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HomeMy WebLinkAbout0500 ELLIOTT ROAD - Health 500 Elliott Road _ Centerville P A = 227 119 �a • �� ; i i �I UPC 12534 A No.2-153LOR �� HASTINGS,IN i I r i i i r e - I i o i r �J�J j( ( S S � � n / t r i Y t o 1. S 4 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM '< 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information I� I forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508420-4534 S14297 Telephone Number License Number 8: 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 Evaluation by the Local Approving Authority 6-30-14 In pector's Knature 7 Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I t5ins•3/13 Title 5 Official Ins i Fo :Subsurface Sewage Disposal Sys am•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. CitylTown 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: ONE OF THE LEACH CHAMBERS WAS OPENED AND HAD APPROX 4" OF LIQUID WITH NO SIGNS OF FAILURE B) System Conditionally Passes:, ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for."yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): f i, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken'pipe(s) are replaced ❑ Y ❑ N FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstructioin is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6".below invert or available volume is less than Y/2 day flow t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow+of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore th10sys(em;fails. The system owner should contact the Board of Health to determine whatIwill:be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is CENTERVILLE MA 02632 6-30-14 required for every page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: } Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO PLAN SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND 3 500 GALLON CHAMBERS Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes Z No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2012---575 2013---772 GPD HOUSE HAS A POOL HOT TUB AND IRRIGATION SYSTEM Sump pump? ❑ Yes ❑ No Last date of occupancy: 6-2014 Date Commercial/Industrial Flow Conditions: Type of Establishment:, Design flow(based on 310 CM 15.203): Gallons per day(9Pd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 - t Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped; gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic;tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 It Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): r Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): f a Septic Tank(locate onisite plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1 If tank is metal, list age'. years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 93) Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.j Septic Tank(cont.) r Distance from top of sludge to bottom of outlet tee or baffle Scum thickness MODERATE ,I Distance from top of scum to top of outlet tee or baffle I Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING EVERY 2-3 YRS I Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): i Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El'other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 p Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0f. Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX WAS VIEWED BY CAMERA DUE TO IT BEING UNDER PATIO/GARDEN AREA i Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* i Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE l MA 02632 6-30-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: f ❑ leaching!pits number: ® leaching'chambers number: 3 ❑ leaching!galleries number: ❑ leaching;trenches number, length: I ❑ leachingUlds number, dimensions: ❑ overflow;cesspool number: i ❑ innovati 6/alternative system Type/name of.technology: I Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ONE CHAMBER WAS OPENED AND HAD APPROX 4 INCHES OF STANDING WATER AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE i t l� 1 . i 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 I' Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 {' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t • I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is CENTERVILLE MA 02632 6-30-14 required for every page. Cityfrown j State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i F 1 k Privy(locate on site plan): Materials of construction: Dimensions j Depth of solids i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I j l I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Officinal Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately r c f d r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5 feet Please indicate all methods used to determine the high ground water elevation: l ❑ 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: PROPERTY SITS ON A HIGH PIECE OF LAND MUCH HIGHER THAN THE