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HomeMy WebLinkAbout1645 FALMOUTH ROAD/RTE 28 - Health 1 b45 Falmouth Road Centerville A=209 086 I� 9MEAD No. H163OR UPC 10259 smead.com • Made In USA t __mac 0?0 _o8&- 901. Commonwealth of Massachusetts p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is ✓ Ma. 02632 3-29-21 required for every Centerville 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. fmngoutf rms A. Inspector Information ;l 4r (SaS(o filling out forms on the computer, Michael Sears use only the tab key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. Company Address South Yarmouth Ma. 02664 CitylTown State Zip Code renen 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes OF 2. ❑ Conditionally Passes ``��` '' ' .qV �.' MICHAEL 3. ❑ Needs Further Evaluation by the Local Approving Authority =o SEARS * No.SI14430 :*` 4. ❑ Fails C, .%F,5►rr NI Sp,�G`O``�� 3-29-21 Inspector's Sign at 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I cam, Commonwealth of Massachusetts :. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ...........cM 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): I 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form j .'I -Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ACM !% 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City(rown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V!% 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. J 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 t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection. Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg A u� Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `cc 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City(rown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: 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 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insP.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Office 440 8 Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 3702 Sq Ft Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: NA Last date of occupancy/use: Present Date Other(describe below): 3. Pumping Records: Source of information: August 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title,� 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: New SAS 2006 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5.. Building Sewer(locate on site plan): Depth below grade: 9,feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form _ I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............ u!% 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 8 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape i Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with in and out tees in place, both covers steel at grade t5ins .doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 P P 9 P Y 9 Commonwealth of Massachusetts : Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I i 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ �i; Subsurface Sewage Disposal System Form Not for Voluntary Assessments u 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. 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.): j 2 D Boxes, 1st Box 1line out steel cover at grade, 2nd Box 2 lines out steel cover at grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts u�. Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form li; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. .V 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2- 500 gal dry wells with 4' stone wells are clean and wet with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts �- a Title 5 Official Inspection Form ��I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y Y 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): I i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 f Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form Not for Voluntary Assessments V!% 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 11' 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: 7-2-09 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: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form - I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments is 1645 Falmouth Rd. Bldg A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 I t A Iry— Page 1 of 2 r f Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size am zoom Out tin "'8 RR Kb WN { ) �3 y S S 6.41 `4 "4 Sy ,-�r 5#A�'w,���w�S�A 1,��5�'•{I5Y'i'��i�k'�Gi� .. t�� sr�t7' � 2r �~ F "x 20 Feet t ;r� Set Scale 1" = 20 Aerial Photos MAP DISCLAIMER c Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w !% 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information SI qr IS as�' on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. LCompany Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 SI 14430 Telephone Number _ License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes `pZN OF, ��i 2. El Conditionally Passes ;ya`�j A OF M'gs'Z/4'••s9 �•, ��. MICHAEL''yN 3. ❑ Needs Further Evaluation by the Local Approving Authority =o: SEARS *: No.SI14430 CIO= 4. ❑ Fails o o % 1� ,5ruiN 3-29-21 Inspector's Signatur 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 rbroken r❑ y q p p g a year due to o 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments V 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: 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 NA g ( Y 9 (gpd))- Detail Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form 15 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 330 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Sq Ft Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: NA Last date of occupancy/use: Present Date Other(describe below): 3. Pumping Records: Source of information: August 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed if known and source of information: New SAS 2009 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000_gal Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with 2 inlet tees and outlet tee in place, both covers steel at grade l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: r Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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): I Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): D Box is clean with steel cover at grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. !