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HomeMy WebLinkAbout0169 ELLIOTT ROAD - Health 169 Elliott Road �Centerville P 28 199 4 1 { No. 4210 1/3 ORA flex' 1 :►:e 100 .3 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 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. �1,5 Important: A. General Information Q When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises.LLC Company Name r� P.O.Box 763 Company Address Centerville Ma 02632 City/Town State Zip Code (508)428-4028 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further E aluation by the Local Approving Authority 1/22/07 T._, J. Inspector's Signature Date i 3 The system inspector shall submit a copy of this inspection report to the Approving Authority-(Board of Health or DEP)within 30 days of completing this inspection. If the system'is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall-submit the report to the appropriate regional office of the DEP. The original should beasent to the,syste'm owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and and fr the condition's of use at that time. This inspection does not address how the system will pert rm in M4 future under the same or different conditions of use. f 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 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 septic 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. 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 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 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 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 ❑ ® 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. 169 elliott rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a " design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 169 elliott rd.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 169 Elliott Road M Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 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)] 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage 2006:111,000 g ( y g (gpd))' 2006:111,000 Sump pump? ❑ Yes ® No Last date of occupancy: 1/22/07Date 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 occupancy/use: Date Other(describe): 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? measured 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/Alternative 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: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 14" 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.Noevidence of leakage.System vented through the house vents. Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'6"x4'10"x5'8" Sludge depth: none Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness none Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? pumped at time of inspection. 169 elliott rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 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.): Pump tank every 2-3years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank is 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 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): 169 elliott rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 i every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 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.Vegetation appears normal. 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 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.): 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 every page. City/Town 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. r T Q A i � y a I y3. O 3 13 31 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 169 Elliott Road Property Address Tom Mahedy Owner Owner's Name information is required for Centerville Ma 02632 1/22/07 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 ground water: 25 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: Used:Gaherty& Miller Model 12/16/94 Groundwater elevation above sea level.Used:USGS Observation well data June 1992.Used:USGS Annual ranges of groundwater elevations for Cape Cod 92-000-01 Plate#2 169 elliott rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF BARNSTABLE LOCATION ` �� 1 E111 0r P(2 SEWAGE # VILLAGE CelfrefVlk ASSESSOR'S MAP & LOTavZg- 9°► INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l M 7�n- 010 LEACHING FACILITY: (type) yX ��T .,(size) GOD NO. OF BEDROOMS 3 BUILDER OR OWNER to/0 L/ ,Q/0V7 'C�D/1 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) J Feet by Furnished LUn FO/G I 1f t3 [ a s at y3 O 313 31 x� TOWN OF BARNSTABLE LOCATION /V9 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT �`� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNE —(05'¢-eh D 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 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 (ZGAt 1 OY (4G a^,G fvRrj O1'61k' '� b COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED JAN 0 6 2004 TO"N OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 169 Elliott Road Centerville, MA 02632 22 Owner's Name: Paul D'eon MAP Owner's Address: PARCEL 1 ee Date of Inspection: December 5, 2003 LOT Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a PEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Condition Passes Needs Fu r Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: December 11, 2003 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 ' Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 169 Elliott Road Centerville, MA Owner: Paul D'eon Date of Inspectiion: December 5, 2003 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: 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 distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 169 Elliott Road Centerville, MA Owner: Paul D'eon Date of Inspection: December 5, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 169 Elliott Road Centerville, MA Owner: Paul D'eon Date of Inspection: December S, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"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. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any 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. 4 r Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 169 Elliott Road Centerville, AM Owner: Paul D'eon Date of Inspection: December 5, 2003 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 169 Elliott Road Centerville, AM Owner: Paul D'eon Date of Inspection: December 5, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Weekend use COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 1 %2 years aQo-per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed Mar. 31186-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Elliott Road Centerville, AM Owner: Paul D'eon Date of Inspection: December 5, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 4" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. (H-20) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments'(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 I Page 8 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Elliott Road Centerville, AM Owner: Paul D'eon Date of Inspection: December 5, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): :) The D-box was level and clean. No solids were present. PUMP CHAMBER: None (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.): 8 t Page 9 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Elliott Road Centerville, M4 Owner: Paul D'eon Date of Inspection: December 5, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -4'x 6'(600 gal.) 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.): The pit was dry. No scum line was present. There did not appear to be any signs of failure. The pit was under a driveway. A video camera was used to conduct the inspection. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Elliott Road Centerville, AM Owner: Paul D'eon Date of Inspection: December S, 2003 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. r T 13 A a I y3 3 13 31 10 ~ Page I 1 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Elliott Road Centerville, MA Owner: Paul D'eon Date of Inspection: December S, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+1- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and water contours map the maps were showing approximately 25'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION a R f S W 4( TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION Property Address: 164 Elliot Road -- CZAE,%`itM-N L.Ll MAR. 2 6 2002 Owner's Name:Joseph Delaney Owner's Address: Same TOWN OF BAR.NSTABLE Date of Inspection: 3/7/02 HEALTH DEPT. Name of Inspector: lease print)Timoth Lovell ` P {p p ) y MAP * `�Z�i .,.. Company Name:Accurate Inspections Mailing Address: 550 Willow Street PARCH • k C1 Hyannis Ma 1 Telephone Number: 508-771-3700 LOT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes :Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatu e:,,,, Date: 3n102 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 169 Elliot Road Owner:Joseph Delaney Date of Inspection: 3/7102 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _x_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _N/A 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. _N/A 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: N/A 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 distribution box is leveled or replaced ND explain: N/A_ 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: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 169 Elliot Road Owner:Joseph Delaney Date of Inspection: 3/7/02 C. Further Evaluation is Required by the Board of Health: _N/A 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: _n/a Cesspool or privy is within 50 feet of a surface water _n/a 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:. _n/a 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. _n/a_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _n/a_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. n/a_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 169 Elliot Road Owner:Joseph Delaney Date of Inspection: 3/7/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _x_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow _x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _x_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _x_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _x Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _x_ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 169 Elliot Road Owner:Joseph Delaney Date of Inspection: 3/7/02 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health _x 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? _x Have large volumes of water been introduced to the system recently or as part of this inspection? x _Were as built plans of the system obtained and examined?