CENTERVILLE RIVER AT THE BACK OF THE PROPERTY I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t M 500 ELLIOTT RD Property Address TROTTO Owner Owner's Name information is required for CENTERVILLE MA 02632 6-30-14 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i k r f i t5ins•3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION Soro ��hO t Rc' SEWAGE M p, VILLAGE, Ul 1 kV,IL- ASSESSOR'S MAP&LOT ,-1 I 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J Cif/D LEACHING FACILITY:(type) Z,' �14W CLV4M�Us (size) Sty &I. NO.OF BEDROOMS``_ ) BUILDER OR OWNERS?eOiS! HJ�`GJnr PERMrrDATE: 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 le4fl°g facility)) Feet FurnishedbyT/1s�7Gb�7un r P,mr 5+ A B o a 3 aC 3(o y a s a6 z 1 http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=227119&seq=1 6/27/2014 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTE[MAR ION�I ,_ 2 3 2004 FHEA�T�,'\NST BLE TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATIONMAP Property Address: 500 Elliott Road PARCEL Centerville, MA 02632 Owner's Name: George Higgins LOB' �a Owner's Address: Date of Inspection: February 28, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: JameslM. 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 DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs her Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: March 4, 2004 The system inspector shall su i 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. 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: 500 Elliott Road Centerville, MA Owner: George Higgins Date of Inspection: February 28, 2004 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: t 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: r 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 J 'Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 500 Elliott Road Centerville, MA Owner: George HiQeins Date of Inspection: February 28, 2004 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 t **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. •I I 3. Other: i i` l 3 I i 'Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 500 Elliott Road Centerville, AM Owner: George Higgins Date of Inspection: February 28, 2004 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 pond,ing of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ' . ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ 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 ice• 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) i 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 i 'Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 500 Elliott Road Centerville, MA Owner: George Higgins Date of Inspection: February 28, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: i 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) 4 ✓ 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? i The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No r ✓ 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)]. Ii I I; 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 500 Elliott Road Centerville, MA Owner: George Hijzzins Date of Inspection: February 28, 2004 FLOW CONDITIONS RESIDENTIAL i Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: I Does residence have a garbage grinder(yes or no): Yes 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: Currently occupied 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): T 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 4 years ago-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 l 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): i Approximate age of all components,,date installed(if known)and source of information: A leach field was installed 1/10/00-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: 500 Elliott Road Centerville, MA Owner: George Higgins Date of Inspection: February 28, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _casti 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) I Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) i If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1006 gal. 1 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" 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.): Page 8 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 500 Elliott Road ` Centerville, M4 Owner: George Hikzins Date of Inspection: February 28, 2004 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: g,allons 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.): i 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. No solids wer',e 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.): i I � I II 8 l Page 9 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 500 Elliott Road Centerville, MA Owner: George Higgins Date of Inspectiion: February 28, 2004 { SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 flow chambers(per as built card) 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 chambers had 6"of water on the bottom. The scum line was at the same level. There did not appear to be any signs of failure. The bottom to grade was S'. A steel cover was to grade. 