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HomeMy WebLinkAbout0110 DONEGAL CIRCLE - Health 110 Donegal Circle Centerville A= 169 — 076 SMEAD No. 53LOR UPC 12543 smead.com • Made In USA. s I i Da Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage[disposal System Form-Not for Voluntary Assessments 51 Limerick Ct AKA 110 Donegal Cir Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2 25-08 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information 1. Inspector Shawn Mcelroy Name of Inspector Shawn Mcelroy Enterprises Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-308-495-0905 S13971 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.l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes - ❑ conditionally Passes ❑ Fails ❑ Needs Further Evafuatfon by the Locaf Approving Authority 2-25-08 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 DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ""This report only descn-bes conditions at the time of inspection and under the conditions of use at that time.This inspection sloes not address how the system will perform in the future under the same or different conditions of use. t5insp•08M Tittle 5 Offimai hispe. Forms.SuosucFam SevrMp Disposal System•Page 1 of 15 Commonwealth of Massachusetts UW Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. City/Town State Zip Code Date of Inspection B. Certification cost. Inspection Summary: Check A,B,C,D or E/always complete all of Section:D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 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 t5insp•08/O6 Title 5 Qfficiat tnspechan Form Subsufiace Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name information for on is required Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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. t5insp-08/06 Title 5 Official,Inspection:Form.Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name information is requi red for Centerville MA 02632 2-25-08. every page. City[Town 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 colifo►m 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 '/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: ❑ ® 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. t5insp•08M Title 5Oficial h,spectim Form:Subsurface Sewage Disposal System-Page 4 of IS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4., z 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name information n is required f Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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. ❑ ® An portion of a cesspool or i is less than 100 feet but greater than 50 feet Y p po privy 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 nftrogen 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 systeml 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`yresn 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 1.5.304..The system owner should contact the appropriate regional office of the Department. t5insp-08/06 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposat System Form -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name information on is r�uired Centerville MA 02632 2-25-08 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available 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 maintenance of subsurface sewage disposal systems? proper 9 P Y 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)] t5insp-08/06 Me 5 offiaal Inspection Form:Subsurface Snvage D'sposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 1 Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 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 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 2-25-08Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatsipersonsisq.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): I t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposat System Form-Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name information is requi red for Centerville MA 02632 2-25-08 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner pumped 11-07 Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped detemlined? Reason for pumping: Maintenance 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/Altemative 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): Approximate age of all components, date installed(if known)and source of information: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•08/06 Title 5Official Inspection Forrrr Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owners Name information is required for Centerville MA 02632 2-25-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) _ Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 Gal Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp-08/06 Tate 5 OffmW inspection Form:Subsudace Sewage Osposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name information for on is required Centerville MA 02632 2-25-08 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.): Tank in good condition with all baffles in place. 