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HomeMy WebLinkAbout0070 ENSIGN ROAD - Health 70 Ensign Road Centerville 8 crl Na?�1b�OR UPC In" ,r ewwad.mn 9 Me&In USA LZ -G�( Commonwealth of Massachusetts W Title 5 Official Inspection Form ID Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 70 Ensign Road Property Address Matthew& Caroline Lee Owner Owner's Name information is n required for every Centerville ✓ Ma 02632 4-7-17 6 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation kCompany Name 374 Route 130 Company Address Sandwich Ma 02563 Citylrown State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-7-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 70 Ensign Road Property Address Matthew& Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. City/Town 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is Centerville Ma 02632 4-7-17 required for every page. Cityrrown 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 Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. City(Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Ensign Road Property Address Matthew& Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 340gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 70 Ensign Road M Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2015-88,000gallons 2016- 102,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. Citylrown 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: Owner- last pumped 3 weeks ago 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New SAS added to existing tank in 2011 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 4 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1'4" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallons Sludge depth: 0 11 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 70 Ensign Road M Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle NS Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle - Date of last pumping. Date t5ins-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 ° 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.).- Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form =, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. Cityfrown 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 0 11 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 was in working condition at time of inspection. No sign of back up or carry over was present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * 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: 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 ,M 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallons ❑ 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.): Leaching was in working order at time of inspection. Chambers were dry with no high staining. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 70 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately FRONT GARAGE DRIVIEWAY rna �...........�..«. . ... Al-247 81-271 A -30' B •2146,E t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Ensign Road ,M g Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 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: No GW 144" 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: 6-12-11 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 M 0 Ensign Road Property Address Matthew&Caroline Lee Owner Owner's Name information is required for every Centerville Ma 02632 4-7-17 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f ' Commonwealth of Massachusetts u Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessment °M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21 2014 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information Ion the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David Mason r� Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 p Telephone Number License Number B. Certification --� G� M�n ca E : I certify that I have personally inspected the sewage disposal system at this address and thatjhe information reported below is true, accurate and complete as of the time of the l'rspection. 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::45.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ? ❑ Needs Further Evaluation by the Local Approving Authority- June 23, 2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the 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. t5ins-3/13 Title 5 Official Inspectio jorm ,,&b.urfa.Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 21, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The observations noted on this report represent the condition of the system on June 21, 2014 only and does not guarantee the future operation of the system. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of . Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-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 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 21, 2014 page. City/Town 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•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 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21 2014 required for 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21 2014 required for 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. El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ '❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21 2014 required for every page. City(rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gpd))� Detail: 2012; 74,000 gallons and 2013; 69,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21 2014 required for 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: Board of Health 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 21, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: June 15, 2011 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments(on condition of joints, venting, evidence of leakage, etc.): Observable components appear adequate. Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Typical Sludge depth: 3" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21, 2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 42" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Scour 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.): effluent level with outlet invert. Observable components appear adequate. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 21, 2014 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 ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21 2014 required for 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 Level with 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.): No evidence of solids carryover. Effluent level with outlet inverts. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 c Commonwealth of Massachusetts Title 5' Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21. 2014 required for every , page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): No indication of hydraulic failure observed at time of inspection. No damp soil Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville MA 02632 June 21 2014 required for every , page. Cityrrown 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 t5ins•3113 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 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 21, 2014 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: 15' 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: 5/2011 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: Town groundwater contour map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 °M 70 Ensign Road Property Address Joe Maddalena Owner Owner's Name information is Centerville . MA 02632 June 21 2014 required for every , page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION e,--r!Or` SEWAGE# VILLAGE C. ASSESSOR'S MAP&PARCEL/ INSTALLER'S NAME&PHONE NO. �11Oj e!e�8oe�+'i -J`Efyic �aoicd SEPTIC TANK CAPACITY LEACHING FACILrfY:(type)T•C�rcy (sj2e) NO.OF BEDROOMS 3 OWNER -1-Me-f�9.9 e'�,r>A LerrA PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). /moo '4 feet FURNISHED BY Jim LerpoE�F I. —46 /vlr- ' �-�9 sa8 s I i http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar--147056&seq=1 6/27/2014 No. 6 t O �r Fee V 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipprication for aigogal 4ipgtem Co`n51ruction Permit r Application for a Permit to Construct( ) Repair(/-I,,Upgrade( ) Abandon( ) ❑ Complete System 2 J Individual Components Location Address or Lot No.^70 Owner's Name,Address,and Tel.No. �� /•✓E�T Assessor's Map/Parcels fj7 e'fi ,s r-P7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. s'S'�o0i�.t oeep h'y• OAvio .99r --W, vAaI— �-�' s—oe 79 jr— 07 0) a;L/177 Type of Building: Dwelling No. of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building 4E'1'�' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 y0 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �X sJ�/y f0 0 0 Type of S.A.S.7���"�/y / 3,N 3 S_,rA Description of Soil cl�is/&, 7�/ 3 3 o a Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this B rd of Health. Signed Date Application Approved by �r S Date V '�, Application Disapproved by: Date for the following reasons Permit No. a 0 Date Issued '' All No. �ZG i f — y Fee / THE COMMONWEALTH OF MA Entered in computer: V SSACHUSETTS Yes PUBLIC HEALTH DIVISION�TOWN OF BARN,STAB;LE, MASSACHUSETTS Application for �Dfgpo cY pgterrt Con-traction Permit Application for a Permit to Construct( ) Repair(G(Upgrade( ) Abandon( ) ❑ Complete System U Individual Components Location Address or Lot No. 