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.): I 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: 500 Elliott Road Centerville, MA Owner: George Higgins Date of Inspection: February 28, 2004 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. - I I A 6 I � y a �g ag 3 a3 3 c� i y as a� 10 Page 11 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 500 Elliott Road Centerville, AM Owner: George Higgins Date of Inspection: February 28, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 15 +/- 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 the Cape Cod Commission water contours map,the maps were showing approximately 15'+/-to ground water at this site. l { I 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 property 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 ` I TOWN OF BARNSTABLE LOCATION 5 ��1 0' 2 SEWAGE # p, VILLAGE �n 1 t+iV a ASSESSOR'S MAP & LOT - -1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��CltfD �y L LEACHING FACILITY: (type) ,Z' `� OW C x(S (size) NO. OF BEDROOMS BUILDER OR OWNER PER- M-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 leac4ing facility) Feet Fumi shed by�_&2e " // ' ^1 y A B o a n as 3 393 36 y as a� No. < d o �- 41 Fee$ 5 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Migpaal *p-5tem Cow5truction Permit Application for a Permit to Construct(X 4Repair(X X)Upgrade( )Abandon( ) ❑Complete System 11 Individual Components Location Address or Lot No. 500 Elliott Road Owner's Name,Address and Tel.No. Centerville ,Mass . 02632 George A. Higgins Assessor's Map/Parcel ✓Z � 7 500 Elliott Road Centerville ,Mass . Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 02632 J.P.Macomber . & Son Inc . J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 Box 66 Centervil'le ,Mass . 02632 Type of Building: + �1 Dwelling X X No.of Bedrooms X Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 gallons per day. Calculated daily flow 3 x 110=3 3 0 gallons. Plan Date um eets Revision Date Title Size of Septic ank 1000 existing Type of S.A.S. LP-1000 existing Description of Soil: Loamy s a nmedium sand Nature of Repairs or Alterations(Answer when applicable) chambers packed in 4 ' of sto. e . H20 ' s fvffl Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by thi B d of Healt Signed Date I 1/3 0/�9t,9 Application Approved byMv- ,a ' Date "!7^/ Application Disapproved for the following reasons '00, Permit No. ON Z Date Issued 1 L—f 7 -— I ^�f -..-r• -'.. �,.'I,•�-.r�tr�;,+..,�.,yw.Y.^tiiw+'•.:.,y ..... ,.�._,+� ,�. � _;--_.: ..-•�i-�' i ...-•a No. ��° Fee 50. 00 T' 1 b may,,,,,,..:.... THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPYicatton for Mioozaf *raent Conotruction Permit •,� Application for a Permit to Construct(X XRepair(X X)Upgrade( )Abandon( ) '❑Complete System ❑Individual Components Locat{{on Address or Lot No, ,0 0 Elliott Road Owner's Name,Address and Tel.No. Cent��erville tl'ass. 02632 George A. Higgins Assessor's Map/Parcel me� 500 Elliott Road Centerville ,Mass. Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 02632 J.P.Macomber & Son Inc . J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 Box 66 Centerville ,Mass. 02632 , f Type of Building: Dwelling XX No.of Bedrooms �t L`ot'Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Y Other Fixtures 'Design Flow 3 5 5 gallons per day. Calculated daily flow 3 x 110=3 3 0 gallons. Plan Date - Number:Qf sheets Revision Date Title -- -- -�\ Size of Septic ank 1000 existing / Type of S.A.S. LP-1000 existing Description of Soil: Loamy sand to medium sand Nature of Repairs or Alterations(Answer when applicable) Adding 20500 a l l o n leaching chambers packed in 4 ' of stone. H20 ' s 6.. ( I /, d& Vi ..,it' CAAu, ,/l Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi B &d of Healt Signed Date 11/3 0/88 Application Approved by Q Date/2-/47-5/ Application Disapproved for the following reasons Permit No. Date Issued ---�. ---- —._. ------ —————— -- ---- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS certificate of Compliance', - . THIS IS TO CERTIFY, that the 6n-site Sewage Disposal System Constructed'(/ )Repaired`(XX.'Upgraded( ) Abandoned( )by J.P.Macomber & Son Inc . at 500 Elliott Road Centerville,Mass . has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 99- K Z- dated 7 Installer J.P.Macomber & Son Inc . Designer J .Macomber & Son/,,1nc. The issuance of this p h 11 not construed as a guarantee that the s s m ..ill funct',n denied A Date T�l.r' Inspector j� �.,�'r z , V, J —�w——� --------------- No. —•-----------Fee 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 00i5po5ar *p!5tem Construction Permit Permission is hereby granted to Construct( )RepairM Upgrade( )Abandon( ) Systemlocatedat 500 Elliott ''Road Centerville ,Mass . and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of!V� Date: l l7' / Approved by . I 3 /�,� 1 6 Fss.. THE COMMONWEALTH OF MASSACHUSETTS BOAR®` OF HEALTH ...........:... ....................OF........................................