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): t5insp•08/06 Tine 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owners Name information is required for Centerville MA 02632 2-25-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons i 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.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08106 Tide 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 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owners Name information isns required f Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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. 1-500 ❑ 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.): Leach chamber in good condition with historical stain line at 4". t5insp•O8fO6 Title 5Offidd Mspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Tale 5 Official Inspection Form Subsurface Sewage Disposat System Form -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 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.): t5insp•08/06 Title SOfficial;Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fora -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owner's Name Informrequired Centerville MA 02632 2-25-08 required for every page. Cityfrown state Zip Code (Tate of Inspection D. System Information (cont) 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. ��- 31 Sri t I .4 t51nu 08/06 P� Ttt€e S OfficW Fnsaec9m fCteTv Subwdace Serage Qisposai System•Page 14 of 15 i u Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct (AKA 110 Donegal Cir) Property Address James Milano Owner Owners Name information is required for Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope El Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 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: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no water at 12'. t5insp-08f06 We 5 Oficiat kispection form:Subsurface Disposal Sewage pose System•Page 15 of 15 CS ' CCommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick ct C-_e�vi°�l ' 1 A 0-7 Property Address �� James Milano Owner Owner's Name information is required for Centerville MA 02532 2-25-08 every page. Cityrrown state Zip Code Date of Inspection Inspection results must be submitted on this form.inspection forms may not be altered in any way. A.-General Information 1. Inspector: Shawn Mcelroy Name of Inspector Shawn Mcelroy Enterprises Company Name 29 Atwater Dr Company Address E.Falmouth MA 02536 Cityrrown State Zip Code 1-568-495-0905 S13971 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. Tqe inspection was performed based on my training and experience in the proper function and malntenan&e of on,site sewage disposal systems. I am a IDEP approved system inspector pursuant to Section f1,�.340 bf Title 5(310 CMR 15.000).The system: t Passes ❑ Conditionally Passes ❑ Fa IS1 --} Xf, ❑ Needs Further Evaluation by the Local Approving Authority = U' � 1 r ok r-1 2-25-08 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 DER 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. t5insp.08f06 Tge 5 Officid Enz�Form.Subsudaoe Sere Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct Property Address James Milano Owner Owner's(dame information is required for Centerville MA 02632 2-25-08 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Paw 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 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 t5insp-08/06 Title 5 nffoiat tnspection Form.Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. CitylTown State Zip Code Date of Inspection B. Certification (coot.) 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. 15insp•08/06 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts ' Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 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. El 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•08/06 Titte 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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 11 of a public water supply well If you have answered°yes"to any question in Sec ion 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. t5insp•08106 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 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or uno" 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 NIA) ® ❑ Was the facility or dwetling 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)] t5insp-08t06 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 „ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct Property Address James Milano Owner Owner's Name informations required for Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 1 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 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 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 2-25-08Date 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: Last date of occupancyluse: Date Other(describe): t5insp•08106 Title 5 Official n Form:Subsurface Sewage Disposal 1bsPectio g System•Page 7 of 15 Commonwealth of Massachusetts IFTitle 5 Official Inspection Form Subsurface Sewage Disposal:System Form -Not for Voluntary Assessments 51 Limerick Ct Property Address James Milano Owner Owner`s Name information is required for Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) General Information Pumping Records: Source of information: Owner pumped 11-07 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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): Approximate age of all components, date installed(if known)and source of information: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp-08106 Tiffe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposat System Form -Not for Voluntary Assessments 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle s'1 Distance from bottom of scum to bottom of outlet tee or baffle 'L6" How were dimensions determined? Tape f5insp-u&i96 Side 5 Of'rum i Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form --Not for Voluntary Assessments .., 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition with all baffles in place. 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): t5insp•08/06 Titte 5 Official'Dmpection 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 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cunt.) 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.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08/06 Title 5 Officiat inspection Foam:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 0fi icial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments am 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 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. 1-500 ❑ 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.): Leach chamber in good condition with historical stain line at 4". t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �., 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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.): t5insp•08/06 Title 5 Official,Insp ection Fount.Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts u. j Title 5 Official Inspection Form Subsurface Sewage Disposat System Form -Not for Voluntary Assessments ,p 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) - 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. 5-1 -p_ 33 ` 94 -- 3J ' �r I � I t5insp 08106 Title 5 Official Inspection,Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Limerick Ct Property Address James Milano Owner Owner's Name information is required for Centerville MA 02632 2-25-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 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: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no water at 12'. t5insp•08/06 Ti 1e5Official In spection Forrn:Subsurface Sewage D'sposal System•Page 15 of 15 THE Town of Barnstable OF T� Regulatory Services saxrrsrnsie Thomas F. Geiler, Director 9$pTE a��� Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal P Y p Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic, System Inspector who conducted the inspection. TOWN OF BA.RNSTABLE LOCATION /Lf __j__ SEWAGE VILLAGE_� Tel"-" �i� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1560 ` 1 LEACHING FACIL=: (type) Lea c4 C �P� (size) NO.OFBEDROOMS�.�____�,_ BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 'Feet - ,Private Water Supply Well and Leaching Facility (If any weUs exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet 9,f leaching facility) 1 Feet Furnished by a w t7 j er c�C -� 31 I Off.Jo I, � LJ CI No. a02 5 7 t t ° Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVIS ON - TOWN OF BIARNSTABLES MASSACHUSETTS o c14 l00 Zip firation foe 'gpo!6a1 6psstem Con$trg ion Permit Application for a Permit tQ,Construct( Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 31_14gg/0-- Owner's Name,Address and "No. ' Assessor'sMap/Parcel / ��� R`V-4 76 C�b Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel. o. � It ��a �g�� 7Z5 'Ic F¢��,Z��tar. .s71 Type of Building: jog_g3✓z'_ Dwelling No.of Bedrooms Lot Size�,Z�sq.ft. Garbage Grinder Other Type of Building o. of Persons Showers( ) Cafeteria( ) Other Fixtures —7 Design Flow �� gallons per day. Calculated daily flow 20 , / gallons. Plan Date 0T Number of sheets Z Revision Date Title / A-4-0 �W Size of Septic Tank Aff00 Type of S.A.S. W S Description of Soil d-6. Ile d'e l G ��' �� � � ' ' x 13 Nature of Repairs or Alterations(Answer when applicable) A,151 l G n.0. Date last inspected: . Agreement: y ` The undersigned agrees to ensure the construction and maintenance of the afore described on-site se a disposal system in accordance with the provisions of Title 5 of the En 'ro n ental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by and alth. Signe �� Date Application Approved by Date 0� 10 S Application Disapproved for the following reasons Permit-- ---------------e Date Issued _--�, ---------- No. '✓ ' r` x y /J -, I Y ..'