(If they were not available note as N/A) _x _Was the facility or dwelling inspected for signs of sewage back up? _x _Was the site inspected for signs of break out? _x _Were all system components,excluding the SAS,located on site? _x_ _Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _x_Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _x _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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 169 Elliot Road Owner:Joseph Delaney Date of Inspection: 3/7/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):^330 Number of current residents:_4 Does residence have a garbage grinder(yes or no):_no_ Is laundry on a separate sewage system(yes or no):_no_ [if yes separate inspection required] Laundry system inspected(yes or no):_no_ Seasonal use: (yes or no):_no_ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):_no_ Last date of occupancy:_Current COMMERCIALANDUSTRIAL Type of establishment: N/A Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgketc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Pumping records came from Barnstable Sewer Facility Was system pumped as part of the inspection(yes or no):_No_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _x_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) —Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval —.Other(describe): Approximate age of all components,date installed(if known)and source of information: According to Town records date of permit issued 3/18/86 Date of Compliance 3/31/86 Were sewage odors detected when arriving at the site(yes or no): _no_ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 Elliot Road Owner:Joseph Delaney Date of Inspection: 3/7/02 BUILDING SEWER(locate on site plan) Depth below grade: 20" Materials of construction:_cast iron _x_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_x (locate on site plan) Depth below grade:_6" Material of construction:_x concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1000 gal tank Sludge depth: V Distance from top of sludge to bottom of outlet tee or baffle: 40" Scum thickness:_3" Distance from top of scum to top of outlet tee or baffle:_1' Distance from bottom of scum to bottom of outlet tee or baffle: 11" How were dimensions determined: Field Measurments Comments(on pumping recommendations,inlet and outlet tee or bale condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): No evidence of leakage water levels are fine the tank looks in good shape Did recommended pumping GREASE TRAP:_N/A (locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity;liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 Elliot Road_ Owner:Joseph Delaney Date of Inspection: 3/7/02 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or,no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0"_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Distribution Box in fine shape and level,The water level was at invert out no sign of solids getting by PUMP CHAMBER:_N/A_(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.): I Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 Elliot Road Owner:Joseph Delaney Date of Inspection: 3/7/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Leaching pit is located under asphalt driveway and cover was not built up flush with asphalt,I do recommend this is done to observe the water levels in the leaching pit Type _x_leaching pits,number:—I— 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.): CESSPOOLS:_N/A '(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:—N/A (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSYIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 Elliot Road Owner:Joseph Delaney Date of Inspection: 3l7f02 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. pe)/v " CF 386 1`� OT, 01 LLAG ! iKSTA LLER'S NAME A A ® dRE$ �--- 7C4Vlce' �R U t L o E R on oWN 1 DT ' PERMIT SUED DATE COMPLIANCE I SSUER hiovs� I — � 13 13 161 i I I y i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 169 Elliot Road Owner:Joseph Delaney Date of Inspection: 3/7/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USES database-explain: You must describe how you established the high ground water elevation: I ti 6 45 199 y ` G BORTOLOTTFCONSTRUCTION, INC. 7G5 WAKEBY ROAD, MA'RSTONS MILLS, MA 02648 f 5118-7.71-9399 5118-428-892ti FAX: SItA J28-9399 !� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO e - PART A CERTIFICATION Property Address:16J 626k,!� 0, & Date of Inspection: 9 Inspector's Name: Owner's Name and Address`. CERTIFICATION TAT .MENT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Passe Needs Further Ev li B e Local,Aproving Authority Fails _ . .... ... .. ... k, Inspector's Signature: Date:�y'��9 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 apprgpriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION S 1M1V ARY• A)SY PASSES: ✓✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.36. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,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,cracked, structurally unsound, shows substantial infiltration or exfrltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - I - t { 1 ;1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 4 CERTIFICATION (continued) Broken pipe(s)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 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 the public health,safety and the environment. 1)SYSTEM WELL PASS UNLESS BOARD OF HEALTH DETERMINES 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 a surface water Cesspool or privy is within 50 Feet of a bordering vegetated,wetland or a salt marsh. 