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HomeMy WebLinkAbout0119 EMERSON WAY - Health 119 Emerson Way Centerville P A = 189 103 I t No. 4210 1/3 ORA Pendaflexe 100/ . f � . v_ _ z_ .. - _ - --=-�� - Town of Barnstable Health Inspector FZ►�r Regulatory Services Office Hours p off, g y 8:30—9:30 Thomas F.Geiler,Director 3:30—4:30 1 BARNSTABLE, * Public Health Division MASS. 1639. A�0 Thomas McKean,Director �ArFD MA'S .200 Main Street;Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE. Anve.mi 2Il2011 Date: 1. General Information: Size of Property: .23 Acres Address: 119 Emerson Way Centerville,MA 02632 Map 189 Parcel 103 Name: ANASTASIA ZINOV FULLER Phone#: 617-840-5675 2a. How many bedrooms exist at your property now? 5 2b. Are you planning to add any bedrooms?NO If yes,how many? 0 2c. How many bedrooms total are proposed at this property(including the amnesty unit)?5 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements.of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to PUBLIC WATER? YES 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or, NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ----------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Date: IzZt , Q:\GMD-Housmg\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyapp 1.DOC ......__..... _................ S� F I , t I ..-.-_.-_ O � (" r\l / l k :1 1 O ! 1 i i G � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P 1�.ty Addressedn Q Owner Owner's me information isreq c j �2, ®� 12-01C) wired for ��,-� �� every page. City/Tmin�- State Zip Code DatVof Insp o 1 Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important When filling out A. General Information forms on the computer,use 1. Inspector: onlythe tab key to move your V!`c J R� e� cursor-do not of sped n use the return key. _ s Ac Company Na ;OC,�. Company Add ALL &A , 02 64� c" frown State Zip Code ��— o$- LL4%- TeTephone Number License Number B. Certification I certify that 1 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 bL� Lo10-3 Inspector's Sig atu 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. t5insp.doc-08106 Title 5 Official tnspec0ai Form:Subsurface Sewage Disposal System-Pape 1 of 15 f,. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pr rty Address Owner Ownefs rM aired d is C - 6 Z rZ required for V�- `��-�- every page. Cfty/Town State Zip Code Date of Ins on 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass'section need to be re aced or repaired.The system,upon completion of the replacement or repair,as approved by the rd of Health,will pass. Answer yes, no not determined(Y, N, ND)in the❑for the following statements. If"not determined,"pleas xplain. ❑ The septic tank is m I and over 20 years old*or the septic tank(whether met r not) is structurally unsound,a bits substantial infiltration or exfiltration or tank fa' a is imminent. System will pass inspectio if the existing tank is replaced with a comp ' g septic tank as approved by the Board of H *A metal septic tank will pass ins ion if it is structurall ound, not leaking and if a Certificate of Compliance indicating that the tank i ess than 2 ars old is available. ND Explain: ❑ Observation of sew backup or break out or high static water el in the distribution box due to broken or obs ed pipe(s)or due to a broken, settled or uneve distribution box. System will pass inspectio (with approval of Board of Health): ❑ br en pipe(s)are replaced ❑ obstruction is removed t5insp.doc.08M Me 5 Official InspecIto Foml:Suba nfooe Sewape Disposal Sy -Pap 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 �G i:-:;me-r -\ y." Pr ty Address Mr (�v1 i inn Owner Owners information is (' P �1 t v\ V z required for _ �t �N\7 _ every page. City ow State Zip Code Date o on B. Certification (cont.) H) System Conditionally Passes(cont.): distribution box is leveled or replaced ND Explain. ❑ The system required pu ing more than 4 times a year dXbroobstructed pipe(s).The system will pass inspectio 'f(with approval of the Board ❑ broken pipe(s)are rep ❑ obstruction is removed ND Explain: C) Further Evaluation is Required the Board of Health. ❑ Conditions exist which require rther evaluation by the Boar Health in order to determine if the system is failing to prote public health,safety or the enviro ent. 1. System will pass un s Board of Health determines in acco ance with 310 CMR 15.303(1)(b)that the stem Is not functioning Ina manner which ill protect public health, safety and the envi nment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cess of or privy is within 50 feet of a bordering vegetated wetland or a It marsh 2. Syste will fail unless the Board of Health(and Public Water Supplier,if any determl S that the system is functioning In a manner that protects the public he th, safety nd environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is withi 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp.doc-O&W Title 5 011idal Inspection Form:Subswface Sewage Disposal System-Page 3 of 15 r �r- . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P.MR&rty Address Owner information is required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation Is Required by the Board of Health (cunt.): ❑ stem has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fro 'vats water supply well". Method used to determine distan "This system passes if the well water analysis, perform a DEP certified laboratory,for coliform bacteria indicates absent and the presence of amm . nitroge d nitrate nitrogen is equal to or less than 5 ppm, provided that no other failur .er5fena are triggered. 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 cogged 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%day flow ❑ (5J Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ I� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp.doc•O&W Title 5 Oftal Inspection Form:Subsurface Se wage Disposal System•Papa 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments P Address rty MA\L,�, M Owner Owner'"bffle inforinabon is every page. City[rown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cost.): Yes No ❑ A Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [q Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ EJ 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 colifonn 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. ❑ lq' The system ils. 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 largllilsystems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in S n D. Yes No ❑ ❑ the system is ' in 400 feet of a surf drinking water supply ❑ ❑ the system is within 200 a tributary to a surface drinking water supply ❑ ❑ the system is located' a nitroge sitive area(Interim Wellhead Protection Area—IWPA)or apped Zone II of blic water supply well If you have answered"yes"to an uestion in Section E the system is sidered a significant threat, or answered"yes"in Section D ve the large system has failed.The own r operator of any large system considered a signifl nt threat under Section E or failed under Section D II upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the ap nate regional office of the Department. t5insp.doe-08/08 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 k Q h�Mo� cal Party Address Owner e' ine information is required for ��\) Vie— Co �nx.J l ©^J -�.L��L1_ [ every page. City/Town State Zip Code Date of Inspedlon 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) Ef ❑ 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? M) ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ❑ 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 Soll Absorption System(SAS)on the site has been determined based on: [� ❑ Existing information. For example, a plan at the Board of Health. d ❑ 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)1 t5insp.doc-08M Title 5 Official Inspection Forth:SubsuAace Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P rty Address owner Ownee me information Is required for v�, every page, Ci1ylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): zz J�0 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes [� No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes [� No Seasonal use? [� Yes [] No Water meter readings, if available(last 2 years usage(gpd)): = Sump pump? ❑ Yes [� No Last date of occupancy: oats CommerciaUindustrial Flow Conditions: Type stablishment: Design flow(ba 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatstpe sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to itle 5 system? ❑ Yes ❑ No Water meter readings, ' ailable: Last date of upancy/use: Date Oth describe): t5insp,doc.oalpg Title 5 Official InspecWn Form:Subsurface Sewage Disposal System-Pape 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pr Address _ Owner ame rlation regLd � 92� � � C�q�7�5 0-7 regtNred for every page. Cittrfrown State Zip Code Date of Inspection D. System Information (cont.) 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: ih Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Cl 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: t� Were sewage odors detected when arriving at the site? ❑ Yes d No t5insp doc•08= Idle 5 Olfidal Inspection Form:Subsurface Sewage Disposal System•Pape 8 or 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Q Emey-r"Eln W . y Address ^� OL Owner is C � n jL--- every page. C4rrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): u b Depth below grade: 1"C) 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.): QW i \ iev �yw roQsP Septic Tank(locate on site plan): it 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 ----------=--------------------------------------------------------------------------------------------------------------- oo �I 1 �. Dimensions: ` 11 —�- Sludge depth: Zll Distance from top of sludge to bottom of outlet tee or baffle 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 Iti y`i How were dimensions determined? �� Wnsp.doc•06ft Title 5 Offldal Inspection Form:Subsurface Sewage Deposal System•Pape 