� Fee THE COMMONWEALTH OF MASSACHUSETT.S Entered in computer: Yes PUBLICHEA .�'H DIVIS ON TOWN OF Bz RNSTABLE'.MASSACHUSETTS 21pp rat" n for 5pogal �pgteTTC �O7complete tru ion Permit ,.,,•� Application for a Permit * Co t ct Re air Upgrade Abandon S stem O Individual Com onents PP ( ) P ( )Upg ( ) ( ) 1 Y p Location Addr6ss or Lot�Io. ,L/w;2'10Z G O2Q4 Nam Atddre s and el.I p. G Al sessor's Map/Pazcel /6 / �L4 76T t Installer's N e,Address,and Tel.No. 7 7 - 3 i -0 (o i ner's Name,Add ss and Te. o. Type of Bum king: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(� Other; Type of Building --NO.of Persons l Showers( ) Cafeteria( ) Other Fixtures —7 Design Flow /4 gallons per day. Calc lated daily flow 20 , / d gallons. Plan Date 8 9 Number of sheets Revision Date 1 Title /�`'�.� C�'��4 Size of Septic Tank Type of S.A.S. Descripti9p of Soil, d' d'e `�l�- 6�_/(D _35 D `S Nature of Repairs or Alterations(Answer when applicable) A.11(5/ � L/G n Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sew a disposal system in accordance with the provisions of Title 5 of the Env-ironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by.this,46ar �=y ealth.nor ,t (� — Sign _.f �'"t,".`'.�. Date 7f Application Approved by r-' Date q y 5 ' Application Disapproved for the following reasons Permit No. 5 g q 3 Date Issued 1� 9 5 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 'BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by at C�� vL��'1 rC G'bU L as,b en constructed�in accordance `. with the provisions of Title 5 and the for Disposal System Construction Permit No. ��{{�Hated `1 Installer 11-a,3 t Designer The issuance of this pent s 1 of be construed as a guarantee that a system wt tI as esigried. Date Inspector-.,__ ss"'" No. v.`� r, `T _ _3 Fee 0 THE COMMONWEALTH OF MASSACHUSETTS t PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Digpoar 6 tens Construction Permit Permission is hereby granted to Construct( Repair( )Up rade Abandon( 'n System located at ��� �/ ��-(�2�G�! G0(� G�viLLE ��i 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 cond'tio s. Provided: Connsst ctio must b completed within three years of th date of this m't. Date:_. 1 �� Approve r • Tow n Of oarnstable A Regidawry Services . Thomas F.Ceile�r,Director 'g public Health Division ' • Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Fax. 508-79M304 Office: 508-862-4644 Installer&Designer Certification Form Date: T 'I v fl g- V1AASt Installer: Designer-- s - _ Olt—] l�'�lGG Address:Address nwin4 Ali bz52,27 5 _ was issued a permit to install a install .; - on a design drawn by septin at s �' 'iC•� C wui - " ( dress) / AN 11D M,11 dated _,-- (designer) / referenced above was installed substanfa accordt tg' V I certify that$ie septic system such as lateral relocationRf the= the design, which may include mirror approved changes �, C7 distribution box an&or septic to*- < CD v I certify that the septic system referenced above was installed with major change (enti relocation of greater than 10 lateral the SAS or any yeltical relocatiion of y of&e septic system)but in accordance will State&Local Regt Woes- r on or certified as bwlt by desi to follow. __ - ::Y":_.._ ......... i '.•� a� n _ it s ) (ABix Desi PLEASE RETURN TO $ ABLE PUBLIC H t'ALTON. OF COMTIMJS EPlE.IANCE WILL. NO'f Bd; ` B C�ALTH DIMS OM BUILT CAliD ARE RECEIVE BY Tl�BARNS'FABLE . TIiAi�iK Y©U. q HeaWSep rMempa Certifiaat=Form - Town of Barnstable P 0 Deparlinent of Regulatory Services l A• ■Atwern�ti, F Public Health Division Date NABS, 200 Main Street,Hyannis MA 0260.1 MKt a •� •, Date Scheduled � Tune_•�._ Fee Pd.� Soil SuitabiliO'Assessment for`Sewage Disposal Performed By: Witnessed By; LOCATION&GENERAL INFORMATION Location Address 5/ L r i✓1 C✓•'�k C �✓ f' Owner's Name Ja t4-) C Y Address oZclo Assessor's Map/Parcel: 6 VQ 7 to Engineer's Name 1)a Lak"a S o ✓l NEW CONSTRUCIYON A�f REPAIR Telephone'# T D k— 3 6 7— /(o 7 Land Use U C,C Slopes(%) © Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Wdei Well ft Drainage Way ft. Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) i p 640 /00 Parent material(geok)gic) 40Z�/J& OV Yfl Depth to Bedrock A ,� Depth to Groundwater. Standing Water in Hole: Weeping from Pit Race Estimated Seasonal High Groundwater DETE g?NFOR SEASONAL HIGH WATER TABLE Method Used: in. Depth Observed standing in obs.hole: - In. Depth to soil MORN: Depth to weeping from side of obs.hole: In, Groundwater Adjustment water Level Index Well# Reading Date: Index Well level _ v..a Adr.f'Actor,....®� Adj. PERCOLATION.TEST No— Iffle Observation 2 71me at 9" — Hole# T4!3—' --- Depth of Penc Start Pre-soak lime® Z / 'lime(9"-6") - : End Pre-soak Rate Min.Mch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) original: Public Health Division Observation Hole Data To Be Completed on Back--------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\,SEPT(CIPERCFORM.DOC DEEROBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture. Soil Color Soil ther Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistenz vel " ,moo ��. �. • - . DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% 1 A41 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cm i 00yell DEEP OBSERVATION HOLE LOG:..- '`Hole# Depth from Soil Horizon Soil Texture Soil Color', Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. o e 4 Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes i Within 5(>D year boundary No v, Yes Within 100 year flood boundary Nov Yes Depth of Naturally Occurring Pervious Material Does at least four feet of nattn-ally occurring pervtous al exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of natural' occurring ery us.material? . Certification I certify that on _ 9 (date)I have passed the soil evaluator examination approved by the Department of Enviro mental Protection and that the above analysis was performed by me consistent with the requir ing,expe Mscribed in CMR 15.0ADate �~ Signat e , Q:%SEPr0PERCFORM.DOC Bk 20244 Ps238 T63121 j h 09-09-200 01 22p DEER RESTRICTION WHEREAS, Elaine M. Kaplan, of 167 Country Road, Hanover, MA 02339, is the owner of 51 Limerick Court, Centerville, Massachusetts (hereinafter referred to as the "property") and being shown as Lot 59 on Plan recorded with the Barnstable County Registry of Deeds in Plan Book, 223, Page 139; , WHEREAS, Elaine M. Kaplan, as the owner of said lot has agreed with the Town of Barnstable Board of Health to a restriction,as to the number of bedrooms which carx be included in any homee built on said lot as a pre-condition to obtaining a disposal works construction permit it) compliance with 310 CMR 1,5.00 State Environmental. Code, Title V, Minimum Requirements for. the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pr,e-condition to granting a disposal works construction pen:nit in compliance with 310 CMR 15.00 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of. Sanitary Sewage and. authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement for the.restrictions on the tiumber of bedrooms in any house constructed on,the lot be.put on record with.the Barnstable County Registry of Deeds by recording this document. ai NOW, THEREFORE, Elaine M. Kaplan, does hereby place the following restriction on the above-referenced land in accordance with his agreement with the Town of Barnstable Board of 4J Health, which restriction shall nin with the land and be binding upon all successors in title: G U 1. Lot 59 as shown on a plan recorded with the Barnstable County Registry of Deeds in Plan. Book 223, Page 139, having an address of 51 Limerick Court, Centerville, MA may have constructed upon the lot a house containing no more than one (1)bedroom with a x standard septic system; or a house containing no more than two (2)bedrooms with an alternative septic system with a 550 gallon,per day or larger capacity. Elaine M.. Kaplan Cagrees that this shall be a permanent Deed Restriction affecting the house located at 51 a Limerick Court, Centerville, MA 02632. `^ For title see Deed recorded with the Barnstable County Registry of Deeds in Book 141.64, Page 195. w - � Q Executed as a sealed instrument this d f September,2005. H W W O pa., Whiting, dian Ad Lztezn or Elaine M. Kaplan COMMON1rVEALTH OF MASSA.CHUSETTS ss. On this day of September, 2005, before me, the undersigned notary public personally appeared Jan Whiting and proved to me through satisfactory evidence of identification, which wa5/#a lwntx,s, /.cec,-< to be the person whose name is signed on the preceding or attached document, and acknowledged.to me that he/she signed it voluntarily for its stated purpose as Guardian Ad Litem for Elaine M. Kaplan. MARYLIN A. SMITH WX Notary Public Notary Publ' 17VY/Ok&110 Commonwealth of Massachusetts My commission ExpiresMar31,2006 My Com lion apires: w;\dk7\winword\forms\milano deed restriction.doc Vf �or-I, - ._..m._..._.........,,_. ..J_ .:._ GAG ., �...,� __„...� •.a_,,;,... 