2)SYSTEM WELL FAIL UNLESS THE BOARD OF HEALTH _(AND PUBLIC WATER SUPPLIER,.IF•APPROPRIATE)DETERMINES,THAT THE SYSTEM IS FUNCTION- ING IN,A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT r The system:has a septic tank and soil absoption system and is:within 100 Feet to a surface water supply or tributary to a surface water supply:,`' The system has aseptic tank and soit absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. _ - D)SYSTEM FAELS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool...: Liquid depth in cesspool is less than G"below,uivert:or,available y olwne is less than 1/2 day flow. T Required pumping more than 4 times in the last.year NOT.due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM`INSPECTION FORM PART A "CERTIFICATION (continued) 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: The,system is,within.400 Feet of a surface drinking water r 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)of a'mapped Zone'II of a public water supply well ? The owner or operator of any such'syste'm shall bring the'system and'facility-into full`compliance with the. groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please"consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast two weeks an4 the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _L/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. _iThe system does not receive non-sanitary or industrial waste flow. i/The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System; have been located on site. ✓The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- s'pected"for condition of baWg'ou 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 existing information or approximated by non-intrusive methods. -3- a, xS 4, , ;n44LL..{r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CIiECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION FLOW CONDITIONS RRISIDENTLAI:_ f Design Flow. --gallons Number of Bedrooms; Number o Current Residents:. Garbage Grinder: Laundry Connected To System//m Seasonal Use: Water Meter Readings, if vailable: a� Last Date of Occupancy: COMMERCLAi/tND JSTRI_AL• ,Ik)p Type of Establishment: _ Design Flow: galions/day Grease Trap Present: (yes or no Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System:' Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: a System Pumped as part of inspection:_AJ,)_ _ Iffyvolume pumped: gallons Reason for pumping: TYPE OF SYSTEM: Lzseptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AJWROX][MATE AGE Qf aU components date installed(if known)and;source.of information: S ge odors detected when arriving at the site:(, -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construc(ion: ✓ concrete metal FRP Other (explain) — Dimisions:�R,s'X'Co ',(,5" ' Sludge Depth: <Z:2'' Scum Thickness:/J Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ;r/Or1G Comments: (recommenda baffles,tion for pumping,condition of inlet and outlet tees or baes, depth of liquid level in relation outlet invert;structural iritegrit , evidence of leakage,etc.) / p GREASE TRAP: k)0 Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — _ — — — _— Dimensions: Scum Thickness:-, Distance from top of scum to top of outlet tee or baffle: 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)'. TIGHT OR HOLDING TANK: /QQ Depth Below Grade: Material of Construction:__concrete—metal_FRP,01her(explain) Dimensions: Capacity:_ gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if . el and distribution is a tal, evid nce of solids carryover,eviden c of leakage into or out of box,etc. PUMP CtL4,MBER:. _C�....._..._._...._.,. ... .___ . - Pump is in ivoiking order: 4 --Comments:-(note-condition.of pump chamber, condition of pumps and.appurtenances,e1c.) .SUBSURFACE.SEW.AGEDISPOSAL SYSTEM;.•INSPECTION FORM PART C SYSTEM INFORMATION (continued) , SOEL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number;_Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of il, signs of hydraulic failur level of pondi g,condition of vegetation, etc. CESSPOOLS: 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 soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:_ Materials of construction: Dimensions: Depth of.Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condjtion of vegetation, etc.) -6 , I SUA SE 6RFAMIE WAGE`DISPOSAL SYSTEM'1NSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 6V LP LP ij �7V DEPTH TO GROUNDWATER: Depth to groundwater: I� Feet Meth of Determination or A proxi ation: Zf /' ' r -7- F tN! ar r ` f. •< y' ti t' 'ar 1 r � •�t A 41 q -4 fir,.y ..P + r .] + e• 4'' •. 4! 'wt 4 ir.}} � " tigv }y o �v �F,s t P a. fir, .L• ` r` *e . �"_ t.r r 7{`a 'r r 'r.� r • �« +f�s '"•� � t" [A.y,a.! - f r� L J. .i,��'�a .«=:�t'"t"r'� r �», 4 Y. .' ! •F Fir 4 a4.x � ,i•• cY,'(� �st,4 rJ s r s :ti' ' {K,,t- .�4 y �r$k 7• , -.�� •++ �;., { November 26,w1986 A: PI � `;f = F k �� }y ~�y4 x S >{,�s - +.•p;� F ,p;, < r['r�eV s ^1,``t ',imr d F .< r ' •� '.f `.X _+y � 1L{:• ^#+.. ! tir `*•.. ,' v .4 r `' �r ! �T' 4 x�i� l��ar�rr . 'r t,t .• tS7.h -cn ,. .. +�«+ " •t r4.''t +~ *M� r[• r t ;4LC, �[ .r ..r rr. ` tr« J , „ i{, s'y t .[ n -� t ! •'� + rxC. xv t F ry r$,s s �7 t` tx '4�,,.,,'••:, '` t F .,�J 4+- 'S�••p,,i'^t r. - ,, t . r.y`. �M t -� ,• K ! �.. +fi{. /t, , � �": ti� * _•. t G• t t !r k .,4 a �tr. , s,, �` .` !, ¢ �,�'"'.A, '�• t tw 6 J «�' '� :v. j ! r JT • P• HOar. "-t i t., •.• 't. ,�° 7ry i,yr r + ! t �ti a !,+ ;�.tr ` '`I69.Elliott"Read r ' f: 4 `; ' x r r` x >• ''; ' !° Centerville#'Ma,,'02632 f �•�,° �� tax n : r f r f '+ems t ;�: ,. .�+.+, �*Cr +,syr 'x' ;� S w x `�< r't.wf ,rt',� '# Jn "�;f# x'x � i',�,e [ •`f,,,�r: 't+ .r ', s _ Y`3 4 S « P 1'"° „,rM+w J x s ' , - , ^.� « - •` �,rrww+ 'f f `, ., r h'fw••< `�h,. ?.. d {,, t .r[' R,«, � ,�.,t+." lY! �.r 4 i F� ['xt"�..µ J� 4 k• N rt°;'-' . :.,. Deartbir. Hoar : , t r t '.•1' i, �` F trek `._ .f¢t. v .