9 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "-c cv- P Address c owner information is required for City/rows W State Zip Code Date of Ins every page. P pechon 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.): Grease Trap(I a 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 outl tee or baffle Distance from bottom of scum to om of outlet tee or ba Date of last pumping: to Comments(on pumping r mmendations, inlet and outlet tee or ba condition,structural integrity, liquid levels as related to tlet invert,evidence of leakage, etc.): Tight or Holdi Tank(tank must be pumped at time of inspection) (locate on site plan). Depth bel gradg e: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): t5insp.doc•0t3 W Title 5 Official Inspection Form:Subsurface Sewape Disposal System•Pepe 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 1 I G Y1\e(-S atn �n9 MpertAddress I ' l Y" owner owner' infbffnadon required forte rule. z ���,I, 10-7 every page. C' frown State Zip Code Date of Inspedion D. System Information (cont.) Tight or Holding Tank(cont.) Dimensi Capacity: gallons Design Flow: gall r day Alarm present: Yes ❑ No Alarm level: Alarm 1 rking order. ❑ Yes ❑ No Date of last pumping: Date Comments(con . on 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.): 1 1 1�bt1MQ� —Row' 2C�, 1 �t owe �;2�Jd b off' yyn CWfoff` Pump sate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working or ❑ Yes ❑ No t5insp.doc•08r06 Title 5 Oftal Inspection Fom Subsurfeoe Sewage Disposal System•Page 11 of 15 I - , Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ' Owner L A\r\r\Ok Ow \� ners information is �_`���t /�� � l required for C� �l�'`C� �` -.S.L�rZ� d�Ll 2=Z I—0-D 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: r leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): s e-. t5i^sp•doc•08M6 This 5 Official In spection Form Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P ddress Owner owner requir aUon is LQ-7 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) C pools(cesspool must be pumped as part of inspection)(locate on site plan): Number configuration Depth—top 'quid to inlet invert Depth of solids lay Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of by uli failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of constructio Dimensions Depth of solids Comments( to condition of soil, signs of hydraulic failure, level of ponding, condition of veg tion, etc.): t5insp.doc-08I08 Title 5 Official Inspection Form:Subsurface Sewage Dispose!System•Pape 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P��� Ey ne�©v\ W%j owner information is required for -u `� C)Z63 h2-a-Lc)-i every page. C4frown State Zip Code Date of Inspe on 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. g � _ Zt Z AL-- 2�1 �31611 o t5insp.(= GBM Title 5 Otlkiel Inspection Form:Subsurface Sewage Disposal System•page 14 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P\ `gndEs�e-a(DV� �Q Owner Ovrne a / Ireeqquirld for� 7'7-7e�y i�� (�(—�(i2n�I.co every page. CHylrown 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: 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) ❑ Acqqssed USGS database-explain: 7-)Q ' Zo��� You must describe how you established the high ground w r elevation: V U c) LiVr �b,-)" I �Ao l n \ SA S Q t5insp.doc•08108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 15 of 15 TOWN OF BARNSTABLE LOG_ATION — SEWAGE t# VNL.AGE ����v_,1_0Vr6 �ASSESSOR'S MAP & LOT/,r9—J-92 NAME&PHONE NO. jL ,LLX SEPTIC TANK CAPACITY ® LEACHING FACILITY: (ty l) - t (size) NO.OF BEDROOMS BUILDE OR WNER _ 1W DATE: ® L �Q� 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 cf ieaching facility) Feet Furnished by r 1 _ ' ,AZ t $ZIt tc ALA r 7S71 » oC) COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FRVED TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A MAP CERTIFICATION PARCEL ; Property Address: 119 Emerson Way LOT (�^� Centerville,MA. Owner's Name: Richard Dew Owner's Address: 119 Emerson Way Centerville,MA Date of Inspection: November 24,2003 Name of Inspector:(please print)Timothy E.Cash Company Name: Cash's Trucking Inc. Mailing Address: PO Box 7 armouthpoR, Ma. 22675 Telephone Number: (508)362-3221 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: xx Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 11/25/03 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. 