----------......._....------.._................... S' Allp iration for Uiipntittl Workii Tonstrnrtion Famit Application is hereby made for a Permit to Construct (V�or Repair ( ) an Individual Sewage Disposal System at: .'. /S•----LCLL/OTT .D . Cam/ 72V ...l ... ocatron-Address or Lot No. ............................ .............••...... Owner ess Installer (��+ � L.e�yS Address Type of Building Size Lot............................Sq. feet ,., Dwelling—No. of Bedrooms.....---'................................Expansion Attic ( ) Garbage Grinder (X) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ...................................................... W Design Flow............`7 e%:5....................gallons p€r-g�serr per day. Total daily flow..........•._4P-------•--_------••_-gallons. W R Septic Tank—Liquid ca aclt y_ __ O .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench No..................- Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No...6-X_4.__.. Diameter".; Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( �/ Dosing tank( ) '-' Percolation Test Results Performed by-_..NO-kMA71 ..._�i2®�S_!�?/ !l/..............•.. Date -$2-: a ...._. Test Pit No. 1.....�......minutes per inch Depth of Test Pit.................... Depth to ground water........................ LT4 Test Pit No. 2....... _._.minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•••-•-•••••-•-•-------•----•••-•-•-••••---••-•---•-•••--•-•-•-.....--•------•--•-••••......---•----.................................................... ODescription of Soil......M1E.P1_{,1.M.......5A 40.n...--•-••••••••--••••--------•---••--•••-••-•--•-••••-•••-•-••----••-••-•-••••-•-••-•....._.. x w ----- lic ------ nF------STDry C o V Nature of Repairs or Alterations—Answer when applicable.....s l .v n..—-----�/TS--> ----------------------------------------------------------------------------•------•---•--.....------------....------------------------------....----------------------------------......._.._......•-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until ertifi to of Compliance has been issued b the board of he lth. Signed PPlication Approved By..... .� 44 ••-•-•--•---------•-- ••-•••A. 1.117 ......... Date Application Disapproved for the following reasons:.............................................................................................................. ------•----------••-•.••-••••-•-•••---••----••••.....•-•••--------•-••••••-••-••-----•-••-••-•-----...••••••--•-•----------•--•--...--•••••-••-•-••-••-••-•-•••-•••--••••••-••••-•••---•.....-----•-•••- I Date Permit No..---.... � Issued..................................................... � Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ............................. . OF.....-.........-......................................................................... . AV '' 1i'a. ilan for Diipniittl Works Tonotrurtinn "amit Application is hereby made for a Permit to Construct (Vl� or Repair ( ) an Individual Sewage Disposal System at: 7:'Ot/S,,_ LGiOT'T 'D. C'E"N x `;2V►GGtr •--••--•........................•-----------•--•---------- --.------•---------.--.-----------•-•---•-••----------.-••--• -------•-•--.-----•---------- Location•Addre .............................................Lot No. Address wne a ^....... ---•--•-.......T.."...................•........ ---:...........................---••-•----.............-•----•---•-............................... Installer (N�'. ,� j,E? Address ' Type of Building Size Lot.......................�.,,...Sq. feet Dwelling—No. of Bedrooms.__.....'...........:....................Expansion Attic ( ) Garbage Grinder (x) '4 Other—Type of Building No. of persons............................ Showers W YP g ----------------•--•------•• P ( ) — Cafeteria ( ) 04 Other fixtures ................................. W Design Flow...........7.e6.....................gallons por•perscft per day. Total daily flow........... ...............gallons. WSeptic Tank—Liquid capacityA:_.----gallons Length................ Width................ Diameter................ Depth................ x Disposal.Trench—No. __----------------- Width.................... Total Length........:........... Total leaching area....................sq. ft. Seepage Pit No..6.X_4..... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( r$S Dosing tank ( ) '-' Percolation Test Results Performed by....N W1_AIV..../ o .!!? _!L(................. Date...... ..'! .'$ - ------------- a Test Pit No. 1.....2.......minutes per inch Depth of Test Pit.................... Depth to ground water....................... Test Pit No. 2......,�_...minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ ------------- .