% 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 , Commonwealth of Massachusetts �n Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 4- 500 gal dry wells with 4' stone wells are clean and wet with no sign of failure I 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface,Sewage Disposal System Form - Not for Voluntary Assessments . v � 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form 11 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I Commonwealth of Massachusetts p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check I ec cellar ® Shallow wells Estimated depth to high ground water: 11 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: 7-2-09 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: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �- _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 1645 Falmouth Rd. Bldg B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 't5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 " r� ti Lot 1 73,043f S.F. 7.58t AC. E. Map 209 Al Parcel 86 Ben chm ark set \ Magnetic nail set EL.=101.45 (Assumed) _ c �1. v P ----- -r- r--u "'� �, TOF=101.88 Bldg. A I (Crawl) #1545 -- 81dg. .��R» " Lyge -a.v✓%) "-�.. rKln CV 000 lb p Lc ved Grlve a r PROPOSED O SEPTIC TANK 6" METAL COVER W `, \r- ?� (UNKNOWN Ed e of �73vement �v w PROPERTY LINE VENT-MANIFOLD 1G1,12 ALL CHAMBERS CB/DH/ -N J Edge of pavemer.t 100 t GC---�J^ Paved Parking -� 9 `1-- BASTN r ao9 -06a-A-O( Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 3-29-21 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when00 filling out forms A. Inspector Information c5'l 15 aS on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. Company r� Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes \p�pO��Zt1 OF t��s��i'/4 2. ❑ Conditionally Passes �.���. "' N MICHAEL 'yN- 3. ❑ Needs Further Evaluation by the Local Approving Authority m o. SEARS *i No.SI14430 •0 4. ❑ Fails 3-29-21 Inspector's Signatur 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order ' I 2) 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): II t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 9 p Y rY ........... �!% 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. Observation of sewage backup or break out or high static water level in the distribution box due ❑ b 9 p 9 to broken or obstructedpipe(s)or due to a broken settled or uneven distribution box. System will Y 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts �- Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 O ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form li; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �` �� � 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: 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 NA 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �w ,vTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 440 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 500 Sq Ft Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: NA Last date of occupancy/use: PresentDate Other(describe below): 3. Pumping Records: Source of information: August 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.V 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square _ Owner Owner's Name — — information is required for every Centerville Ma._ 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: New SAS 2013 _ Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 8'feet Material of construction:' ❑ cast iron ®40 PVC ❑other(explain): -- - Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): - 7' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 2500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2500 gal Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 2500 gal tank with 3 inlet tees and outlet tee in place, both covers steel at grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 � t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form FiI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E U mou g Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): D Box is clean and has 4 outlet pipes with steel cover at grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 18 i Commonwealth of Massachusetts �m ,P Title 5 Official Inspection Form -1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I, 1645 Falmouth Rd. Bldg C D E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: M Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 3-29-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 4- 500 gal dry wells with 4' stone wells are clean with 6"water and no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page: City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form j rlI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 11' 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. 7-2-09Date ❑ 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: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE LOCATION ' &41m\Ak.A k'SEWAGE N Z-013 VILLAGE mfpr i ASSESSOR'S MAP&PARCEL ; INSTALLMIS NAME da PHONE NO, "Jr } SEPTIC TANK CAPACITY R00 a 22 LEACHINt3 FACILITY:(type) 4Q���(j A ,6 _ (size) NO,OF BEDROOMS OWNER PERMIT DATE: 3 13 COMPLIANCE DATE: Separation Distahec Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility &spry yy�.y Stan�f e e'ew�fr�' ,My~1 G Private Water Supply Well and Leaching Facility of any wells exist on ' site or within 200 fl:et of leaching facility) N Fect Edgo of'Wetland and Leaching Facility(If any wetlands exist within 300 foci of leaching facility) / Feet FURNISHEID DY r 14, i F.aj u ia3 Gs (iGL t r d V f �a0 Q 73 In Cd (b & ,'o6 i i Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name / information is Centerville ✓ Ma. 02632 3-29-21 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information c51 5d5� on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. VQ Company Address South Yarmouth Ma. 02664 City/Town State Zip Code r 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes `��w�����t1 OF 2. ❑ Conditionally Passes .