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: 119 Emerson Way Centerville MA. Owner: Richard Dew Date of inspection:11/25/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: xx 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: I have found nothing that would indicate at this time that this system meets anv of the state or local hailure criteria. B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 119 Emerson Way Centerville,MA. Owner: Richard Dew Date of Inspection:11/25/03 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 15303(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: Title 5 Inspection Form 6/15/2000 3 1 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address•.119 Emerson Way Centerville. MA. Owner: Richard Dew Date of Inspection:11/25/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ xx Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ xx Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool xx Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool xx Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow T xx Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped xx Any portion of the SAS,cesspool or privy is below high ground water elevation. xx Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. xx Any portion of a cesspool or privy is within a Zone 1 of a public well. r xx Any portion of a cesspool or privy is within 50 feet of a private water supply well. xx Any portion of a cesspool or privy is less than 100 feet but greater than 50 fat 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 most be attached to this form.] La (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 — xx the system is within 400 feet of a surface drinking water supply xx the system is within 200 feet of a tributary to a surface drinking water supply _ xx the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 119 Emerson Way Centerville, MA. Owner: Richard Dew Date of Inspection: 11/25/03 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No xx _ Pumping information was provided by the owner,occupant,or Board of Health xx Were any of the system components pumped out in the previous two weeks? xx _ Has the system received normal flows in the previous two week period? xx Have large volumes of water been introduced to the system recently or as part of this inspection? xx _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) xx _ Was the facility or dwelling inspected for signs of sewage back up? xx _ Was the site inspected for signs of break out? roc _ Were all system components,excluding the SAS,located on site? xx _ 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? xx _ 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 xx Existing information.For example,a plan at the Board of Health. xx _ 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)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 119 Emerson Way Centerville, MA. Owner: Richard Dew Date of Inspection: 11/25/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 Number of current residents: 2 Does residence have a garbage grinder(yes or no):-iW Is laundry on a separate sewage system(yes or no):AX7 (if yes separate inspection required] Laundry system inspected(yes or no):Ajo Seasonal use: es or no : (Y L) . Water meter readings,if available(last 2 years usage(gpd)): awt-Ali goo a`ao l•yo(d6Q Sump pump(yes or no): Aio Last date of occupancy: 11/03 COMMERCIALANDUSTRIAL 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: Barnstable Treatment Plant Was system pumped as part of the inspection(yes or 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: Asbuilt card indicates that permits were pulled for upgrade in 3/95 by owner Were sewage odors detected when arriving at the site(yes or no): Title 5 Inspection Form 6/15/2000 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: 119 Emerson Way Centerville, MA. Owner:Richard Dew Date of Inspection: 11/25/03 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:7" Material of construction: xx 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 gallon seotic tank Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle:24" Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: 0 Distance from bottom of scum to bottom of outlet tee or baffle: 0 How were dimensions determined: measured with slude iudae Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): septic tank is in hood shape and show no sign of anv faillure is and tank in Good shape,no leakaae GREASE TRAP:_(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.): Title 5 Inspection Form 6/15/2000 7 i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 119 Emerson Way Centerville, MA. Owner: Richard Dew Date of Inspection: 11/25/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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.): D-box shows very light carrie-over and very little decav box is in ok shape and is working , but should be replaced in near future. PUMP CHAMBER:_(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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 119 Emerson Way Centerville, MA. Owner: Richard Dew Date of Inspection: 11/25/03 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type xx leaching pits,number:2 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Leachinq pits show no siqn of anv failure. Pit#1 is a dry hole with no water line and pit#2 has only 12"of water with a 6"water line neither oit shows anv failure according to state and local codes. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 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.): Title 5 Inspection Form 6/15/2000 9 j, Page 10 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 119 Emerson Way Centerville, MA. Owner: Richard Dew Date of Inspection: 11/25/03 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 AC D=03' ae, 3D=c�y� i ?�F=a, O G D O LP*'( i i fi r LPHZ 6 W—.I i1 i ( iu -r in ^ _ O _ P Title 5 Inspection Form 6/15/2000 10 -AQqe., 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: 119 Emerson Way Centerville. MA. Owner: Richard Dew Date of Inspection: 11/25/03 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 14' 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) xx Accessed USGS database-explain: CC Commission You must describe how you established the high ground water elevation: Auger to 14'no water, Note next page for calculations. Title 5 Inspection Form 6/15/2000 11 Permit Number: Date; 11/24/03 Completed by: Timothy Cash HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 119 Emerson Way, Centerville Lot No. m-189 par-103 Owner: Richard Dew Address; 119 Emerson Way, Centerville Contractor: Cash's Trucking Inc Address: PO Box 7,Yarmouthport Notes.. No water encountered STEP I Measure depth to water table 11/24/03 14' to nearest 1/10 It. ...............................................................................Date inonth/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: - lJA Appropriate index well................. miw29 QWater-level range zone............................... ..................... STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to 10/03 9.0 water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level zone (STEP 28) determine water-level adjustment .................. ..............................................�............... . 2.2 STEP 5 Estimate depth to high water by subtracting the water- level adjustment(STEP 4) from measured depth to water 11.8 levelat site(STEP 1) ............................................................................................................. 71 TOWN OF BARNSTABLE y `iiGIrT 1Z9 Mi'SlI,U LI/ SEWAGE # ?a sfkar�iot�, Val, AGE �!r—lIle ASSESSOR'S MAP & LOTM-197 ?-If) INSTALLER'S NAME&PHONE NO.CRSA 5 1r SEPTIC TANK CAPACITY 1000 QAL S ,AlC -501 ,LEACHING FACILITY: (type) A keACA/W R�S (size) NO.OF BEDROOMS Jr- BUILDER OR OWNER gtC/1A,ed ?)ew PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility > Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �As�r T.eycta4 Tve <Tmo& . C's� I ACIG 'aC R�= IPA 1'0 'BE= d3 AF=,2I ' e BF= 23' o ID- 0 T,,anr nF RARNSTABLE 1 = TOWN OF BAR NSTABLE LOCATZON VILLAGE �� SEWAGE ME AS SSOR'S MAP � ) LOT INSTALLER'S NA _�� PHONE NO.� ` SEPTIC TANK CAPACITY o d 0 2 LEAC RING FACILITY:(type) r e NO, OF BE (size) PRIVATE WELL OR PUBLIC BUILDER W OR OWNER ` ATE DATE PERMIT ISSUED: S'I � DATE COMPLIANCE ISSUED.:- VARIANCE GRANTED: Yes _ FEs.....1.0........ No.._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphration for Diopoiiul Worko Tomitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( 1"'an Individual Sewage Disposal System at: Locat' t Address or Lot No. .............•......_._ -• -•---'----•-----•- ----------------.......... --------- --•••------'-^----•------------.....................___...................__. O • y Address W --- --- -----------"I-----1-------1-1-- Installer Address PQ d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........s5�---------------------.-----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------------- W Design Flow............................................gallons per person per day. Total daily flow.......-------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width--------------.- Diameter-----........... Depth................ Disposal Trench—No- -------------------- Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area-------_..........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by----------------------------------- ...................................... Date....................................... Test Pit No. I................minutes per inch Depth of Test Pit.-.----______----_ Depth to ground water_..--.-----.--_---__---- (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ •---••-•--••----•-------•----••-•-----...-•--------•------------•---.....-•••--------------------•--......................................................... 0 Description of Soil..................................................................................... -----------------------------------------------•-------••-------•---••---------_.. x U ....••-••••••••-•-•----•••••••••••-••••-----••--•-•-•-•••-••---•---•-••--•-----•••----••••-•-•....--•-••--•---•--------••••-•••-•-•---•--•----•--•-----•----••••••-••--•••......-••---•---••......-•-- W -------------------------- ---------------------------------------------------------------------------- --------------------------------------------�__ 1 UNature of Repairs or Alterations—Answer when applicable.---.--_-�--,T- r> -__-.-.�-____- --_.