'f0 DNS/6y, �� Owner's Name,Address,and Tel.No. X/ 1'T G er.v�- J'o+e�'ijjilO�.f l c�ivi{ c �- Assessor's Map/Parcel/Sj) Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S'rQoOic t �o h'�' Ora vVo .er J1° Jr Type ofZOilding: i Dwelling No.of Bedrooms Lot Size r" sq. ft. Garbage Grinder ( ) Other Type of Building f No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 o gpd Design flow provided 3 yd gpd Plan Date 6— Number of sheets % Revision Date Title Size of Septic Tank c�"X f T�n 6 /o 0 o Type of S.A.S.T���"�y 3w� r Jf A Description of Soil 0. Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this B rd of Health. Signed Date Application Approved by lr ,Zl % Date Application Disapproved by: Date r for the following reasons Permit No. a©(, 1,3 Ll Date Issued — ( f i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandcnned( )by at �iL,f'/G,i1/ C-ep has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Sil"07 �G�s�O 6 f/f� Designer lam/ d/.1J $ /0,1,4J"0'"' #bedrooms 3 Approved design flowy 0 gpd The issuance of this permit shall not b construed as a guarantee that the system wid function des+i' n•d) �t Date U/ f y�� �! Inspector / ^ r No.Y��i t{ ' � -• - -_ ---r• -- -- -- --.--r-P- - . r.-- --- r---.- Fee -! l�C..+; — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wi5po5a[ *pgtem Construction 'Permit Permission is hereby granted to Construct ( ) Repair (1A ) Upgrade ( ) Abandon ( ) System located at .� 0 Cr/1/ J'/G /y' /P O 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 this permit. Date t!J / �I Approved by ! ' \ 1"Y1 Town of Barnstable b RegwatGry Services t Thomas F.Geiler,Mector Public Hebb Division nomias McXean,Director 200 Main Street,Hyamis,IOTA 02601 Offioe:.509-962-4644• =Fax: 509-790-6304 Installer&Dalt ner Certffic.A2Y, Farm Date: Des�gpex: d�« � r Tnsta}ler:+��� �� •�:(�� Address: . Addresson, icocou"Ir :' was issued a,pezxz-,zt to install a (date) (insflei} septic system at o 97A4l� ,,Y, based on a design drawn by Y I� f X1 4— 0M dated (designer) ' ! ;,certify that the septic system referenced Above was installed sub sfantYOIl acca d gn, which may include minor cam raved-changes such as � $ � �clslizbutaon bdx and/or septic tank.. i, ocatian oi'the ,� I certi What the septic system xefemced, abbve was in `wit3x' changes.'a"a greater 40 Q lateral reloizWbzs"of the SAS or-any vent-,j A6f tea' 'of asaY t of the.sepi��d" tom)but iRi accordance with State��oealAeg�ons. Phan revisit cex ifi.ed asVu*. `by discs �6 follow. �' r M 4lMgs `y ON ° (7aastaller°s 3xgnature) •. � ,,,$' � � 5y ' �r s Sig�.ature} � •�• �['�.gip J�ere� , A`J1<N A l:f J4?AkLe_. `. r• C IMAL ,LAN .,+,pW��yy L/N. J.173. A 1J • v a D k�3� �.U..1T:AJE E: 1� "l : :B �' LIE P Q.llftyi�,Sepdcmesi er Certi ce iop,Frj= ' �Y�: ,jY` y TOWN OF BARNSTABLE LOCATION ,� �� `r'� �'r SEWAGE# VILAGE G ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. "� �E8oecaJ'c°"�7i� `r`~Q�ic6 SEPTIC TANK CAPACITY LEACHING FACILITY:(type)-Zire'`c-'el (size) 3 A-a.s"�v a NO.OF BEDROOMS 3 OWNER �'ocr 1���Did.9 LE•vA PERMIT DATE: �_ir—�l COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility '"Fe 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). '4 feet FURNISHED BY � � � y 9 �� � J - � � E��r1��� IB o o Est C ,�°�k �,_ 3 8 y i �� ,� ., ��:? ,r joy E �q o2s�orb � � �� � 9 � / . t . � y Town of Barnstable P# 3 d Department of Regulatory Services aeaarar BLZ Public Health Division Date /ZL �Q j 200 Main Street,Hyannis MA 02601 Date Scheduled //. Time/ Fee Pd.� Soil Suitability V abillitt y Assessment for Sewage Disposal Performed By:�° i" 1 ("'i Witnessed By: LOCATION&GENERAL INFORMATION Location Address ---k%u F t/.�i,( yam- l �. Owner's Name I-`IT(\1G�CJ►"lVIt-�,C- Address Assessor'sMap/Parcel: Iy 1 .056 Engineer's Name { `,I NEW CONSTRUCTION _�-�7R.EPJAIR'v!� Telephone# A�>) �/� 11C1 Land Use �1 f t N 1 `/l/ Slopes(%) '4 y Surface Stones /yl. Distances from: Open Water Body>l.10 o It Possible Wet Area>100 It Drinking Water Well/O-fl Drainage Way >1 40V ft Property Line >/40 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) LU __J V1, C� nt I ref A 1 Parent material(geologic L � �5� Depth to Bedrock Depth to Groundwater: S ding Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date 41,ja Time Observation Hole# Time at 9" N i :t tl Depth of Perc �Qt� p Time at 6" Start Pre-soak Time�J �(DoO Time(9"-6") End Pre-soak Rate MinAnch L V� Site Suitability Assessment: Site Passed_ Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\S EPTI C\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Cher Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. '' =� Consistency,°,o Gravel U -� & l.oa�H � C y 4-0 C M 2• 1/ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel .91t-3a `' LVM4►tiSah I "fig � �•►, G 2 5 Z 3 DEEP OBSERVATION HOLE LOG Hole# IV Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel w DEEP OBSER ION HOLE LOG Hole# —1 � DDepth from Soil Horizon Soil