�`4`� `MICHAEL 'yN= 3. ElNeeds Further Evaluation by the Local Approving Authority 9 SEARS ; `* No.SI14430 4. ❑ Fails , , • o .FRTIF�`� .o �nfn 3-29-21 Inspector's Sign at 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 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 form should be sent to the system owner and copies sent to " the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 i Commonwealth of Massachusetts �v Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. ` 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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. El ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: 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 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 r cam, Commonwealth of Massachusetts Title 5 Official Inspection Form 5 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 489Gauons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 6525 Sq Ft Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: NA Last date of occupancy/use: Present Date Other(describe below): 3. Pumping Records: Source of information: August 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form yl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 3-29-21 required for every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: New SAS 2009 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 30' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 20 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gal tank with inlet tee and outlet tee in place, both covers steel at grade t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u!% 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): D Box is clean and has 3 outlet pipes with steel cover at grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u!% 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑' leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts ,z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 3- 500 gal dry wells with 4' stone wells are clean with 2"water and no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration r Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts (p Title 5 Official Inspection Form - hI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 11' 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: 7-2-09 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: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 f cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 .p �a ,a Page 1 of 2 Town ®f Barnstable Geographic Information System ! Parcel Viewer Custom Map Abutters Map Size Zoom OutlIn ------------ J i 14 r J�.Sty #�Y Wig F i rn F ) 1aur5k'v+ tu, 'tt A 4t s m vn u am CID Y `4 A, ....... Sat Scale 1 i4 � 20 / Aerial Photos MAP DISCLAIMER Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 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. Inspector Information !#J5 ate 1p on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. Company f8y Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes _\N OF 2. ❑ Conditionally Passes ?�. MICHAEL..tiN 3. ❑ Needs Further Evaluation by the Local Approving Authority = SEARS No.SI14430 4. ❑ Fails i,�,�j,•.FRTIF�. G,`O``�� ,r.�•. 3-29-21 Inspector's Signa a 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ ,u!% 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ...........� !% 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owners Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u!% 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts �w 110 Title 5 Official Inspection Form yI p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r C Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in-Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 f c� Commonwealth of Massachusetts �= Title 5 Official Inspection Form aI e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: 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 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 i Commonwealth of Massachusetts �v ,p Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 3-29-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): NAGallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: NA Last date of occupancy/use: Present Date Other(describe below): 3. Pumping Records: Source of information: August 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 34 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �Ie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 3-29-21 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 24' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gal i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with inlet baffle and outlet baffle in place both covers steel at grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u!% 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Igo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): No D Box t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3-29-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �V4!% 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 3-29-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is a 1000 gal pit pit has 1'water and stain line at 24", walls are clean with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 3-29-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............c 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 3-29-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville Ma. 02632 3729-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 11' 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: 7-2-09 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: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. Bldg G Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 3-29-21 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 i Town of Barnstable Geographic Information System Passer!VetMr07 + om!�8{t Lbutters Map We Zoom OUt J 1111 111In 11 i ' E CN\ r X fs2.71 ti ;1 t '1 i pY9 ✓�n I ,J;; w_�y�•yQ, MAIN A Set scale V = 20 ! Aertal Photos MAP DISCLAIMER !`nn�.rinN 9MX_9f1/►A Tti.tn nfRen�otil�le dA6 Art rinAta r�renr h"n•t/www town harnctah(a ma ...,..----._,_ �_ .._.�_.__ . . . .,.. r � p Commonwealth of Massachusetts Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1645 Falmouth Road (Bldg A) Property Address I'? rC> Bayberry Square ~' Owner Owner's Name information is ✓ '. required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection µ't 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:out When A. General Information % J �O on the computer, `.