•--------•------------------•--•-------------------.. •------.... *......... ........ -------------- -...-----------.-----•-•--------------------- 0 Description of Soil....._M16b. 0m-------sA&A--'---=--•-•-•-•------------•------------------------•-•----------••••---------------------•-•-••--•-•--•-•--------.. W U •--••-•---••-•---------------------------•-----•---------..............._..........----------------------------•---••--......_..-----------•••---------•...--•---------••----------•-••-----............ -----------------------------------------------------------------------•------ ------------------------------------------------------ •------------------- •---------•------------••------- ----------- Nature of Repairs or Alterations—Answer when applicable___-_s3!..... F........-`_.7"aN F t��O v Iv o...._P ----••-------------------------------------------------------•--------=------==----...............--------------------------...•------••----------•---------------------••--••-••----•-----........._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until ertificate of Compliance has been issued by the board of heAlth, Signed.............. � ....:.i./.:._ . ............... f............_ Application Approved By...... ..a...0 ...................... Date Application Disapproved for the following reasons:-------•-----------------------------------------------•-•-•---------•-----••-•-----------..........._....--•- ---------------------•-- ==-............................................................................................................................................................................ �© Date Permit No......... ?-M Issued.................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................:......................OF..................................................................................... (Intif iratr of Tout rliattrr THIS IS TO CERTIFY, ThaA the >Idivi ual Sewage Disposal System constructed ( ) or Repaired ( ) by77.....: .----W`.......�--'t--. .u ........ ...... ....------...............-•--------------•----......•.... •.._..... Instay� -•� at. t , ........................ .............................. -l 5�._ .t_1 .......................................•----- . ---------••--•----•. has been installAd in accordance with the provisions of TITLE 5 of The State Sanitary Code as Aescribed in the application for Disposal Works Construction Permit No. .=._�p'�............. dated....11_ -1.3/-�5............._........ THE' ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GURANTEE THAT THE SYSTEI9A IN1 L FUNCTION SATISFACTORY. DAT .................................................. - Inspector...... . ._ ........._.......... ........_....... THE COMMONWEALTH OF MASSACHUSETTS f ' BOARD OF HEALTH -- `'A t ; .........................................OF..................................................................................... o No......................... FE>e..:...~ .... . ... Disposal lVorko 'unstrnrtiu f rrmit ' Permission is hereby granted...... .......................... -.. �8. .G.ZL%t!_'.c=-� to Construct ( ) or Repair ( ) an Inc�vidual Sewage DisposalS t atNo......... - - 1 '................................1 i?a---•-•--••-- biz5v�-3- --••---------------------•-------•-----------••-•--------..----.----- Street f as shown on the application for Disposal Works Construction P it No.c ..:/ � Dated.._��_/_.�� ................. - - .-- ....................................... DATE. -� I �� Board of Health •--•---•------••---•..............•••••----:........... FORM 1255 A. M. SULKIN, INC., BOSTON - ---- , TOWN OF BARNSTABLE ` s a _ j LOCATION 01�/�f t3 T f: D SEWAGE # VILLAGE C elt1 re x i.1d Ile ASSESSOR'S MAP & LOT 9 INSTALLER'S NAME&PHONE N0. - . ,Z A -r CAI l SEPTIC TANK CAPACITY > o. LEACHING FACILITY: (size) •5 00 C44 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: I �O Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I i 00 \ _ TOWN OF BARNSTABLE LXATION.,�0 QP ��i D`� /: ,� SEWAGE # co— ` VILLAGE C 4 X V®Ile ASSESSOR'S MAP & LOT A s 11 / INSTALLER'S NAME&PHONE NO. J pA4 A C 0 ,14 e t 9 6Al SEPTIC TANK CAPACITY Z_LEAC,HING FACILITY: (type (size) Ufa® G 4 4 NO.OF BEDROOMS y t BUILDER OR OWNER PER DATE: COMPLIANCE DATE: G 10100 ®0 . r Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet `Private Water Supply Well and Leaching Facility (If any wells-exist on site or within 200 feet of leaching facility) Feet , Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by j � n. r wr 4".i �f � �� � ' !y� '� � � � r x a � / �'� ��/ t� � � . ; r .. 