ure Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ZZ Imo— Consistency,%Gravel Flood Insurance Rate Map: Above 500 year Flood boundary No_ Yes Within 500 year boundary No / Yes Within 100 year flood boundary No A Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u gnat rial exist in all areas observed throughout the area proposed for the soil absorption system? � If not,what is the depth of naturally occurring pervious material? Certification I certify that on U (date)I have passed the soil evaluator examination approved by the Departing nviromnental Protection and that the above analysis was performed by me consistent with the required tra expertise a ex erie�lc, d cribed in 310 CMR 15.017. Signatu Date t0 r f Q:\SEPTIC\P ERCFOR,M.DOC COMMONWEALTH OF MASSACHUSETTS �Z231 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED PARCEL ®5 �" AUG U 9 2004 LOT . " -.-- TOWN OF BARNSTABLE TITLES HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 70 Ensign Road Centerville Owner's Name: 7 a nn i d A nh i c./W i l k i n G(dec) Owner's Address: Date of Inspection: CZ yy s Name of Inspector:(please print) W i 1 1 i am > _ •Robinson Sr. �� . o, Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 c:, Centerville, MA co --� Telephone Number: (5081 775-8776 w cam. r- CERTIFICATION STATEMENT co m 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: L/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: /sL . , ✓� Date: —off --0 Z'/ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of 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 I Page 2 of 11 a OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 70 Ensign Road Centerville Owner. John Zannidachis Date of Inspectlons Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy tem Passes: I have not found an information which indicates that an of the failure criteria Y y na described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Sy m Conditionally Passes: One or more t •� .� system components as described in the Conditional Pass. section need to be replaced or repaired.Th system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,ti or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. The septi tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,cxhibi substantial infiltration or exftltration or tank failure is imminent_System will pass inspection if the existing tank is r laced with a complying septic tank as approved by the Board of Health. •A metal septic will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that th tank is less than 20 years old is available. ND explain: Observatio of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pipes) r 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 r quired pumping more than 4 times a year due to broken or obsmTted pipe(s).The system will pass inspection if(w approval of the Board of Health): broken pipe(s)are replaced obstruction is n =,vcd ND explain: ' Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 70 Ensign Road Centerville Owner: John Z nn'd chi Date of Inspection: . C. Fu her Evaluation is Required by the Board of Health: C nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing protect public health,safety or the environment. 1. Sy em will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the Sys m 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. S tern will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 rface 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 frodl a private water supply well** Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 70 Ensign Road Centerville Owner: John Zannidachis Dale of Inspection: ! D. S)�(ern Failure Criteria applicable to all systems: You mkist indicate')-res".or"no"to each of the following for all inspections: Yes o _ 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'/,day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped y portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface 'ater supply. y portion of.a cesspool or.privy is within a Zone 1 of a.public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 f ct from a private water upply well with no acceptable water quality analysis.(This system passes if the well water analysis, erformed 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 hilrogen 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.] ( eslNo)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. L ge Systems: To be onsidered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• Yo ust indicate either"yes"or"no"to each of the following: (nic following criteria apply to large systems in addition to the criteria above) yes n the system is within 400 feet of a surface drinking water supply — _ e system is within 200 feet of a tributary to a surface drinking water supply th system is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped Z ne 11 of a public water supply well If you have swered"yes"to any question in Section E the syslem is considered a significant threat,or answered "yes"in Secti n D above the large system has failed.The owner or operator of arty large system considered a significant thre t under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The sys ern owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 70 Ensign Road Centerville Owner: John Zanni dachi�� Date of Inspection: Check if the following have been done.You must indicate`)es"or"no"as to each of the following: Yes Nol _ �1_// 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 T Were as built plans of the system obtained and examined?