\```p�� N OFrMgS,S use only the tab �.��`�• ""' q �, key to move your 1. Inspector: fillin out forms cursor-do not James DSears AMES =g: J use the return = - m ke Name of Inspector Y• co Capewide Enterprises 0— o ; r� Company Name � �F� 153 Commercial Street Company Address Mashpee MA 02649 City/Town State Zip Code 5008-477-8877, S1623 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 Q-al� 4-10-18 spector'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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 system is a 1000 Gal. Tank two D Box's and two 500 Gal. chambers. 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.doc•rev.6/16 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 1645 Falmouth Road (Bldg A) v Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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): ElThe 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.doc•rev.6/16 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 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 COE=is less than 6" below invert or available volume is less than %day flow rL£A Cd WC t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Iti(A Title 5 Official Inspection Form -0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owners Name information is required for every Centerville MA 02632 4-9-18 page. Citylrown 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 6 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 16,000 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 4L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /j 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 required for every page. Cityrrown 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form 110 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg A V ) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 gallon precast tank, two D Box's and two chambers. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection El Yes El No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 440 8 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 3,702 Sq. Ft. 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: NA t5ins.doc-rev.6/16 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 1645 Falmouth Road (Bldg A) �v Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New leaching installed in 2006. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 8' feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): PVC piping 4" SCH 40 and cast iron. Septic Tank(locate on site plan): 8'.6" 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: 1000 precast H-20 Sludge depth: 1" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I c Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg A) v Property Address Bayberry Square Owner Owner's Name information is Centerville MA ' 02632 4-9-18 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 29" 0" Scum thickness 8 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Tape-Plan Past Report Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping, tank at 8'-6" below grade. In and out let tee's. Both cover's steel at grade. No sign of leakage or over loading. 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.doc-rev.6/16 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 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: 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.doc•rev.6116 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 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 required for every page. City/Town 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 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.): Two D Boxes existing. D Box at 7' below grade one line out. steel cover at grade clean and solid New Box from 2006 at 9'-6" below grade two lines out. Box is clean and solid w/steel cover at grade. No sign of over loading or solid carry over. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 required for every page. City/Town 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.): Leaching is two 500 Gal. precast chamber's H-20 W/4'stone on ends. Sides and in between chambers. Chambers have 6"water no high stain line no sign of over loading or solid carry over. Chamber's are 9' below grade w/steel cover's at grade. 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 ElYes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg A) r P operty Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 required for every page. cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road (Bldg A) Property Address Bay err Square Owner Owner's Name information is MA 02632 4-9-18 Centerville page. required for every 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 15 of 17 Map Page 1 of 2 'own of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Oul:111111 111in iR KA F 4 + S t tf X � I OY l S is tS' 2 X-4�. 0 20 Fee t F. r' Set Scale 1" _-20 Aerial Photos { MAP DISCLAIMER r r,nurinht,)nnr,.,)nnR Tr umn of Qarnalahlo AAA AN rinhlc racann httn://www.town.hamstable.ma.us/arcims/anngeoann/man.asnx?nronertvTr)=2090R6A 01&... 4/29/2009 Commonwealth of Massachusetts a Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells N 11' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 7-2-09 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: T.H. BLDG B.7-2-09 11' no G.W. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 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 1645 Falmouth Road (Bldg A) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f '• r Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form Not for Voluntary Assessments � 1645 Falmouth Road, (Bldg B) r, u Property Addresstia Bayberry Square . ; Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 ,} page. City/Town State Zip Code Date of Inspection +5+ 4?; 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 f d on the computer, ���``���,jH OFfM,gsso,,�� use only the tab 1. Inspector: .�`°� 9cti% key to move your O?= • G cursor-do not ,lames D.Sears =�: JA M ES m use the return Name of Inspector S key. :Co Capewide Enterprises �'•.r o *_ Company Name '%,�'•�RTI F��.