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Q.4- as g � I, k s I ! 1J 1 1 H i � i iu r� ..�$ J gyp' ". r� .1% ,,s. y'.•' $ `�.„+ti..:K'.. -.:,1,;,'1 �"/� �" `.� ,-ya''•��'`-� •yr�,,•ref 5� _ -. s / �r i� 3 yr. VV` i.4—i.�� `' c� •t 10 F r Pv'O O's C4 W—e- A/A f#71 ,. K .r * • d Wit++!'rr' hp r, ,s do t is t L4 s - " - • r IV 14 .14 s, 4 .Nsr•.n.r�VpNf.t. .: t.� 1;'}` A I • ;, _ . •1 J FYI ;a. 1 I' Q _ �. rn}rO VOHb06e941'•/. x _ No _ L 0 r I I O �. -I �♦ Nern.ra'N'�Nt.t♦' , �Q ra .IIO ,� .. 0 1 • I t I ) Ili 1 ) I• I_ ". l" III' .� � y o I'I I to O p O n 1. pp Q — -- ra. •-- .. I '�� Q _, e� Mnrrw�WHY09•sYc i ,.I 6 I „ Norvrl VDMt.t. - - II _______ _____ ________ I ' N.rn.r�VPN t.t♦ 07 I• I I• . f is - � I„. 1 avd+.. 43 ei 3 := R 10 GOPYHght4ii999byKelmetn5f®erAeaocietes: f �" DRAWN BY: 4n meae pbm ae protected under PeGerat - q`q PROJECT:. .� �. iF eoPyeigntL.eurs.meoriginetPlacnsxroftnis' Pldn �V'J - _ ,. '(ODDW.f�ALI&�f I IZ plen la a hheo Ing W construct One No o W ' In Onemprithibit Lf1wiLhou eXprestlpn Or prpFe991pn➢IB Ilginq De5lCJner m feYae la proNbiteo WI U. exPretlwfiLLen permle,ion of U.Defigner. 7771 ' I�snnatli h.Ldlsr A"ecIA4•69.+ LOCATION: REVISIONS: arawhq,corttmed on the'.doeemehta ­01 be brought to the atte-or of the Desig p Cn men e L - pr4ftSSI9n01 building design- of r Y ding tb t cenetcudt�on con,[itute,thexac Ptewe commercial•reeldentlel - - - - a tne,e dowme ,and an4 d,ueP}nae,,error,end/or oml„�ov, P.O.BOX 1 149•HyfnNe,MA 03601 e0e.-Y90.9937 - oec me the responeibnity of the a ....;k9fOler/Nt9Gge81A13G0m•YNlWk90dQ01aRGOm ..' b'ildirg contractor. t - A — F. ♦ .. w yfyK a L. J. q , 0 I I I VOH S A S 4 f 1 . 4aaoa s> ate[ I Z I� i i I I tl � - i I I VOHx Iv I 0 I _ ]F �x I A a • COPyright 01999 by Kenneth Sadler Associiatea:- .. DRAWN 81':.' Q IG These Plans are protected Under Peasral 1 fi _ PRO ECT• GopyrigM taws.me oriOMI purchaser of this Man # 12)65: T�DA W.z plan is autnoritedto wnstruat one and Omy ;3 n one home using this plan.Modification a - Professional Building Designer reuse IS PCOmbiied without expreaawritten A P-119im Of the Designer. A , 0 •� writ'all—pancies: d/d!omibbion9 eppnrna.+l+hadlsr/4saoGiaks•; LOCATION: in the not- oh,En, ,and/Or O REVISIONS; draKMb contained the-tt do entb ahanbE ontain d the e[[en[O Of the Debigrwr prI t th anm cement 9PessfanalbutltllnB deslOn, Epn of pc�cc`n[„tu a—aadhg the It,EE - commercial•.residential'' _.. _. of thew —Mentb and any.. -P.O.BOx 1149•M - o—epanclee,errors and/or.Omissidns yennb,MA 02001•900.190.9922 :.._..ksadlKaksadaalQM1GOm.LLYWkaadeslgROOm.':. beOUAGE�rnponMbilltyd Me ,.ontractor. 4 �cus TEST H OLE LOGS NOTES: ' ASSESSORS MAP: SOIL EVALUATOR:✓ � 66 PARCEL It710 '= 1. VERTICAL DATUM: -- - -- _._ o, �*962 WITNESS: lr� ;_ V•1• ' ' �/ FLOOD ZONE: - ^� ��-r �S 2. MUNICIPAL WATER AVAILABLE. I REFERENCE lit.-� �O�yG 2Zj�� 3 �' DATE. ��, 1 3. SCHEDULE 40 PVC PIPE��O BE USED THROUGHOUT SYSTEM UNLESS ---�- -� Z OTHERWISE NOTED. PERCOLATION R I M ')GLr' y BUG - �f� 4. ALL PRECAST UNITS TO CONFORM WITH AASHTO: to TH-2 TH-1 5. PIPE PITCH 1/4„ PER FOOT UNLESS OTHERWISE NOTED.. DIOL44(6 6. ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE WITH MA. ENVIRONMENTAL (�,t�5,) .�� f (p v w Ub CODE (TITLE V) AND LOCAL REGULATIONS. LOCATION MAP \ / �l 1 1 7. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. r2 -; L" � y � �a� kA(7, i55t f:b -_ ry Wesu_kT, ov� tin LA1 -2 1 Benchmark set Hydrant (spindle) G1 n � .�V (Jke _ Q-C3 . ..--- ?� Gl 11 now El.=f 00.35 (Assumed) Z, 7 -t` 2, ��a 1 r 99.03 • 8.41--, UP/11Sta16 PK/SE �+S . 98.03 SEP7'1C SYSTEM DESIGN / x 98.45 10r5 FLOW CSTIMATE l 100.18 or 1097.63 . 100 / gg BEDROOMS AT i GAL/DAY/BEDROOM = I� K/TCK/F-ND� GAL/DAY r J x TANK o 99.83 8 S00035 ' GAL/DAY x 2 DAYS = Z i GAL 99.83 . /98.76X� ,� hh / USE 16VV GALLON SEPTIC TANK LOT 59 x 99.6 95.68 SOIL •n 3aORPTION SYSTEM 9 s.78 h 17,236f S.F. 47.34 t 0.40E AC.Map ` ,,l.. C� `_�'4;;` _1.t�• r - I(r-�tomr 9501 " 169 0 x 3Porcel 76 -A�S4 17 ...0 _I n -A\ �.p / x 13__ cwr �s 94. 3 / p TI•' T�'� 4k. -} SIDE AREA: �F� �' 1�1 XZX O 1 � � {' 9k i � � 1 / � BOTTOM AREA: I� X O i1 53. 1� I x 9V2 x 100 9 I /D 93.51 I6.17 SEPTIC SYSTEM SECTION4\.9 a _ $10� I x 99.33 O o ; 1 �. i � x 98. 8 � � .14 x 100.39 � 3 / 91.62 ,al ,� h(t 9locD x 99.83 O 95.04 j / Q° k �!'O►� v ELEV e x 1 o+� 0 I ELEV s (� 5 D-BOX '�q 9 �� -� ' i---► �`'r�grl ;, I, Z / 6/ A� GAL �� ��ELEV I C. 27 \ 9 f0 .� �a SEPTIC TANK ELEV L ( I IbrX l3 � + 'Or 3 r� C 90.487 �t � / 94.75/ �� �, ,���� 1 . SITE AND SEWAGE= LAN 1% i TERRY m� ,� '77Q'�f� psG� 98.90 �f /f Ary 0.08 8 WARNER BASIN No.3872t LOCATION: . / PREPARED FOR: 2 CLJ` 1 Scale. 1"=20' I J-� ��S 91.40 90.49 SCALE. P/1157/4 DAVID B. MASON, R.S. 0' 20' 40' 60' DBC ENVIRONMENTAL DESIGNS DATE: Z EAST SANDWICH, MA DATE HEALTH AGENT (508)833-2177 3 --