(If they were not available note as N/A) v Was the facility or dwelling inspected for signs of sewage back up? V 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 te mainnance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on:. Yes no _ ;✓Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)j 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 70 Ensign Road Centerville owner: Date of Inspection: O FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. 3 Number of bedrooms(actual):_ DESIGN now based on 310 CMR 15.203(for example: 110 gpd x 4 of bedrooms): 0 Number of current residents:•A,/A Does residence have a garbag grinder(yes or no):�v Is laundry on a separate sewage system(yes or no):,LU [if yes separate inspection required) Laundry system inspected(yes or no): v Seasonal use:(yes or no):4V Water meter readings,if a ilable(last 2 years usage(gpd)): 2003 — 73 , 0 00 Sump pump(yes or no):._&c) 2002 — 42, 000 Last date of occupancy: COMMERCIA NDUSTRIAL Type of establis ent: Design flow(b ed on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap pr sent(yes or no):_ Industrial w i a holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water mete readings,if available: Last date o occupancy/use: OTHER describe): GENERAL INFORMATION Pumping Records Source of information: ,lam1A Was system pumped as part of the inspection(yes or no): 4i dd If yes,volume pumped:__gallons-=How was quantity pumped determined? Reason for pumping: TYre FSYSTEM ic 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: Were sewage odors detected when arriving at the site(yes or no):/1,6 6 Y Page 7 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE DISPOSA L SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Ensign Road Centerville Owner: John .anni rear-h' s Date of Inspection:, z BUILDING S VER(locate on site plan) Depth below ade: Materials of onstruction:_cast iron 40 PVC _other(explain): Distance fro private water supply well or suction line: Comments on condition of joints,venting,evidence of leakage,etc.): SEPTICW TANK:_(locate on site plan) Depth below grade: '7-0'' Material of construction:�L/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) r il Dimensions:_ � & L �, g <. Sludge depth: L/.e. " Distance from top of sludge to bottom of outlet Ice or baffle: ,2• i�i 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:IQ•'_ How were dimensions determined: ILL.1. Ly R s Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 2C' is. it /Yr n GREASE T P:_(locate on site plan) Depth below grade:_ Material of nstruction:_concrete metal fiberglass_polyethylene_other (explain): _ Dimensions Scum thic ess: Distance fr m top of scum to top of outlet tee or baffle: Distance fr m bottom of scum to bottom of outlet tee or baffle: Date of la pumping: Comment (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related o outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) IiProper ty Address: 70 Ensign Ro ad Centerville Owner: John Zannidachi,s Date of Inspection: TIGHT or HOLDING T K: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constructi concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity. allons Design Flow: allons/day Alarm present es or no). Alarm level: Alarm in working order(yes or no): Date of last p mping: Comments ondition of alarm and float switches,etc.): DISTRIBUTION �/BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): )� PUMP CHANIBE . (locate on site plan) Pumps in workin order(yes or no): Alarms in worki g order(yes or no): Comments(not condition of pump chamber,condition of pumps and appurtenances,etc.): 8 i Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Ensign. Road Centerville Owner. John Zannidachis Date of Inspection: dp� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required) If SAS not located explain why: Type 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.): _ CESSPO S: (cesspool must be pumped as part of inspection)(locate on site plan) Number an configuration: Depth—top f liquid to inlet invert: Depth of sol ds layer. Depth of scu layer: Dimensions f cesspool: Materials of onstruction: Indication of oundwater inflow(yes or no): Comments(n to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials o construction: Dimension Depth of s lids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Ensign. Road Centerville Owner: 7nhn Rannidachi Date of Inspection: �� t' . 