l Description of Soil t I Nature of Repairs orAlteratio s�(Answer when applicable —�o�' Sl�W Srti ST ra 11 1�W SG l C SRN — o_�Qn �T —ryrw� Date last inspected: Agreement: ' i The undersigned agrees to ensure the construction'and-mainienance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment7CodTd;ot to place the system in operation until a Certify- cate of Compliance has been ids- ed_by y of He 7 gne�� u Date ld'�) 6 Application Approved by Date Application Disapproved for the foll. ing r sons Permit.No. f `".S�4 Date I,ssued. ————————————————— ——————————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS G` Certificate of Compitance THIS IS TO CERTIFY. that the On- ' ewag Disposal System Constructed( )Repaired(Upgraded_( ) Abandoned( )by do ... at SK < as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permits all not construed as a guarantee that the syste wyll unction as designed. Date /a-"' 1.3 ' f' Inspector V ———e=————————————— ——————————————— i No. t, Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,, MASSACHUSETTS I Ii!6pogar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( (pgrade( )Abandon( ) System located at ea krA tit:e } V and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. i Provided: Construction must be completed within three years of the date of this permit. Date: 3 — q/ Approved by �� NOTICE:This Form is to be Used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) P--Oca I, ��— ,hereby certify that the application for disposal works construction permit signed by me dated �oZ—, "'`�fO , concerning the property located at Ce k:h-- meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: —1 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. j:cert D �f �, i TOWN OF BARNSTABLE LOCATION Q9 /3 SEWAGE # I .LAGE C �/l�C/:!//�I�. ASSESSOR'S MAP&LOT 0 - 1 Sr INSTALLER'S NAME&PHONE NO. ', SEPnC TANK CAPACITY T � :19ACHING FACILITY: (type) { Q/)G}1 (size) -No.OF BEDROOMS v'Z � ?`•:BUII.DER OR OWNER PERMTTDATE: AP '« y>: COMPLIANCE DATE: .....:Separation Distance Between the: ;:1r7iimum Adjusted Groundwater Table and Bottom of Leaching Facility Feet ?:.Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by 02 1 Town of Barnstable P# Department of Health,Safety,and Environmental Services Public Health Division Date 367 Main Street,Hyannis MA 02601 SAPMABM° A Date Scheduled Time Fee Pd. ili Assessment or Sewage Disposal Soil Suitability .f _ Performed By: Witnessed By: LOCATION &'GENIttAY✓YlV) (� 1VIAT�( N _. . Location Address Owner's Name Address Assessor's Map/Parcel: Engineer's Name r NEW CONSTRUCTION REPAIR Telephone d Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well R Drainage Way ft Property Line ft Other R wetlands in proximity to holes SKETCH:(Street name,dimensions of lot,exact locations of test holes dr pare tests,locate we p tY ) RECEIVED JAN 10 1997 LT cPT.�} r HER TOWN OF e LIE 9 i{jS �t q i t ' J j Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater ; I)ETEIt INA`�YCJl'0"FO SEASONAL T�+GHA�'E�TA Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: _ r undmotpr Adiuctment ft. ASSESSORS MAP NO: .2/y . PARCEL N0: �� No..?anS k•-7 THE COMMONWEALTH OF MASSACHUSETTS t oVEo . BOAR® OF HEALTH 00"00140Q=rietiaDqcnwn�TOWN OF BARNSTABLE NV6 A131jurtt tam cur iripwial Mudw Cfa mitrurtion Ilermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Z Grp Gam ' �c * )rorilion-:\ddress or Lot No. C!. 9�..V - V/ ! '-•--��-- ------------------------------------- ------.----•--•----••-------..._.._•---------------- .-............ ..-^---....- ........... • w•ncr - a^ . ddress )��{ ` -- -••-----•-•-- ------•----•------•••••----------•................ � Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms,...�---------------------------- ....Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons.---------.---.--_---.---. Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity........--..gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench--No. ..................... Width-------------------- 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 ( ) � Percolation Test Results Performed by-------- --•-------•--••--•......---•--•----•......----•- •-•••----•-... Date........................................ 0-� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ !? Test Pit No. 2................minutes per inch Depth of Test Pit.-.----.--------.--. Depth to ground water........................ --------a----------------------------- -------..---------------------.........------------ ........----------------------------------.---- O Description of Soil........!;�2:7Rn W --•-••--•--•--•----••-••••••--••-•-•......•....................... W -••---. •--•-----•.......................•-•---•-•••-----------------------•-----•----•-••-...