�s ♦ 4:' Your,lette VA r r t_, :. Ft } r datedrNovembef 8,,1986, ii acknowledged rt Sr r� •r«ea` _„P A r•14, !�Z -• ¢ k t,w + ,�.! �� + [ + !* {F ! � +.e * xx '�,; 1r. 'ti :g "n :f,~f •lit L• i�. _�T: +`� "'`/" '` �i �< .The'on-site sewage-system,design.plan.,located at Lot 11—F,11iot Road, Centervillle; Assessorts.n Map: 228;*.ParcelNo. 198,'meets all offthe�requi'rements'of the+State Bnvironnientalt,Code; •, ° �_ « 3 t rTitl6 5 A+iinirr um kStanda'rds°for the Subsurface'.'13isposal•of Sanitary. 86wage, and 'Local , k �-Re 'ulatiohs f r the'TownA f 'Barnstable "g_ o o. The,plan:was ,carefully reviewed by: a Registered , ° Santta ran qualif led`in all aspects'tof an=site 'sewage disposal. . U S kyGeoiog,ical'-"Survey 6toufdwater aldj istment was 'made,tq determine• the a maximum. groundwater*elevatton': using'a.soil 'o'bseiveition:hol6 where ',water ?was encountered'-on.,an adjacent lot I` his .«is,an,�acceptabl'e'-and`conservative "adjustment:` Ground,water was 'not '._ 'observed�-in 4,31 ,l12 2`'foot obser.vation� ole'+in':th+e.'vacin ty+sof the `proposed leaching�facllity .; on,Lot 11 In`'additt6n, tfie#character'of.�the;soilAs",adequate for an on site,septxc.�system y v. : r T1�e Conservation commission for the 'Town of Barnstable`apptoyed' he design7at a'hearing' on N_ ovember 1,2, 1986. g 4t.Y r-. .L x ry ''+'.- •« c J -g Y. 'r c,r "'t W '-» h l<.' iJr .•,,` �.�9F h'. 4• t ".,! yCb.,.. }i ��l«r i : :S+?� r t .'ti+y •..« , ....-,« y �- , 1 '�/ +r`. r •,.r^ fY 'r= Thank,you' veiytt'much for',pour Anterestlease' all -James -'Conlon, Healtli-,Inspector Y y 775=1120 Ext 18 to at r _ z K 2't if 'you have`any questions.{� tt, .A, ' Sin r < cerely«yOUT& #Ft!i s x a Y t ,.t�! i•f - ,»� rr �"l. s ax� t'r 1;' 4 R� ,s: �t'e�'�'.+ 'F..�.�.t :: Y. yr r i� r ,•� ' ti5 J #!x r ,tir !a C 'Jt r r JohmM ,� : 7 y �7 Directorof.Public Health st t « a .w t r .. 'Town of-Barnstable r �'t� $ - �} N `., * . 1.. � ♦ ',f '� � � r� �•. C .eq�,!w �-�tr. ��f ,.�' � �r t"� r a t�'` �+ ,� ��•� r 'S_ JIuIIC/bs'. ,, ^ r .,�,,, •, r' _ .� ,r4:Yr` �xl , .. �# � S s„ r 's r ' :� "t +ti t ti r.k:.``}* t .�,xi r�+�« }; ,<�;r�' ,��,y' � a •t � ti +� � '� ` •�" .S '4 '' •` a '<' r + r. 1«t _ -1 , .,,. 4 �«!' { Al •[.. i, s` ' .a 4y, ,� y •', r i ; f`^ry��'4, ¢ .e '..r r. .#. f .•F k ,�'�y'• .,.= r � r 3^. �. .k- w,. 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C®/.ter cs�.�-v�it��-✓/�.-. /C.m � �.1. i cs'�'r 8 � �'�,�r/o v.ara.r� �_ Cs�i d kc r��t..�/.e../_4t_,✓_ tee. /_�'7-..G"i�Gt.!�� aC� of L,v_!��?'•�-1—� C ka-cs- �r G rt $ r /i-cz9,N eS ? s ;—'n /r c�cr,.r•/v �✓ C fr O g. Se- a �.��s e o rJ`�s �� e txs a be o'-� �! CT���r' �_�+.� �r f. _cS �S�o,c cz c� i �.�•z r csa �ca x �_- r--��O�4 �✓o,r, ow ; / -C�/ G f/ 6 �i'�.az D'G'/�.-r m--✓r a� GY t� C rs�cSr O H. v ks 6l_ wc- ,r`,., �S/� yew�+�d�.•.-� ✓Ts��r�;Y�-�%a c�m. ikt, c..��s ��Ne�f.•�. ' c--c^w v-i e-u s • O H �/ c3"+ eiG �- e �--v s.i ccr t� _�.�/_O �JO.r_•iK _a. GO�✓/ � _.�. �_�J lZd• !/O_i�... �r-Y�_O�S_.._ . ®.4- S C>C .. W!•t J C� �. c.o ors'�c+��� 3� .�e. /�0 y .� .d �3-r' wr YL%`S D�' O�-a /©w r�mow' �e /K� ®�A� CR,�c�.�L✓ a ��,�•L.�,'�P�%.G�K CAS-C � �=--Tim r rS AO/F) dfL- ./r !'�^ S�vee 4 F� .y- /y 'Lt g. ✓s C !Yr i,Y_ c p a � /�-6 p 'j.4 c, c✓a ✓w,sue ` � � � � • ' �. `� - • _ • , � ' __ k ... � � ., +, ^, � ' ..y � r _ . � _ � . � _ t .� - . . �' _ 4 ti •.. ' ` �� _ � � , .z - �;. ,._� ,, .. � .♦ _.. .. .. e _ _ ' �.. _ _ f l � * ��•._ � � � _�___�.—.--�_ _�_ .y.._,.,. a-,q e- o Cam., ¢-� ,�,/le, i�� o �� �e.. e �. �-�.,- r�•°✓Je ✓�� — ..___ �� �7L"�a,—. .<;'�,Lr'�'iR/,�c`�_N�/—.G�V'n�//'•"_7_�G`yV/ 'F.�J�yo` }�v�eH;:t"'_._. ✓o..r esa�ee ea.r� rC'�o e....� 3� e= �8 �J i7�'✓��5 ? - .._ -- `---—✓ �i�« Ly a c e — rG"zt, OC V`yC- �.. €�� p��s5 i r�a m—e;/cl�'�/—✓Ost c� J �©`r'm.-�G3-s^ — --�/__/_�✓_/✓�+7_._c�/�-r�-J_!Gv_c�_��p..'9 O ;� c��k��p t� off' �� ..._- gtv�,s �-r�.�.s� .�''c�r,� �� �,`tsar 4 •zc� ��` ' D'�-�oi,[i p v� -��c� -cs.S._ c�ve- • a ti /`� /-/d av L' .-_ �, I � � � '`1 i • \ 1 FINC TOWN OF BARNSTABLE Q OFFICE OF »ea>reT.sr, MA/L BOARD OF HEALTH i639• 367 MAIN STREET HYANNIS, MASS. 02601 February 19, 1986 ¢/'i46ts John and Helen Hoar c/o Daigle & Company 1645 Route 28 Centerville, MA. 02632 Dear Mr. and Mrs. Hoar: You are granted a variance to install an on-site sewage disposal system on Lot 10, Elliot Road, Centerville. The variance would be from the Board of Health Regulation requiring' four feet of natural pervious soil material beneath the bottom of the leaching pit. The." ' following conditions apply: (1) The designing engineer must be on site and supervise construction of the septic'' system and certify in writing to the Board of Health that his design has- been strictly adhered to prior to the issuance of a Certificate of Compliance. (2) All other regulations contained in Title 5, of. the State Environmental Code, and the Town of Barnstable Health Regulations must be strictly adhered to. This variance is granted because the bottom of the leaching__pit will be located 7.3 feet I above the observed water level us usinOft-Nipg the probable maximum high g ound w e'formula would be 3. ee wit ;t a=natural pervious material 3:2 feet Cabove-the-maximu-m-proba-ble-high y.__- ater-,-in--lieu-of the-r-equired_4 feet. It was the strong feeling of the Board that if'this system is installed according to plan.' that it will provide essentially the same protection as a system in full compliance. This variance expires March 1, 1987. 'Ve y truly yo rs r , c /�GI'ryy�a GOi,.�i✓rsl� ii> ..f... ! Robert L. Childs :•,�trl, �Y�s�sr- ��c .�,, r �...,,to 0 Chairman Lam.