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. 1 9 D 0 ply 10 i .Page'l i of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Ensign Road Centerville Owner. John Zannidachi Date.of Inspection: '7- SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Cricked with local excavators,installers-(attach documentation) ccessed USGS database-explain: You must describe how you established the high ground water elevation: G o 02 0-0 11 1 LOCATION �EWACE PERMIT NO. Est° I - - VIL=LACE INSTALL R' NAME ADDRESS , S UILDE R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED / �� P r Y/ tom. S T �8 K L, p S%���� ^^ 66-9 No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... W/.. ..... .......OR.........j J, ........ _/.,f � -E.................. ApplirFation for Biipnoal Works Tomi rurtion ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System 94 14 at: �� . .................................................... ......................... S�' . Addre_sso ion � � 2 X5� o rA resso. .v a 1k/ 4, � .... ....... . ........ ...... // Owner a ......................... --------- Q ......--- ...- .....---------------------- .............. Installer Address U Type of Building Size Lot......I_qt.0®O-...Sq. feet Dwelling—No. of Bedrooms___._________________________________Expansion Attic (��� Garbage Grinder '4 Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures -•-•••--•-•-•-- ---•--------... . W Design Flow.................S.-S................gallons per person per day. Total daily flow.............1.3__0...................gallons. WSeptic Tank—Liquid ca.pacity.iflJ v allons 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 (X� Dosing tank ( ) Percolation Test Results Performed by.............•-•••----•-...-••---••.....----------•----------•--•-•--•---- Date...............................--....... Test Pit No. 1..f'03.minutes per inch Depth of Test.Pit_________ _ ____ Depth to ground water---A.I._Ulrt A- (i, Test Pit No. 2-.&,� inutes per inch Depth of Test Pit........ _ Depth to ground O ----. 0 1---------------------••------ -------------------------------------------- Description of Soil............................. --...�............L 4..e1'I =�' �.�0( x W ---------------------------------------------------------------�_._ "tom------------�'�- ------- --------•--•----•----•---------------------------------=---- VNature of Repairs or Alterations—Answer when applicable............................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTTLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board of h1 Signed................... ........-••--�.... _.�...... . ---•- -•--- + � Application Approved By- 1Y_e...... ..... .• J ------------- Date Application Disapproved for the following reasons:-----------•----------•--------•------------------------------•-------------•--•--- ............................ ............................................................................................................-----•----•-------•-•-------•-----------...••••---••-•••---....---=----•----••---•--••------- Due PermitNo......................................................... Issued....................................................... Date 3 o. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF /HEJA�L-TH ( Aptiration for Eliopo,ial Workii Tonitrnrtion 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at LA-, .. ....... .............. ..�-.....1_----`•---•---•-`--_ --........... .............................................- .......................... Location-Address or Lgt.No. !r -e� fl J- :.. fd ��!f✓j r� (/11 f -e- s i-1 Owner D t s r �� � ss �r W ..........:.............::. ._. .._.......,,..J....._...-----�••r._........... ..........---------............................_..................---._..........._........_..._. Installer Address U Type of Building Size Lot----- �_ t_C ....Sq. feet Dwelling—No. of Bedrooms--------_____...............................Expansion Attic Garbage Grinder */j)� aOther—Type kof Building ____________________________ No. of persons__________..........._, _._ Showers ( ) — Cafeteria ( ) Q' Other"fixtures --------------------•-------.... ;;..... WDesign Flow..__._``____.__. _r___�..................gallons per person per day. Total daily flow______ _ '__?"a___._.._______._____gallons. W Gi Septic Tank—Liquid capacity �U_U0gallons Length................ Width.__...__._.__._ Diameter................ Depth................ x Disposal Trench—No_____________________ idth.................... Total Length.................... Total`leaching area...................