06-08-1999 03:56PM CENT OST FIREDEPT 5097902385 P.02 tnaxe appuoauon to tocar rire ueparanenT- Fire Department retains original application and issues dupGCate as Permit. ez (L lZ/l APPLICATION and PERMIT 1=ee: 10.00 for storage tank renwveJ and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148,Section 38A, 527 CMR 9.00, application is hereby rnade by: Tank Owner Name(please print) George Higgins X svmm a aAt g roF peReu Address 500 Elliott -Road, Centerville Sheet coy state zp 1111117X • • :• • • - Company Name Advanced Environmental Co. or Individual Advanced Environmental Prnlr Print Address P.O. Box 472, S. 'Dennis. MA Address PrNt Pant Signat (if. ng;t Sign (if p ng no e IFCI Certifret Other C IFCI Certified = SP Other Tank Location 500 Elliott Road, Centerville steer AdWeSS �n Tank Capacity(gailcrs: 500 Substance Last Storer #2 Fuel Oil Tank Dimensions x length) �o Remarks: Firm transporting waste Advanced Environmental State Lic.n MV'5083856100 L5 Hazardous waste mari�est E.P.A. # Approved tank disposal vard Abandon in place Tank yard# Type of inert gas Tank yard address Centerville 01920 City or Town FDID# Permit# June 8,_ 1999 June 22, 1999 Date of issue Date of expiration Dig safe approval num*er- n/a ` Dig Safe Tcu rrr-Tel. Number-800-322-4844 Signature/Title of Of' -r-_ranting permit y" After removal(s) send Fcm ?-290R signed by Local Fire Dept. to UST Regulatory Compliance Unit, One Ashburton Place, Room 1310, Boston, MA CZ-08-1618. FP-292(revised9/96) UtNI UbT 5067902385 P.03 maKe appucauon to local rtre uepartmenz. Fire Department retains original application and issues duplicate as Permit. APPLICATION and PERMIT Fee.:-rip 00 for storage tank remcvaJ and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148.Section 38A, 527 CMR 9.00, application is hereby made by: George Higgins Tank Owner Name(pie. print) x sQnatvre aouyrey rapenna/ Address 500 Elliott Road, Centerville Straex Ur Sties Irp Removal • u • _ Company Name Advanced Environmental Co.or Individual Advanced Environmental Pot pelt Address P.O. Box 472 , S. Dennis MA Address Plht �( Signature ' ap 5cr Signa ;rrr- J C IFCI Certified Other _ IFCI Certified = 'ct 4 Other Tank Location 500 Elliott Road, Centerville 2,000 SeeerAddeea.; , .. Tank Capacity(gallcrs: Substance Last Storec #2 Fuel Oiler Tank Dimensions(Cia x length) Remarks: I Firm transporting was, Advanced Environmental State Uc. # KV5083856100 Hazardous waste maribszg E.P.A.# Approved tank dispcszj va:-d Abandon in place Tank yard# Type of inert gas Tank yard address Centerville 01920 City or Town FDID# Permit# Date of issue June 8,. 1999 June 22, 1999 Date of expiration Dig safe approval number. n/a Dig Safe Toll 3;�Tel.Number•800-322-4844 Signature/Title of Offi��-ranting permit v After removal(s)send F--r T, 7-P-29OR signed by Local Fire Dept to UST Regulatory CompGzfx---unit, One Ashburton Ptace, Room 1310,Boston,MA:2- ,&1618. FP.1>09 rrovkad q/W TOTAL P.03 06-06-1999 03:56PM CENT OST FIREDEPT 5087902385 P.03 MaKe appucauon to tocat rtre uepartmenL. Fire Department retains original application and issues dupfrate as Permit. a°�m _ --� APPLICATION and PERMIT' Fee: r1�0.00 for storage tank remcvzJ and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148. Section 38A, 527 CMR 9.00, application is hereby mace by: Tank Owner Name(pie print) George Higgins -� X Sgnarais aotrr+rq rorpermd) Address 500 Elliott Road, Centerville sneer City stile Lp . o to • • - Company Name Advanced Environmental Co. or Individual Advanced Environmental print PAI? Address P.O. Box 472 : S. Dennis MA Address Prof nnr Signature app ,cr- Signa appl" ;cr- J L IFCI Certifies Other IFCI Certified - Lr# Other 500 Elliott Road, Centerville Tank Location Tank Capacity(gallcm: Substance Last Storms ��22,000 e1 Oiler Tank Dimensions(fit~ x length) Remarks: Firm transporting waste Advanced Environmental State Uc. # MV5083856100 Hazardous waste marries E.P.A.# Approved tank dispcs&I,-d Abandon in place Tank yard# _ Type of inert gas Tank yard address Centerville 01920 City or Town FDID# Permit# Date of issue June 8,. 1999 Date of expiration June 22, 1999 Dig safe approval number: n/a Dig S�IR Tel.Number-8M322-4844 jSignature/Title of Offic-r_ranting permit � I After rer:k)ual(s),send Fn.^.. 7---29OR signed by Local Fire Dept_to LIST Regulatory Ccmprjarx—_Unit, One Ashburton Placo, J Room 1311',Boston.MA 1. TOTAL P.'-ri:�" { . o -� ,Y Y ' l aj rn =� 3 G O r O 000 ` -� 0 Oo o �- v 0 OoFl o 11 � 0 a x ,1 � vC _ o 0 n 2 m LilN II II II II 1 i C � o v I - 44 I • li I' I I X I J1 C N x � w 0- 7 kuk sp to ��- 0 Vo Yg i ,x U 11 M, (p II ,_0 A_ rs y_ -s _�._ �---ALL E-�F-J. &Wo St L�VE�. t +at �� FeAA2 - bAe"+a to 14..i M,S.L_ M ^t c U$rr0i ''- 'r' �M!'�� ,++ \D-- PtV-44 ,A►UL LIWES A, Mial,mJjA dP Ab I ,s�--�+ � �/�_'~ � !! � s� � "i r Unt l-t S�, �*yT1-{�►.�t3 E 3dP'i�_+G.►!�i E D. 1_..J._! 'f' '; i �3} e.d�i P+ft5 Ta AWD 04 T r _ _ ftc Cam,'ST 12A:wj cam. >,�o u r€ Ace v,/c i- ! �j i- ALA. 45 EorwC 1'<wKS, P+5'r �+g.x1,o.J �n� , /► tii c� _- _._.__ +..r._-.�.. .-.:..T"S=: i [/'�j �/���) ,� J i L u _. i'.M V..•�f.._�L LQ.�1J! i 4"� .J l�L •: 1 4- _ .N^'_{14.. 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