-ak ,4P BOARD OF HEALTH y"rg TOWN OF BARNSTABLE J M K/m m ~-� ---- ---- cc: Cape Islands Surveying :41Anu r - nd1 1���'••'� ,• ,.�' nal t•, ranges of grou- -• water level .' • per• o• " -- =_ 'e Zone A, 0-2 feet • _ _ ""�.-c • t, Zone B, 2-3 feet �. �_•: �i= �cv_sa:•'- . ' Zone C. 3-4 feet � _ 3�5 _ - ' + ". . 4 .• Zone D, 4-5 feet - --- ' - "• - � -ram . . . - „ neat .,�''�'fi�r"�; �,-.�` �.. :•. = .�„_,„_,;; Zone E, g er than 5 fee Ing X14, a O� p �• :�� - � ,s._ J.--� �^� ,G••• :,1•\:i:'_�i. i- - .:.�. .:� y :l; fl � !• 1 pia J'�' ram; iol: Ar. W 1 yl' •/L, t�V +f��� '•� .O _ ` 'tw •OJ a� 1 ;t(".� ^ ^� :�• .`i. ' '-•' _ •n•"�h•\ � ^ o�� (I _yvT®`pV):. •' •L o ^ 7/1�a� '''���� `a: b� / L 44. IV �J t � �. • �! ,i rj��/ !v -Qi'a + i y •.fi* �1^ < <Q ��•.L'L �' •j • ' p + f 414 •.. ♦ • ♦ ,• fat R + ♦.'� • �• .4+ II i--+ f•:.rf��_ +.! .t' _ •.7_� rC.. �.� •y� ' Qo� ' i`'�1s� S're.1, r � `. �` '• J_' •o.' .:� :t, � :`i �`:;:�= =L� yes � - -\ mrANNIS IIARsojt 07 of ze • ' aLr�/a:�.e.•�.'-+tom/ 1I_;� 'O••`• �-1�� ��G�,/-1 �je-.rCC3C/.�' .,�5 �r L v O O��✓� // 1'i [ is ,� E>S< -J'ti� No......CL .. .. . .......... - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH w ....................OF..... Q.�"��!.F. ._b�� Appliration for Dhipvii al Works Tonstrurtiun Frrutit Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal System at• ✓ � 1...:.1 Q......... �//-��----- ---•--••---...... c-� r( �-//' ..................................................... Location-Add es or Lot No. �o! ✓� .--•-_. Q_ "------------------- ------•••.----••---...----•---- •....---......---------------------................ Own / Address w -- ` ......... �., Installer Address Type of Building Size Lot_.;� --_z.9.7.Sq. feet U Dwelling—No. of Bedrooms............................._..............Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures _..._._.. W Design Flow______________________.....................- gallons per person per day. Total day flow............. ._ ...........gallons. WSeptic Tank—Liquid capacityl�0kallons Length_....6._. Width'U_. �'_. Diameter................ Depth J"._.__7... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..........l-------- Diameterz 4_.7 Depth below inletyi. d...... Total leaching area... ..?-3-sq. ft. Z Other Distribution box ( t<) Dosin tank ( P,- 36/' / ~' Percolation Test Results Performed by. !C r'. !.G__.__/!a.s...................... Date..:�� �.1-.FY............ Test Pit No. 1......Z-_-__minutes per inch Depth of Test Pit..-?..' 4`Depth to ground water..... r3. Test Pit No. 2................minutes per inch Depth of Test Pit...._............... Depth to ground water........................ W .................................. 0 Description of Soil•.?•--y -•--•• ..... --•---•--•-----•--•-•--------------------------••••- Z ----------------------------------------------'r-------•--- -----------------------------------------•------------••----------------------------------....------------ 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'L 1 5 of the State Sanitary Co e— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' s by he oard of health. Signed........ -•---................................................ ..........--••--•........-- �� D to Application Approved By.. /`��'� • - ----• ---- --. ... . � . ---••----- Date Application Disapproved for the following reasons:............................................................................................................... ..........................................••-•••--...•••• ----••••-••--•--•••-•--........••••........._.........••-•-•-••••••----•---•--••••••••••••-----•--••--••••-•••-•-•-•---••••--•••-•...._..-- / Date Permit No.....��.. / -. Issued ....................................................... Date 1 �4 1 No. - � .�`~2 Fss.. d O THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .......`l................OF............................ .7"5.. /,2 Appliration for Disposal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct K or Repair ( ) an Individual Sewage Disposal System at: --• °- .._ --•----•- ..o. ....... /....._... r r✓! ...................................................... // Location-Address, or Lot No. Ar .4........1 �_.ars r ..................•--•................. ...--.....-•---------•................................ 1 Owner y / ............................................Address .............................. Installer Address UType of Building Size Lot_.Z_G____Z.9 7Sq. feet ... �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '11 Other—Type e of Building No. of persons............................ Showers Pa YP g ---------------------------- P ( ) — Cafeteria ( ) P4 Other fixtures -•---�::-----------------------------------------------•-------------------------------------------------------------------------------------------- d W Design Flow.........................-a -----........gallons per person per day. Total daily flow............... ...........gallons. WSeptic Tank—Liquid capacity/.� allons Diameter................ Depth-!:_r__- . x Disposal Trench—No..................... Width..............I..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........../........ Diameter.j,<.�..6.... Depth below Total leaching area....-3...Z-a.sq. ft. Z Other Distribution box O Dosing tank G/ ~' Percolation Test Results_ Performed b .�<r_x. .._.. _... >�._.../ c..s..................... Date...1Z.�����............ a Y t r •-•ry- Test Pit No. 1.......�.....minutes per inch Depth of Test Pit... Depth to ground water...... ............... fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M ....