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet___....________._._. Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank Percolation Test Restjlts,�''S S Performed by..............................................................I ----•••--•- Date........................................ a Test Pit No. 1_______________minutes per inch Depth of Test Pit._.______ram_..___ Depth to ground water.. /_ _ t!: .. 44 Test Pit No. 2'/Ilminutes per inch Depth of Test Pit........ ���'__ Depth to ground water... �+ ---------------------------------------- ..................................................--•--------•---•----......-•-•-•-•-------.....__. O Description of Soil................•---------- �.. ......-17 f✓S t�- x ............ ...t r.�-------...-- ------j; xj -----------------------•-----------•-------...--••-----------•-- W U: Nature of Repairs or Alterations—Answer when applicable......_......................................................................................... --------••-------------------------••-----••------------•--•-----------••--••--•---•--------•----••----......-•----------------------•-----------------•--------------------------------•---•-..._-•---- '.Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITY-E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue�d`,by the board of health: Signed C_, r� '1'f/Z----•--•r ✓......�q�,.ry Date Application Approved By..............'�"- � J__ ._... // Application Disapproved for the following reasons:............................................................................................................... -----....-•---------•------•-•--------------------------------------•--------•---•---------•-•--------------•-•--•-----..------•----•-•-•---•---------------•••--•-------...-••--•---_---•-------------- Date PermitNo......................................................... Issued....._._......------•••---....._....................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Vf. f .............0 F.......... .., .�,! /.r /_ ............ Tertifirate of &-impliFanrt THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (1- or Repaired ( ) by........................................... ,! a' ------._._ ' ...................... ----•------ -- - -- ----- - --- Installer has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... _____________ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. J+ ?. DATE.........................Z..V�,g.�_-:.............................. Inspector...$C=AL4-�/. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, OF.......................... FEE.......... ........ Diopos al Workii Tonotrurtion rranif Permission is hereby granted........................... .?� -------•---- "•�?Ir ef-•-��---L� ........................................ to Construct (J)or Repair ( ) an Individual Sewage Disposal .System at No ,r •_------•----•--._._.i:'. Y___.......a._..... _ `� `3 .----• ° -• "fit- -'�' , -�5.. --.•--•--r ....---••-- Stree - as shown on the application for Disposal Works Construction Permit No_________________ __ Dated.......................................... ---------------------------------------------- DATE.................................. ��oard of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS r� l ALL tjATUA G�Ga1A/M TO RcMAlt-1 P L T rr h r f > U -S7Uap,eo .I.QD'; f=20M. ET t r ) u k a n (�ivEl' UNLESS A tir0i1CC[ of i#�TE*lT i5 ex "' u Flt�� PEK rile SrA( wL"rc.ANDS' AST.. N Wlg,� g u .I" 1 I_e t f 1 4 �0 p(a'ACN•��T Wll'` a s,z#� • ;a x to t �(�i�(} .� �� .,x ^+1 ,1-�+./, 12� (O!•� �9. r� a, ;?" ". _� ;1l1 ( ��rA 1� - �5�:/ysr,§� ''t��x*�v�j•.1c�x��4.t ��?�' 4a 3'�, :7 At:ewN1z--� TgM.� 9 `�e(1 D]a' S +a71, fO�Ft �'Ar�1T T"� 6 LGXPAN.f: �A! p '.#fit zw r ;� , U r R a 0 A 'I l 5,OQO s.F. u \Ntun—! ica OF h1 I F20WT S, ASS`' S 10 ERT. ti ALB Gar xu A: x a x A P ' z , x t xw9 .9 s tik } v OF S SIONA� LEGEND ERTtFIED PLOT PLAN. EXISTING SPOT ELEVATION '04 EXISTING CONTOUR ---- 0 .�.�_ x oA ® FINISHED SPOT ELEVATION FINISHED CONTOUR APPROVED BOARD OF HEAL T _ � $ su ASSO DATES/0 AGENT' � �4 DATE { � F{ ~w y At't,y'S k � 't5 LDREDGE ENGINEERING CQ IN CLi .NTH :M d C THAT THE PROPOSEDY ERTIFY _ EGISTERE REGISTERED JQ�1 .Nth. +DI' ' -3 8Ut O:IN4 :'SHOWN ON THIS PLAN CIVIL LAND " 3. rt ,� mO0NFORMS TO THE ZONING LAWS ENGINEER SURVEY DR. Y Q ' xSARNSTA E, ASS. r rfi .., ,w. z 712 MAIN ST. ,` ,` ` GATE G.HYANNIS, MASS LAND SURVEYOR, r 20 FT M/N /VOTE �. /F E/TA'— TN,E.SEPT/G TANk OR LEACs/twG Plr ARE /YORE TNA/V I2"BELOW /O P7! MJN GR•+40er�� 24'O//I M ETER C'O�yC'RaFT - COi/ER SNALL ®F 9-V0V6Al7- TO 6J;AOE.(�AN EXTRA coNCRl.'TB 4+PYC OJPE ' xiE.4YY CA ST/RO/Y C01/ER Sh+.4I-Z--!3E US ED' MJN. P/TCN ' �,• ,E4 IOI��. COVERS /8"PFiQJ=T. /F/N .ORIVEJr1tAY � 2 nliN. CONCRL°'TE c3�•�aE CODER CLEAN :SA/VO Q: 4.w L/!Qu/O LEVEL--*_ = 4 - 2 LAYER :di MlN:o/TCJ/ G.