-s ................... ......................... •••--•-•---•---•---•-----••••••••--••••-•••••-•---••••••••-•---------••----••••--•••••---------•-----------•------•-••--.....••••••--•-•••••••••--•••......................•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be Is, by the board ol.health. Signed ....... c -. .—..gcf.5. Due Application.Approved B J - Application Disapproved for the following rearonr: _--------------_ ..............._....._-----------_------ ........ ........... ... -._...-------------------- ----------..............-------------------------------------------------------_._... ---------------------------------------- Permit No. .... - ..C�---- ------ -- Issued -------------- D�f— ............... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH p TOWN OF BARNSTABLE Ropmat Workv Tongtrurfian "antic Permission is hereby granted.�._�P�, , �,,.,�., ..�/ �i✓! -------- .............................................................. to Construct ( ) or Repair (.� an Individual Sewage Disposal System atNo........................ ......L-,,< ............... --... ......................................... Street C� � / C Dated as shown on the application for Disposal Works Construction Permit _'�`�--..�.�....... - � ----- - - ------- Board of Health DATE........................ = ? ...........-----•-----------•------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certif rate of Comyliance THIS IS TO CERTIFY, That�the Individual Sewage Disposal System constructed ( ) or Repaired ( -'" by ���.. c. -.ct/.-.. 3r --- --------------- -------------------....__------- ---------------------------------------------------- -- ---.. � -�w�ith�the o : e. 1/S - - ----------------------------------------------- at -- has been installed in accordance p q ITI.E 5 of The State Environmental Code as describbred in the application for Disposal Works Construction Permit No. -...._...._ .------'5--��5; dated _.-...-/..^--1-S. -... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... .... ----- 7�------f`��-�- --------.. Inspector �.- -- �.. 3 No.3- 7.�+� � Fia......��..U... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphration for Di-tipnottl Works Ttimitrnr#inn lirrudi Application is hereby made for a Permit to Construct ( ) or Repair ( ')-'an Individual Sewage Disposal System at: •ocat' i :\ddress V or Lot No. /Jl Q....................................... ----. ---------•--•--•-----••--•---•---•---•-•-•----............------•............ •._ .. O wrier --------------------------........................................................................ Address ......................a", -—--------------- Installer Address UType of Building Size Lot............................Sq. feet .� Dwelling— No. of Bedrooms-------- --_-_-_---____-_____-_-_Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons-------_-------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------------------------------_-------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length________________ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.........._.........sq. ft. Seepage Pit No_____________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by----------------------------------•---------------------•---------------- Date........................................ a Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ r3 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 1:4 -------------------------------------------------------------------------................................................................................... 9 Description of Soil.................................................................................................................................................. ..................... W V --------------•-•-••----•••-----------•-•----•----------------------•--------------------....-•-----------•-----•---------•-•--•--•-----•----•.........--------•-•-••---•----•--•------•---•-•---....... --------------- ------------------------------------------------------------------------------------------------------------------------------------------------- ....._..... U Nature of Repairs or Alterations—Answer when applicable_____..;t���.�---------- --------- . �.......... .5......................... ----------------------------•----•••-----•-••--.•-•-------...-------------------•-----•---•------------•----.........------------•----.....---------••--•....---------------------------•--••-••-------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beerf-issued by the board of health. _ 1` Signed -------------------------- --------- Dace Application Approved By ----------t -^~`J- D 'e, ....... .....: .=ca---1- . I Dare Application Disapproved for the following reasons: ---------------------------------------------------------------------------------------------------------------------------------------- ... . .............................. .................... .............. .............................. ... .... ............................ ---------------------------------------- Date Permit No. ....... .f..... ..