-•---••-----------------•-•-----•---------------------_......--•---..............__...---............................................................... Description of Soil...'-_'3'............./-.E ...�_ � 45 0, / . ------•---------------------------------•---•--•••-----•-•----------•-------------•-•------------------........_.------ �—lU -•-----------------------------••-------------�....... j ru✓ ilr. c ......--•----•-•--•-------•-----•----••---•-••--•----------•------•-•---------...........----------------- 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 TIT1Z- 5 of the State Sanitary Code— The undersigned furdier agrees not to place the system in operation until a Certificate of Compliance has been iSsu A by the oard of health. Signed--..........` ..0.............................................................. � Drat e ., .. — DT-- ­----------- APPllcatlon Approved BY ate Application Disapproved for the following reasons:................................................................. easons:............................................•--......---------•-- .............................................. .........................................................................................................................................................................................................Date Permit No..... - !`-'' ------- Issued..--•--------•-----------------••--•------- ate....... Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH .... :.: .........OF............15: < U.. ............. 01rdifirtttr of ToutphFanre THIS IS -0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b :;� - The State S ----...-- g� I staller. J ---- - has been installed in accordance with the provisions of TITLE 5 of Sanitary Code as descrtd in the application for Disposal Works Construction Permit No.._ .. . :�_>?..cr.._....... dated------I___ . Sr...------G-- _ . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... ,/?3 .........................................•------....... Inspector.....(. -------•---......--------------••----•-------•-•.......•--.._._..._.. THE COMMONWEALTH OF MASSACHUSETTS ��h/I ��? BOARD OF HEALTH �' t`'r�t�l 2 OF......... /�: ,� ,✓ �, . ............................ EJ Q•� U .... �.. -- FE ��. ....................... �C_:-O R i Iv G s , tdT'SFaI� $Yk � n�irn ill Prlattt �►�r�c�n�rw Permission is hereby granted---------1•-•`y= --------f `� " ---------------------------------------------------------•--------- to Construct (✓) or Re air ( ) an Individual• ��rage Dispposal Syst,� , at No...---L.. --f------, �- �....---.�'' ..f�.:;.= �7`'• - -"Q`' y ----...... i r u Street �"��- as shown on the application for Disposal Works Construction Permit No. Dated......2_/2_:;/._...�..«..... �. •------------ ---k--- r �p Board of Health �FQRM 1255 HOBBS & WARREN. INC., PUBLISHERS - r , CAPE & ISLANDS SURVEYING CO. INC. C ENGINEERING DIVISION 131 Spring Bars Road Falmouth, Massachusetts 02540 617-548-5486 March 31, 1986 Town of Barnstable Board of Health 367 Main Street Hyannis, MA 02601 RE: Sewage disposal system, Lot #10, Elliot Road, Centerville, Ma. Dear Board Members, This is to certify that the on-site sewage disposal system for the subject site has been installed within a 1" tolerance from the design as shown on the permit plans dated December 23, 1985, and revised January 31, 1986. The final inspection of the system installation was made on March 31, 1986. Very Truly Yours, .J. Bertrand, P.E. - OF Mq�9 CC: Daigle & Co. cy o RKNARD � 10 Bayberry Square )ASS ��`• Centerville, MA 02636 BERTRAND No. 29894 FSS�CNAL i LI3Ck"I SEWAGE PERMiT NO. VtLLACE 4 IMSTA LEER'S M A M F 'ADDR15S I UILDER OR OViq ER E"iTLrcEV/1 L Lc _ IZO A T E P E R « I T I S S U E D DAT E C 0 M P L I A N C E U E D i r Hav SF C-A-it &F `r ti T P "TANK I N�c�r 7 q 36- ,6 " y'6 If 161 LOCATION SEWAGE PERMIT ISO. .. -Low /D u�� 12n l�a�!s - Z62 26— r3 L VILLAGE HSTA LL ER'S M A M E A, ADDRESS22 / ° )416d ST — V/t[ F �U U I L D E P OR OWN ER ATE PERMIT ISSUEDVN_` ZZfrAr DATE COPLlANGE ISSUED 191 o i , 9 , 3F d 3�H21 �gnoH Wr vx a ♦e, t !~ 4 - k. '.�;,r� ,' 'y'"�'f .,•,�, r �., ij: .• + 4, 4=rl r f r ..k', .° ,�"- "'.•r 'r r r `e i ai<� ...N. '`'k - 11'' ri' -. 'f '€&ryy`1k�_s i ,�A i `< <��. t rr;i ''4 i�r• r { ti ° t., y� ��i+ �L ,ya Y t .t{ �! i '}+ ,y.t sr.t i.,iyL n,y • wt �f. i S''c 5°S y`9 yt"` T. '�:,�,}, '°m ++,,,���� e'#_::Yi K, ,. << .r, .o � 1tr r- rq �,d t',f •M }��. #' :.s.'\i� r` Sw y ...t(.,R w r*.:yT P rp<.-ins.i'F «.:q � ' nrk Y _ ..°aF' it •�' < i t ' q .3 t �. 'Y,i ,. 1 ;w'• - F F a P r P.. ,S ,t i \ K +<,F yi � }. i�. tt t• aY�'kS,�.4��}*'ffv"�✓! '�•i a._� S P7,a{� w r .r� t � ��r <r ry , � A •?i, 'S,.�'• <w�^Y'� a � a 8-; .,,' t A•,9`;,y�? �,s Y..` , �r r ` i �r+ wT�-. a i. .a,b C �. ••"�< ,;: '• � 7✓ "y,Nr' y:, f y:..f ,. 1Y s '.4 a a:a ; � , ••..• F ti l x T• n .,k �wP ,,+ .R s,< _ 7t "" , ;Frn T.31'j a,r . '' j� . , v+,.'rfi t.a '•r' ~ .+' I.N"�`' r yq +5 l� .. .4 1 t� �+d r �, 7 ,,. t ,L.f. .• AS. i •:l '�¢". r ;k, xv: �t •^- ., i � r - , f �d 1 t ti r r '+ ,y t i i e >, x "4 I Zl+. � &s ,,�•�� r t_, ti kt`r� �,+ .- t ' t 4 }. < - tw�t,�'� r t ' { Cr c n'.. 1 �• .�t �r '� {_ i + +e+fi`dam Y= " _*• ar�' y A, ,•~z{�.fi.1':l � + ° �-• , ;! '; y- r ..f x^t ,,r t, 'Cht. �t r .. 't Februat 19 19$5 r ` r d r '. < P .,yr r < < \ - •a br^,` S a _� K - '""•s+ t .w d ,�\•?. :Ar rl a r s..K t t< +_'+ 53. +,. 13, 3 a as ? t E1 w.� 4 s i t:'.' . �,ri°' r ' t-•r-` r 3, . t +"� ., �. < t• 'r� i tss ,'_, � ^: �..x .; u't � ♦ 1i• i �,}� t .,�e f 1 ti'r �.,5 x T r .1� : } 'i *. t ,.y... y4 ., �A ay n=� t •i r'•.ac wt.,' ti. IY i r � rare - � •"� 1 .,y .ru' i•r, + .