�L.3 S u T� °• s • �: • •s s sP or �,• WASHhW SIZING SEPTIC TANK D/ T.. s °v , . `;. • o ;,� ,BOX 'O. f I. � A . �I ►° �� ° ��� r �.� -� .y w,n s w.ti ;.M•aA > `t A 4r.-� 0 •,.•'.°LF��E.pC�T/%VC. o °s • •` 3V4 a1 �� 1 i ?t `� O • °..' GYIIs • • Os.O WA5NEA s r a :' �...: -•' "• '"ti '„,, Z. �O • '!`. � 1,1 ..,� _�•.�{: •` :.:, ". `';: �' •. --.-:^ :.... -, - s,r.: -$' :7".` v' i 2 ,wt �3 .S; '0: '��. �� :rM'`� �y.r�e?i� ? as�•,._;,'�is2 _+� .. - ..�,, 'W s r'fw- a-s. �.. .ca, +#*�.,r a � � �y r, .� ,1':6 '•:•'� � '° • •1�.I -O .0 ` S..x • a z;' s f v° • a " a o d D P�EC�45T.SE.E.oAGL r • _ n':w n x. h < ° a -• s •'�.�L; 46 i s:i. _e: O P/ yzj T DR.9lJ/V 1AWR'/' PLEVAT/®XS :t.' ,•sr�t INVERT AT:O[//LD/NG _ FTC d Ff8'x Z�S" 5�'l ..r"' ," ,.. . ' � -}a` <-f;, _. .%D �; D/AM. '�• .'y��'_. D(�,SSFETABULA,:TION�` r / LET. SEPTIC,T�/VJC 48`$' Flr ?8'x w t� / ry .'.x.: n ,6µ a ... Q, - :?a,'s f x r' " ,�_' "':.- •t..; ..pa.4. s{ $.(� ,. G/ARCfT O1lTL7`SEPTIC TANK Fr. Y �.'Yr A�� t,a.fit. ...a�,'i.8� �t�r j .vs �s+"-, �J��r .TE' Ti'+06E�c n'z:'1 #+,W 3: k ""'� :;;r!.�.z, p 4 v oaf �� a / T /43!/T/ON 0 IT f. G �✓/13L�7r D S R B X �-� � :: �a .SECT/O/1l` 4F st >_ A w;:; .�• �* �"�� , �, OV LETD/STRlB/l7'/ON BQ,Y `fig 'L 'FT, w,`, x t, 1 b x x s';"' r` ..,,4 a- t ;:` E ,�„.r' .. .{` F .y� pfzw .,"' yi ''.' `ia�' ?" �,, 7 'y '•4 S4 T ag a SEWAGE G/SPASA'L .Sr 7'EJ'�'J /NCET LEACN/NG PJT FT. r sry scALE ��" s /•-v" ► D/MENSJOJV DES/GN CR/TER/A � o/NFnrsroN g � Ft., NUMBER OF BEDROOMS s- 3 4 D/MENS/ON C q FT. rN. ,AReAGE DiSPO.SAL!/N/r b SOIL. LOG ; SOIL 7- 3T TOTAL EST/M.4TEv J=LOry 3 3 0 SAL.IDAY SOIL TEST A/ SOIL WS17 40Z NUMBER 011w 40ACMI V4 P/rST f^EcE✓. /y!,d I—RtarY, DATE OR SOIL. TEST S/OB L,EACHlN6 PER PIT /��S41 PT. 2r RFSlJLTS h/ITNESSED BY i OOTTOM L64C//!NG PER P/T $Q: A'T. PERCOtAT/ON RATCs�11E/ - MJ�/�IINCN TOTAL 4LZ4CHINCr AREA 4-(0 SQ, FT. � )REleCO3LA77/ON RATE 02 RESERt�E GEAC'//!NG AREAS SQ. FT. .. �ZN OF 2i I I- 4' 1N OF/y �,P �y'. L b s / T � 9� z ��:, MED i. ALB T y JOHN � f�;�V l �Ll �•`�-�1' o BERT ► 4 n MORSE v, N 7 CA No.10951 0 al-DREDGE ENG/NEEIP/NG CO,JNC. eL:�,O 712 lHAtN.ST. 6 �NO SUR��y HYANN/3 MASS. �t�SIONAI��f� �] 'NO GROUND YYATL°R ENCOU/VTL�REO G1 GM0U/VD YVATER AT 6Z-HV. JOB /VD, d Z3 SHEET Z-OF Z- ASSESSORS MAP : /y NOTES:_ 7-_.- _.__. _:_� TEST HOLE L 0 G S C` PARCEL : # �� FLOOD ZONE ,{,lp� � � SO I L EVALUATOR : l L Z 1) The installation shall comply with Title V and Town of Barnstable Board of WITNESS,: CL���-/ cL�� 1. REFERENCE: Health Regulations. L- DATE:� (b /b 2._. - --- ----.---_-- � _......_ 2) The installer shall verify the location of utilities, sewer inverts and septic PERCOLAT I ON RATE: -G / , t components prior to installation and setting base elevations. ti � �-p 01, 62 ' ! lo� gravity p piping " � � 3) All ravit septicto be 4 inch Sch 40 PVC at 1/8 per foot. The first TH- 1 TH-2 two feet out of the d-box to the leaching shall be level. vpw'f4) This plan is not to be utilized for property line determination nor any other, Q„ VRw— / -5 purpose other than the proposed system installation. Lo t0_ �� (� p 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H10 septic components. t 7) The property is bounded by property corners and property lines. LOCATION MAP �i� gip ' Gt 8 The property owner shall review design considerations to approve of total i'L(� Z,� a 10 �� ) P p Y g pP 40 design flow and number of bedrooms to be considered for design. Receipt Iq � � of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. V 2� 1�3 7,• ��� 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall _ r+ `a�' '1�n`- � (►J :� g� '1 1 _.q0_��wl�..(�? _ +�l' be removed.along with contaminated soil and replaced with clean sand per • �'7[_��� / �"�1 � � � Title V specs. ____ft __�65� 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service SEPT I C SYSTEM DES I G N line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW ESTIMATE owner to ensure such. 12)The installer is to take caution in excavation around the gas line if such IBEDROOMS AT I GAL/DAY/BEDROOM -��GAL/DAY exists. 13)The installer shall verify the location, quantity and elevation of the sewer 4 TANK � ✓ lines exiting the dwelling prior to the installation.PTIC14)The installer is to determine if other sewer lines exiting the structure exist I GAL/DAY x 2 DAYS - GAL and if so,to be re-plumbed or tied into the septic tank. ----' USE ' 9y GALLON SEPTIC TANKC��jl�1�1 SOIL ABSORPTION SYSTEM -. O 4A16D SIDE AREA: �x Z- �� I�v �C Z X 4, Lief ;wsttf,.i u;� BOTTOM AREA: dJ iti {r�t I Ft SEPTIC SYSTEM SECTION NNt � 41 ID . . �' G f N I GAL y� 1 0 0 SEPTIC TAN _ t �oUyL� S I TE AND SEWAGE PLAN LOCAT11 ON : MR 1 PREPARED FOR l �' 0 W TT AA J (-2 CALE• I DAV I D B . MASON Raj DATE: I� z DBC ENVIRONMEN 'AL DESIGNS J w EAST SANDWICH . ' MA Z DATE HEALTH AGENT ( 508 ) 833- 2 177