-...>r�~.Q�.CJ................ Issued ' - Dace y F� TOWN OF BARNSTABLE LOCATION / n SEWAGE VILLAGE ASS SSOR'S MAP & LOT��'�j —/03 INSTALLERS NAME & PHONE NO. V SEPTIC TA14K CAPACITY /(� L-EACHING FACILITY:(type) / (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERS DATE PERMIT ISSUED: �, l DATE COMPLIANCE ISSUED: �"' VARIANCE GRANTED: Yes No /� J r � , (b tic k OF -t4OASE- �i pn .-..n .:-�.�n.--+-ri.:-.,...+'..--.^-rf.-._..�.;+w4�.,++-..,-....w. -.^.-r--...:...w--;sin`«.r.,rw,-'„-�".'r'nw.-...r'•."'e.,'..,-.�...,- ,...-. TOWN OF BARNSTABLE BAR-W 5997 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager A 7 , " 't rUt... Address of Offender 11T C1 �.yv��a✓�- � MV/MB Reg.# Village/State/Zip a ".4 Business Name AA am/,pm, on 20_ Business Address` �N;0 L r - Signature-of Enforcing Officer Village/State/Zip Location of Offense A PA 'D $/00 T.;-.Cd WOU ° F 1C>5v,*-f Aot""CEnforcing Dept/Division Offense 3 5 3 - At Facts �� CP'�- Th}s will serve only as a warning. At this time no legal action has been'taken. It' is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE BAR—W 599 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager �' I� ti„� z " � Address of Offender ` - �"t' � MV/MB Reg.# Village/State/Zip ! i f Business Name V am/pm, ,on 20_ r ..+,n./J,.,.✓*•r fie` t Business Address Signature of Enforcing Officer Village/State/Zip Location of Offense _ � f ,,A '� `�' 4 • 14.;Z 155,7—r -4 _ M1KA1_ ''-0 `*'- - Enforcing Dept/Division _ -Offense ,. r�. � --Facts, � ,� V Cy,,... � - � '�• �' ,•��' � � • `� � ' C.,.- This will serve only as a warning. At this time no legal action has beentaken. !`4pi is the goal of Town agencies to achieve voluntary compliance of Town *- Or c dinances, Rules and Regulations. Education efforts and warning 'notices 'are - . `'attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. - Y w WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. 0 Citizen Web Request Page 1 of 3 P X. & _ A �f s s e7,a r t "9 t fiat `rk�J, I T 0V „coCtCIC'.t Citizen Request Management Route ,, t. Request Information _._.._.__.....__.._.._..--------.._...........---- -- ---_----__-- Request ID: 32101 Created: 9/24/2010 8:48:30 AM _ _ ..............._ ....- Status: Assigned To Staff Assigned To: O'Connell,Timothy Health Office Anonymous: Yes Request Category: Section 353-1 Garbage and Rubbish Routine work: No Estimate: No _.._._....... .Date.scheduled: -- ........... Estimated 10/8/2010 Change Estimated Sep October 2010- Nov Completion Completion Date: Date: Sun Mon Tue Wed Thu. Fri Sat 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 i 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 .1 2 3 4 5 6 Created By: Crocker, Sharon Priority: — Medium _ Health Office _..............................- Citation Numbers: Requestor Information --.................__.................-_._...-..-.-......................._. Requestor Request DETAILS: LOCATION: 119 EMERSON WAY Centerville, Ma 02632 Request Parcel Number Ma Ii56 Repeat Violation (see two in Aug Map 11w89 �' Block: R3. Lot. 12010) Caller said the household trash is piling up. The homeowner is just Parcel_Lookup I piling it on top of open garbage barrel and 10 crows are picking 1 through it. Another caller complained http://issgl2/intemalwrs/WReque8t.aspx?ID=32101 9/27/2010 wN Citizen Web Request Page 2 of 3 of the household trash piling up on curb all through the week, it starts piling up as soon as the trash is picked up. Crows are into it also. Caller also stated that there are many people in &out of this property, not sure if the owners live there. Caller — -- __..........._....._____.._....._____..._____....__._.........................___._.. said this has been going on all summer.This call came in on 9/23. Email: Edit.._Re..q..u_estar._Info_r..mation Track Request Progress Request Work History: Internal Note History: Entered on 9/24/2010 8:48:30 AM f. by Crocker, Sharon System entry on 9/24/2010 8:48:30 AM Assigned to O'Connell, Timothy Enter work progress: Enter internal note: (Viewed y everybody) (Viewed internally only) r I I ( E S I E Y• A, ( Spell Gheck SpeIl�Check Add document or image link: I Browse You care also type in a folder name to see eve,tI'ir r the, i i er http://issgl2/intemalwrs/WRequest.aspx?ID=32101 9/27/2010 `v r: Citizen Web Request Page 3 of 3 Current Links: ........... _ _._................_.................... ....---..._ ........ ......-........................................ ......-....-.._...-- --- ..... -- _.-..__.._. ........ Time worked on request 10 Response time Time entries are in hours. E anip=es of time entries: l_25; M, 0,75, 1, 3.5, 025, 0,10 Response time. Measured from the creation date to your first actions on the request, o not include nights, weekends, and holidays in response time for most departments, Save changes Check to notify town employee below g to review this request. Save changes and notify Health office citizen* . Crocker, SharoC Close n requestBrief message to reviewer: C Close request and not ify tify citizen* - r 'r ;ti y works if e'nnail address was given Update � Spell Check ? Public Use.: Printer.Friendly.Vers o.n Internal Use Printer Friendly_Version http://issgl2/intemalwrs/WRequest.aspx?ID=32101 9/27/2010 Health Master Detail Page 1 of 1 N ( ,ayc.ed I.