+ d;+, , C d,+., p ti.y�E a.�L � ^,v �d.. � t,.._ •�k { t e.�;' ,y •t •. - a �.:. r .. Helen'Johnand H?, c"�S,- s +� �.. as r i'}` :yi. i>'k ''."„ k r a`� (d. i rY•t t, r {pl,�• ,it d „ r c oar,d `� .'«,A r� ,a,� 'w '+,fit s. i •r 1 f=dy c/o Daigle 6'a>Company °' ✓i {Y j w II a i a''.a•,r '` 2 ''r e ' : � 1645 6ute.2��8%rj * } lky. wlrax4G',� S 'Centerville,,ni�• f�2�32-i /r., i y , • ' ,�' ,• '.�. r t r `.�+u� * •� S �i�r *-.._,t i , � 1 "�r., •\ ��� ii { �.t t+t°`ark"�'fd ( i".:�r Y,ls +0 d '.`" +'R,. '4,.� �b t•A � < t d r Asa X<r < • Dear�idr. and Jars.'Hoarz S < d You aie gradted ativariance io install an on aite4ew446 41eppsal^system on. Lot'10;.Biliot''� { _ 'Road; Centervitle ';The,'variance would be`from the Boat@'o! Health�Regulaz(on requi ink fi w r f four feat ;of:natural petviou$ golf aaatetial,beerieath the,Do"ttom oP'Che",teaching spit. The following condition's�apply• ar Y_, ,. „+ .'."py 7 -,w n:..i E,..X� i it frr -r� i.�a 1r ! t n g .i`.+�J - .t + • ls ;� r a..* ` * ".'.'•' '� ' ,A„ S l.,''$ '/irY ' s.x.d.\ yP ;tl:a r L• �" d Sri ! ` ' T r✓ °'P a' t ' i v� a�' �.-;�`� �"d'`,��t'a-Rf �'.' r •s �-. �. y,wT.'�,k � "' ,u '•i' �.a�r .� ,`" '. y.r,..,�; �.. }a�* -aTne:destgning engineer;must.,be ion,°^site,and "supervise.construct#on oP the septic, "f system;an strictly in •zvriting tci`zheoarii' of ,Haalthy,that yhis.d�si$n'rlas tieeri strictly adhered to;prior-.to the;'issuaace'of a Certi- cite of Com �.•,'.�' �_ �' +*.�'" a,.k `,,i,``Fy F t< ' �'«•�-_}✓ 7+ '` I +y'a a +''} �"' 6.<,•" # '.i� � .�'�"Sw+< ;{L. �t c. s_ •."!i'�� f. th � :r•r'` S s:�' ' yaJ �, �a; :.• +" .� i. ;, `< Ss ;(2) , All other'regulations contained in tTitle 5,=of<,the utate.^Bnvi'roninental ode, and the Town oP-Barnstable:,Health Regulations must be str�ctly,adtiered tp "� r` k s�4x �' � '�. I.t i • .da.t�� �� 't4Y a.ld:( •:.+ • ' .. +t ..t 4 1 k� � ,, I • •, .�111'is� ri a '�.. �,rx r :., ,a� .' � ,: tt' +s .. • i 1,* i r �, ,C+! . < a ante is granted,Because-the-bottom of_•the leaching,pitk vill tar{lofted 7:3rfeet above,'-rhe,,`obseived 'vraterr,leveL-#The -radjustment,,us#ng,, the,probable -,maximum ,high, gFounci;viater� formuta, .would, bey .3 feat with:`the:°�riatutalpervious `materai�3:2 feet; s {. gar a abov the max#tt um probable;high'ground'tivater in lieu of.:ttie required' feet. � W \ r�k•1`_W f.r't , +°.r + j + "!. r, - i t • <.° sw": +. t't & .a, a w. i ,".v;'•t, S Y,y. =y..+Try' d i"}.:.d' �; �� r4`�6' ,�.i '" }, =•1 .-�f G `, . 4 Iti�xwas the heron feoliri''of.the" oard that:iP�t i h I a g g �, h s'sy$tem.,is !installed according to plan that it kwill prdVlde essentially`the,same protecttan assa system in full;coMpliarice. iK i' # ��'...�i ',.. i '3', Ya fn v, i " ' ' �t�t.3 ;., d - , a,f wY a:{t }}. ,, r + „ rn` •1 .f. <Y <. i' _r*`i r Y .di�a,• P;• ,,.Y._.^yT ! 1 f i 'i°• „` r Y ;This aariance.expires 2ifaichF2,*1987; t Y y s' tl z s,vi v r •;, ••c a. i �} yr• "• _ _a�� af.. ,, t h ` +"'✓ .3' ! .,'� r 2 i �a: �, :'s �v•, „ >< - � r :�� ti,r y � •"G , � �� rt� ,� �,'[' + a4• •r g !. ` •f �.' P �• w '41Yit,• ,+�'r'� !} '`�rC � !� "'F• \. r ♦ !•a{ 't d�.r �r ..` t.��"`Y.,d + w r � ,_!r�^'s•..A: r . Vet �tily (� r< r4 T Ip<l 9 tS " < Sr+Ia r f j y i♦ \ 4 r It 4 t k �.`tr. {, w;f 's''M�s f't' ."fir ,,k �.+ d. .c r� "'L., •T "`,• A.T#` _• 'LP yi, n,ti<- ( �• ra '.:�.v F...� F •q ti t -d'. �. t� ��v_ n f i � ✓�*. Y ,�� a r � �y k+•ti a �• Lt .,f 3 , �.. a ft r N a ,S•'.' a A.r Y�:+ - k r, no", �' Y'+<' F. " i�. r 1 i"lrr• •i t„'.t . tk sr fy. - bete` ,ir t 74Gr '" s ;•u*'4dt !, erg{dt r .:ti }{ ^ ,x •'-� • W� yt ,� r a s •1 � xd',xf j`.. �.t t .sr 6:• A. "�'< _ •. .t�'++ s+ hairman �:- e 3 `. �w ;.y„ rr:�rya;_j.q�t"'•, a "�, ++ti} A.r!" '�� ,df? F r w, tMft ii .�. •\ \ � a ,'r ar. . Si• BOAR n©P"HBALTI3f4`> ? k .}, �'v : h" 7"'�f ,, ,f�d.t; _ ;• 1• ,.r F ,,�. 9 <3 7. ,ar � ..,� `% ll� ,a .1• � _ sx'.'. .;ir .,� w•"•i .r'.� i r �« y F r, r !" ,{ a `=1 T©Wl�'CIF;"t1�3ARNSTABLB `^� c .o: w; P``w t° h : + ,.fjt:3`•c Ay + :`''# t s,. ' ]x 4f. 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"i S�•'� I• lag No. DATE_ TOWN OF BARNSTABLE FEE ds — �F TH E TJ OFFICE OF i BAHMAI IL R E. s BOARD OF HEALTH � YA p i639• \em 367 MAIN STREET �aMIR HYANNIS, MASS. 02601 VARIANCE REQUEST FORM All variance requests must be submitted five (5) days prior to the scheduled Board of Health meeting. NAME OF APPLICANT D ci IT I-e— co TEL. NO 7 7/— ADDRESS OF APPLICANT /6 y✓� �7�c 2�� C�a74�'�t ��� /H� — NAME OF OWNER OF PROPERTY J° -. He I-e x R r SUBDIVISION NAME 5pr,# DATE APPROVED ASSESSORS MAP & PARC NO. z z 8' /9 9 LOCATION OF REQUEST Lof/O ��lto7� ReV Ce-. 74rr1///e VARIANCE FROM REGULATION (List regulation) Tow•. �' �7-/2- s�P� VARIANCE REQUESTED (Specific request) r+yl o u S o r� Cj�!e v e /'.Q. �cv.0• 9 rou� ry 4�c. G��/. by vi'2llli vcG�rin��� S � - REASON FOR VARIANCE (May attach letter if more space needed) g6r�c. �4. 9pvv.tcf w'�`u- �g,6l�e l�ewrve - w/7� ><4 r��Q �i a s �m�.,A ��a. to�-�! rc�. ..i7 .•. .8.b'� C�•� �e f" �se. ��� PLANS - Two copies of plan must be submitted clearly outlining variance requested. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPPROVAL Robert L. Childs, Chairman Ann Jane Eshbaugh Grover C.M. Farrish, M. D. BOARD OF HEALTH - ­ I _ ____ -___,_.______,___,___,___.__,__,__._ _____,___________.__1_­_.____ __ _________________.______ ___ __ _ ______.__________,___ ____ - _ ___ ___ , - � - , -­ - ­__- - ---,-- _ - ____ I---,--.---- ­ _____1_._____i­_,__,_____­__11 1-1 I . I .. 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