------------. ---------- ---- U Nat r Re air Al ations—Answer when a icabl - --- -- �"" ..--../..�? `�t � E __ ysz 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 h been issued by the board of health. j . Signed`.. ................... ...:.........................- ... ------- -........ ..T Date Application Approved By ............ . ��//e. , �....... _ ✓:. :� Application Disapproved for the following reasons: ............... ......... . ............................................................... --.......--Ee-................... .............................................................................................. .. . .................................. . .-- ............................. ........................................ Mw Permit No. ..-.:51-_7------------------------- Issued ...........Cj.- a-----.. ................... Dare 0,2/U Fizz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ppliration for Di jpo!3a1 Work.6 (fou gtrnrtiun amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at -" .. �/�____1_ -•.....-•--••----• -•-----•-----••-----------------------•-- ...-•-••...........................--•- Location-Address or Lot No. t................................a its Addr et S �.4�..! ,.\G G _.../_7 Ll??!!t."�--•--- css ....... L--••---�..................... 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 ( ) dOther fixtures ----------------------------------------------•------------•----------•-. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `" Percolation Test Results Performed by.......................................................................... Date......................................0.4 .. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .......................-............................................................................................................... !�O Description of Soil............................... ._k....................................................................................................................................... U .................................................................................................................................................................. U Nature of Repairs-or Alterations—Answer when...... applicable '' J- /E, -..... ......... �yc._ ..-• �..................... 1..._.. f ..... 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 jbeen issued by the board of health. r Signed .C�^-�:%�� .. �` �- '. ''. ..... --. ... ...... .......`. ............................. - ` ri Dare' ApplicationApproved By ......._.. .. \x�i.._�- .-.V. .. -.." ......................................................................... ....9_-... -[a.r.- .- J Dace Application Disapproved for the following reasons: ....... '.......... ............................................................................................................ ..... . ................................ .. . ................................. . ..--............................................................. ........................................ Date Permit No. ---5.1..'" ........................... Issued .......... Cf _�'�------��. 3.................... Date ----------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (11-Er#if ra e of C�omialtttnrP I THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired by ...c--------- �' �/---------------- _ ---- ... - - _-...- -D fG, c � 1�� G 5-�- � ( _ c / t j at ............ _--------- ._... ...-_.._... - has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......... ...-...,�-,�...- ._�.- dated ....................._............ ...._..- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _ DATE ...................... ....... --........-_......_....-- ..... Inspector ...--....... _ -.....:.._--------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH TOWN OF BARNSTABLE � FEE.........................— Diapos'tl Workii Tonotrurtion Prrmit Permission is hereby granted__ i- .............................. h------- ---s-----•--- .......................... 4 T L to Construct ) o� Repair (�)�n Individual Sewage Disposal System \ C lid <-'}- r_� -t-� U v i / /: i at No. ' `� Street ('Z` /'� +� as shown on the application for Disposal Works Construction Permit No..,7_v___�__..__ _/_._ Dated____..9.-. ." _. ?....... ............................... � �------------------------ -------- `� — Ll t .---•------*---------------*...... Board of Health DATE •-----•-------•--------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS E_Q TOWN OF BARNSTABLE LCCA':UN `S` SEWAGE # VILLAGE4?/e%l//I� ASSESSOR'S MAP& LOT b -15- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY V 679 I LEACHING FACILITY: (type) (size) 0 NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: /2 ._COMPLIANCE DATE: ,Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet .Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i ?? TOWN OF BARNSTABLE LOCATION -� � ��L �- -� SEWAGE # ql -S-7 VI .LAGE �►-tP�yl1/G ASSESSOR'S MAP & LOTS j. CRAIG MEDEIROS INSTALLER'S NAME & PHONE NO. 78 LINDEN ST. �— SEPTIC TANK CAPACITY Its 00 YNIS, MA 02601 -7-7 quo LEACHING FACILITY:(type�_, -+a,,,2 6QnG,L--6z1 (size) NO. OF BEDROOMS sZ- PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER -f 14v74AO,k..S DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED- VARIANCE GRANTED: Yes No ^� 177 J\ I V 0................7 ...... Finc. .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD QLP HEAL r"t _ ......OF.......... 431hipmal Application is hereby made for.a Permit to Construct or Repair an Individual Sewage Disposal System at: ...............0. K....... ............................ ............ . ........ ... ------------ S ............................................ L a,' n• dress or t No. f . .......... ,4 ..�:j....... Q� .... ... . ............................... ........./ . . .......W.... ............. Owner aAddrefis / 44nAle?� J_--_---------_-------- ...........6U....... —-------------- ----------- ----- -- -------- ....... Installer Address U Type of Building Size Lot............................Sq. feet Dwelling-3 No..of Bedrooms-----------3............................Expansion Attic Garbage Grinder Other—Type of Building ------_------------------- No. of persons.--___--.------_-_--_--_-.-_ Showers Cafeteria Otherfixtures ----------------------------------------------------------------------------------------------------------------------------------------------------- Design Flow-__,_-__--- .......................gallons per person per day. Total daily flow------------3--0-.0...................gallons. 9 Septic Tank�Liquid capacity---/J'-3V- llons Length-----k..... Width_....#...... Diameter................ Depth ..... Disposal Trench—, No---------------------- Width.... ....__.___.._. Total Length_-.___--__-_---.---- Total leaching area--------------------sq. f t. Seepage Pit No......I------------ Diameter......6.040 0 t belovy,inlet---- Total leaching area------------.....sq. it. Other Distribution box Dosing 76 Percolation Test Results Performed by.--- Date--- --------------------------------- Test Pit No. 1----------------minutes per inch Depth of Pest to -round water_---------------------- T Pit:.---......_...__... DepK Test Pit No. 2................ni(nutes per inch Depth of Test Pit-.:.-_--_-_______--- Depth to ground water--.--.--.--____---_-._.. a ---------- ---------------1(_.�-- ---- --.. . . .. ......-------------------------- --- ----- r ------------------------------ 0 Description of Soil---—---- ------ ...... ------------------- ------------------------------ .................................. . U r'C - ---------------------------------------- ----- - . ............ -- -------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------- ---------------------------m--------------------------------------------------------------------------------------- ------------------------------------------------------------------------------ Agreement: The undersigned agrees'to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The under,Wined further agrees not to place the system in operation until a Certificate of Compliance has bee ued by e b 0 alth. Signed/-1--- - -- --- -------- --- ------------------------------------------ -------------------------------- * Date 41 Application Approved By------ -7- 7 ...444411074 -e------------------------ . ............... ..4!�---------- �ea - Date Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH ..........0 F....... ................................................... Qwrtffiratr Lif T"'UntlifiAttrr HIS, TO CERTIFY, TI h Individual Sewage Disposal System constructed or Repairedr_l� the n y...; b� .......... . . .. .............. .............. ------- A - --- It- --- _&A-1 In al... ---------------------------------------- at _ ) ) ...... -- ---- . ............. ...... -------All V has been installed in accordance with the provisions of AM �I of The State Sanitary Code as described in the application for Disposal Works Construction Permit Nc ----- .... .�e----------------- ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF..........jj��. .......... . ...................................... No..------/7.�..... I &"� FEE........................ LIT, trurtion V n- rAft Permission s reby granted----- -------------- ...... 1 ge/ 4�'>e I -------------- to Cons or Repair an idu �e.wa isposal Syst V1 C at N --vt.... Street as shown on the application for Disposal Works Construction Per it 0-. ... ated....:r-7-7.- 7 . ....................... -- -- --- -- ------ 11A��__ - . .. .... .. ................... ,Board o -Health DATE................................................................................ FORM 1255 H01313S & WARREN. INC.. PUBLISHERS N o...........(74..... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEAL S ..OF......... ............ Appliration -for Disposal Works Tutuitrurtiou Vninit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: - V C.,h," r ..................................................... .............. ....................................................................... .................. �qfa)on-"Ildms or Xot No. --------------.................... ............................... . ... ............ . .... ............ Owner Add ss 'r .. of ....Ls. ............................ ------------0 2: ...... ............................. .......... .......... 7 Installer V Address U Type of Building Size Lot............................Sq. feet Dwelling_-3-No. of Bedrooms----------- ----------------------_-._--Expansion Attic Garbage Grinder Other—Type of Building ----------------------------- No. of persons..._____---_________.___--_- Showers Cafeteria Other fixtures ------ ------------------------------------------------------------------------------------------------------------------------- --------------------- Design Flow__________ _____________________gallons per person per day. Total daily flow___--_____—Cl--0....................gallons. 9 Septic Tank I Liquid capacitv_.tJ_ZT_ allons Length----k-------- Width-----4....... Diameter_-.---_-.-._--_ Depth..---�-------- Disposal Trench—No- -------------------- Width-_--_--__-----..---- Total Length_................._. Total leaching area....................sq. f t. -ptll below inlet.................... Total leaching area------------------sq. it.Seepage Pit No....../............. Diameter..._. Other Distribution box Do C /9-2, 76 Performed by..- Percolation Test Results Date...-t...................... --------- Test Pit No. I................minutes per inch Depth of Test Pit._....._...__....... Dek to ground water------------------------ ;1-1 Test Pit No. 2--------------.-minutes per inch Depth of Test Pit-.-___.-____________ Depth to ground water-..--.---_-----.--.--. - ------------- 0 Description of ------- -------------------- ------------------------ ---- ---------------------------------------- U ---------------------------- ------- ........... -------------- --------------------------------------------------- -- -------------------------------------------- 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been-4 sued by e b a d opl)ealth. Sied. ...... ....... ....... ---- ------------------------------------------- ................................ Date Application Approved By._.. ...7.z/------------ Date Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- ............................................................................. --------------------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE,COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �44-7 ..........OF.....A6 0�4,,J,,L.................................................... x1rdifiratr of mvkamplialurr THIS I TO CERTIFY, T S );�at the Individual Sewage Disposal System constructed 4��®r Repaired by.. - -- -------------- ---A4...... ...................................................... ----------- .............. I taller c t--—- -a - -- ------�? --- V--r--- ----- ------- ... .. .. has been installed in accordance with the provisions of A of The State Sanitar, Zcve as described in the __ application for Disposal Works Construction Permit Nc� e" -- -------Z- ------------------- dated_Jam- -7-1/................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector------------------------------------ ............................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 HEALTH %, - 6A 4) OF......... ....................................... No. /7� FEE- ........ ........ ............... LIT, butt Pr-rutit Permission j�is,hereby granted---- . ...... _�................................................................ Repair- n,�n '.v..id. I S wage ......................... to Con f v Ymt'k 'r t pisposal 5y a .52...P-45 .. ..............k.��..... ------- - ------- - ---- X Street as shown on the application for Disposal Works Construction Permig No.-__ Dated___5_.-_7.. 7.4---------- ............4-t�- ------------------- DATE-------------------------------------------------------------------------------- FORM 1255 H0813S & WARREN. INC., PUBLISHERS Itttfp LOCUTION SEW- &(�E PERMIT-VJO. VILLAGE e — — — ''/d9- o 86, IWSTNLLER lJ&ME- 6 ADDRE �D BUILDERS Q &MF- A DRESS DATE PERNA1T ISSUED '07— — — — D&TE COMPLI &MCE ISSUED ; — — — Li 11 . 14-�l -�,- Tr -, , I �1.1,.�11 I 1, I ..-TT'l-l"ll I I , , , � I I .5 I I I . . 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