-. As, 10ViNvc- onne- Health Master Detail M rtda,,,Sorel,�r Application Center Parcel oo-- __,,p Sciection Itenols / Parcel Septic Perc Weil i Fuel Tank Parcel: 189-103 Location: 119 EMERSON WAY, CENTERVILLE Owner: FULLER, A ASTASIA ZI OV Business name: Business phone Rental property: Deed restricted: Number of bedrooms Os Contaminant released: F* Fuel storage tank permit: vmn- ;Save I?arcel'Ghariges i Return toLookup Parcel Irafo Parcel ID: 189-103 Developer lot:i...OT 47 Location: 119 EMERSON WAY Primary frontage: 100 Secondary road: 7. Secondary frontage: Village:CENTERVILLE Fire district:C O MM Sewer acct: Road index:0502" Asbuilt Septic Scan: 1-39103_1. Interactive map Town zone of contribution:AP (Aquifer Protection Overlay District", State zone of contribution:C3i1T Owner Infra Owner: FULLER, ANAS[ASIA ?INOV Co-Owner: Streetl: 119 EMERSON WAY Street2: City:CENTERVILLE State: MA Zip: 02632 County Deed date: 1/23/2008 Deed reference:C185072 Lana Info Acres: 0.23 Use: Singles Fang MD1--01 Zoning:RD-1 Neighborhood: 01 Topography:!_,vel Road:Pa;ed Utilities: Public Water,Gas,Septic Location: ..0 nstruction Info B.,iilti:€€� `�:Ye��>€a_i lc7r ,.r., j', �a : c-a.. � �� '_�.�='OOHS 1 1972 3709 1324 15 Bedroomsl3 Full Buildings value: 143,600,00 Extra features 2J, 00 tic Land value: • 51,30(i.00 ' http://issgl/Intranet/healthMaster/HealthMasterDetail.aspx?ID=l 89103 9/27/2010 f �,,vlth Master Detail Page 1 of 1 F c<{;€gad I,, AS: IOWN`:cconne; �����i s � �' V��L�I� (Mond cpte€ Application Center Marcel .00l<up Se lectiol? Items Parcel Septic Perc T Well � tse €�6� Parcel: 189-103 Location: 119 EMERSON WAY, CENTERVILLE Owner: FULLER,ANASTASIA ZINOVf Business name: Business phone Rental property: ' Deed restricted: F Number of bedrooms 0 Contaminant released: > Fuel storage tank permit: T- Save Parcel Changes ReturnA E 5kt p , Parcel Info Parcel ID: 189-103 Developer lot:LOT 47 Location: 119 EMERSON WAY Primary frontage: 100 Secondary road: Secondary frontage: Village:CENTERVILLE Fire district:&0 MM Sewer acct: Road index:0502 Asbuilt Septic Scan: 189103_1 Interactive map Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info Owner: FULLER, ANAS(ASIA 2INOV Co-Owner: Streetl: 119 EMERSON WAY Street2: City:CEN T ERVILLE State:MA Zip: 02632 Countr Deed date: 1/23/2008 Deed reference:C1850/2 Land Info Acres: 0.23 Use: Single Fam MD'_-01 Zoning: RD-1 Neighborhood: 01. Topography:Level Road: Paved Utilities:Public Water,Gas,Septic Location: Ccsrstru ti - _ . t on In o B::i, n^ 3Y-:;';'u'# : r, r: or, 1 1972 3709 1324 5 Bedroom 3 Full Buildings value:$143,600.00 Extra features: $20,200.00 Land value: 5"151,300.00 a � 3 _ _ ,I)TT1__i on n7 - nNl'7 Vln1 n i .V THE Certified Mail#7008 3230 0002 5177 9572 � rqk, s Town of Barnstable BAPNSTABM MAS&1639. Regulatory Services ♦� Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 27, 2010 Anastasia Zinov Fuller 119 Emerson Way Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE CODE The property owned by you located at 119 Emerson Way, Centerville was inspected on September 27, 2010 by Town of Barnstable Health Inspector Timothy B O'Connell, R.S., because of a complaint. The following violation of the Town of Barnstable Board Code was observed: § 353-1 Responsibilities of Owners and Occupants: Garbage and rubbish not stored in proper receptacles. (Weather proof and rodent proof. i.e. plastic garbage can with a lid.) Trash strewn about property due to improper storage of garbage. You are directed to remove the garbage and rubbish from this property and dispose of it properly or place it within proper receptacles within 7 days of your receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Failure to comply with an order will result in a fine of$100.00. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Tho s McKean, CHO, RS Director of Public Health Town of Barnstable QAOrder letters\Re fuse\119 emerson way centerville.doc j i I 04 f a E Dz 6 � T 13 (� ;D f o � P o r , ......... . �w 1 1 6 --- , 3 f i r $ 1 i t is 1 1 l L i aT t : i ' ��� ='&SOR r MAP NO. PARCEL 165 . 10 CA�T� ` N ` ' ` SEWAGE PERMIT No. VILLAGE N 5�A—t—I—E—R'S NAME SS S UILDE R OR OWNER D SUE D DATE COMPLIANCE ISSUED z 0 d✓n. QL ,y � -� �' �� ��, � � 0 � .� .. N � � � . �� . . �� • :. y ASBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE r' `(U 1 P✓ ASSESSOR'S MAP& LOTL� NAME&PHONE NO. SEPTIC TANK CAPACITY L1:ACHING 1' U"TY: (ty ) (size) rt - NO.OF BEDROOMS BUILDE OR WNER 5 n DATE.DA OF COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility i Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility,(If any wetlands exist Within 300 feet of leaching facility) Furnished by 0 i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=189103&seq=1 1/21/2011