•',�0\��` 153 Commercial Street ,� '1 N SPEG\\``�O Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification 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 4-10-18 spector'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 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. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Fa Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1645 Falmouth Road, (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 system is a 1000 Gal. Tank D Box and four chamber's. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f c Commonwealth of Massachusetts Title 5 Official Inspection Form F� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I c Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg B) u Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 4121M is less than 6"below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1645 Falmouth Road, (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road, (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 galon tank D Box and four chamber's. Number of current residents: 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 330Gallons per day(gpa) Basis of design flow(seats/persons/sq.ft., etc.): Sq.Ft. 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: NA t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road (Bldg B) `J Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? El 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 1645 Falmouth Road, (Bldg B) u Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing 4" PVC SCH 40. Septic Tank(locate on site plan): 2' 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: 1000 Gal. Precast H-20 Sludge depth: 1" t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road, (Bldg B) u Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town 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 29" 1" Scum thickness 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Tape-PLan Past Report Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping. Tank at 2' below grade w/steel covers at grade. Two inlet tee's,outlet tee. No sign of leakage or over loading. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I c Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: 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.doc-rev..6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form (ia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road, (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town 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 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 is new 2009. Box is clean and solid w/steel cover at grade. No sign of over loading or solid carry over. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts x - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road, (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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 is four 500 Gal. H-20 chamber's w/3' stone. Steel cover's at grade. Chamber's are 3' below grade leaching is wet on bottom on high stain line. No sign of over loading or solid carry over. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road, (Bldg B), Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road, (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Lot I 73,04J± S.F. 1.68f AC. EXIST1 TO BE Map 209 AND Fi Parcel 86 Ben chm ark Set Magnetic nail set EL.=101.45 (Assumed) 9 f i - (Crawl)Og "a ve d of N ► °`f 0'-� Parkin g N TP-2 000 01,63 ~O O O O (� �gOPOSE 40' 16. Paved---D ive It r PROPOSED METAL COVER ti SEPTIC TANK 1 (UNKNOWN WEd e or' W oovemen! W ' ) W PROPERTY LINE VENT—MANIFOLD 10 1,1 ---, ALL CHAMBERS CB/DH/F ND �O�b O Edge of povemert 100 Paved oo— Park in g'1 y------ + 9g�98,71 �99 BASI!�i c Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road, (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells N� 11+ Estimated depth to igh ground water: feet ground water elevation: Please indicate all methods used to determine the high i 9 ® Obtained from system design plans on record If checked, date of design plan reviewed. 7-2-09 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: T.H. on Design plan 7-2-09 BLDG B 11' no G.K. Before filing this Inspection Report, please see Report Completeness Checklist on next,page. t5ins.doc•rev.6/16 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 1645 Falmouth Road, (Bldg B) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form MP Ala Subsurface Sewage Disposal System Form - Not for Voluntary Assessments —U 1645 Falmouth Road . Bldg. C.D.E.) ,u v~ Property Address '' Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 r required for every ' page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms Sl:#—1.2 &--)L on the computer, ���� �H 0FtMgSso,,�� use only the tab 1. Inspector: .����' NO key to move your -per:' cursor-do not ��: JAMES N use the return James D.Sears =�. :m ke Name of Inspector :Co y py Na Enterprises . o� Company Name �i � 153 Commercial Street °���i,,,st�tN S?'- Company Address ,B Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 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 4-10-18 spector'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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 2500 Gal. Tank D Box and 4 Chamber's. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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.doc•rev.6/16 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 1645 Falmouth Road . (Bldg. C.D.E.) emu- Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityfrown 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 JEEM is less than 6" below invert or available volume is less than 'h day flow Z E,4 C111#6 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form F+� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square _ Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping.more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts �9 Title 5 Official Inspection Form pia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: 2500 Gallon septic tank D Box and 4 Chamber's. Number of current residents: 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 440Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Approx 500 Sq. Ft. 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: NA t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town 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: NA 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form <i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 D Box and leaching 2013 Permit$2013-174. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 8' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 7' 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: 2500 Gal. H-20 Sludge depth: l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) u Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town 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 NA Scum thickness 0" Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tape Past Report Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping ,3 inlet tees. Outlet tee. Tank at working level. Tank at 7' below grade w/steel cover's at grade in black top lot. No sign of leakage or over loading. 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.doc•rev.6/16 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 1645 Falmouth Road . (Bldg. C.D.E.) V Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form l!Y/iv Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town 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 NO 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 is 8' below grade w/steel cover at grade. Box is clean and solid w/4 line's out. 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: I t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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 is four 500 Gal. Dry well chambers. Chamber's are 8'-6" below grade w/6" water. wall's are clean. Steel cover at grade. No sign of over loading. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m — e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I TOWN OF BA"STABLE LOCATION C k SEWAGE# Z013- 17`f VILLAGE e yi P. , ASSESSOR'S MAP&PARCEL INSTALLF. IS NAME&PHONE N0, SEPTIC TANK CAPACITY a f� LEACHING FACILITY:(type) 4� 40 (size) 1 X NO.OF BEDROOM'S OWNER PERMIT DATE! 3 21.7 COMPLIANCE DATE:�•�_ Separation Distance Between the; Maximum Adjusted Groundwater Table to the Bottom of Leaching Facilitypeed'fr Private Water Supply Welland Leaching Facility of any wells exist on b24 site or within 200 That of leaching facility) Edge of Wetland and LeachingFacility(If any wetlands exist within 300 fcct of leaching facility) � Feet FURNISHED 13Y 1 � b 0 . ' M \ J` 110 4 u 11 U 11 y u i r'N � In Q eb n t� en 9 'd E99L "N N61 l 5[H 11 'add Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l% 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells o Estimated depth to igh ground water: 11 + 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: 7-2-09 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: T.H. Bldg B -7-2-09 11' no G.W.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 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 1645 Falmouth Road . (Bldg. C.D.E.) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ; a i•,� 1645 Falmouth Road (Bldg-G) tJ k.W` Property Address Bayberry Square Owner Owner's Name informati for every on is required Centerville MA 02632 4-9-18 ^' ;•: page. City/Town State Zip Code Date of Inspection yid, 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 Informationy3 �� filling out forms Up++++++uuru�/Z� on the computer, use only the tab 1. Inspector: key to move your O; G cursor-do not James D.Sears =z; JAMES .: use the return Name of Inspector key. Capewide Enterprises Company Name 5'�i, TT I IF r� 153 Commercial Street I N SPEG���`O�` Company Address reAan Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ca��� ' 4-10-18 I ector'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 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. l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 system is a 1000 Gal. Tank and pit 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): i t5ins.doc•rev.6116 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 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ 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: i ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 l c Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 N ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in Ell=is less than 6" below invert or available volume is less than day flow P, r t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis, [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form l�i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? _ ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) V Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank and pit. Number of current residents: 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR NA 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA 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.doc-rev.6/16 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 1645 Falmouth Road (Bldg-G) `J Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, OR, 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.cloc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 34" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 2' 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 Gal. Precast Sludge depth: 1" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town 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 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-TapeSludge Judge 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 at working level. Tank at 2' below grade w/cover's at grade. In and outlet baffles. No sign of leakage or over loading. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form .F' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: 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.doc•rev.6/16 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 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 required for every page. City/Town 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 No Box Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ Noy 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form <F' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 5' precast pit w/steel cover at grade. 8"water in pit w/stain line at 20". No sign of over loading or solid carry over. No high stain line. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) u Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form <N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg-G) `J Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-9-18 required for every page. CityTTown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Apr 0518, 10:01a Capewide Enterprises 508-477-4977 p.3 'ylaF Page 1 of 2 Town of Barnstable Geographic Information System em Pumas! Vi"W Custom M8p Ou"r6 flop Seta ■ . zoom Ou4 11111111tn 1 0 1L vy \ J t 74 � J t tyllr ti' N r � � e low iy .. I SWIG V m 20 t ' Aertal Photos � Mai DISC LAIiNER 1. � � rM,.rinN�NIR.�JI7YA Town of Q.n�otil.te taa art.:w.r,,,..�,,,, ti �11�T1'i/W�.LWtf1W't1 (1A11'1CfAF1IP TY10 tlolo�niw�n/n........,,..._.-;�_�_ ......_.n_.__ •.� ��___ _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road (Bldg- Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to high ground water: 11 + 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: 7-2-09 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: T.H. BLDG B. 7-2-09 11' no G.W.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins.doc•rev.6116 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 1645 Falmouth Road (Bldg-G) Property Address Bayberry Sic uare Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IIZI 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square G Owner Owner's Name F: information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection f,• 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 5� �a9lo� filling out forms `0pttttuuip11/ use only he tab on the r �` �(H OF/ygsSq key to move your 1. Inspector: �� • cy% cursor-do not gam:' JAMES N James D. Sears use the return Name of Inspector 6• key. p s v: SEARS Capewide Enterprises =*' . � 0 • Company Name �� �%..ty T I Ir A�j 153 Commercial Street °'oi,F 5 ►N SPEG`\`°� Company Address �B« Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 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 4-10-18 spector'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 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 I the same or different conditions of use. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i - Commonwealth of Massachusetts a Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and three chamber's. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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.doc•rev.6/16 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 1645 Falmouth Road. . (Bldg F) V Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 is less than 6" below invert or available volume is less than '/z day flow k E14e 1A1( t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts It Title 5 Official Inspection Form 5 Subsurface Sewage'Disposal System Form - Not for Voluntary Assessments o 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 gallon precast tank D Box and three chamber's. Number of current residents: 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 489 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 6525 Sq. ft.. 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: NA t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form M Ie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Piping is cast iron and PVC, cast iron into tank. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-20 Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 1645 Falmouth Road. . (Bldg F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town 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 Note:Outlet cover under black top. Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping, Tank at 18" below grade w/inlet cover steel at grade. Inlet Tee. No sign of leakage or over loading. Note: Outlet cover paved over. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 110 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form '- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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: 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.doc•rev.6/16 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 t 1645 Falmouth Road. . (Bldg F) u Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 o 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 at 2' below grade w/steel cover at grade, Three lines out. Box is clean and solid,no sign of over loading or solid carry over. 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: i t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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 is new 2006. Three 500 Gal. H-20 chamber's w/4' stone, side ends 2' stone between chambers 4"water. No high stain line. No sign of over loading or solid carry over. 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.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form 15 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Map ��•� � Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Mai Abutters Map Size Zoom OU41111111MIn rR ICU fr 01 + ter; OM NI* >•� z - r t O> z� �~ �'� �.L^ � ,:� i+ � .�.. ___...-.--•.^�..^-+� Ali s �•. Set SCO4e 1" = 20 j Aerial Photos �Q � MAP DISCLAIMER (`nnvrir+hl 9f1f1R_OMA Tmu"of namatohin MQ GII ri,#.rncono }it}'Y1•I�VIRIl!{R71'11t71/Y1 il'-iYt1 C�"A I'1IP YT1`,S' IIC/AY(`.imq/nnnai-nn 1flhn5iT A env?nrr►HPrht TT7-'J nQnQ C%A of R, A11011nn0 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells C 11 + Estimated depth to igh ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 7-2-09 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: T.H. BLDG B. 7-2-09 11' no G.W.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form ! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Road. . (Bldg F) Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-9-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file . 15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B ' Property Address Bayberry Square 6= Owner Owner's Name =' information is required for every Centerville MA 02632 4=20-15 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 ng out forms A. General Information on l the computer, I Sr \.``v�` �� .OF IMgsSq use only the tab 1. Inspector: � �O�S\ �yG key to move your = DAMES N cursor-do not James D.Sears use the return SF IRS Name of Inspector key. Capewide Enterprises,LLC R�}f ._ ' r� Company Name p� �F 5 I N Sa P�C'��``��` 153 Commercial Street Company Address Mashpee MA 02649 Cityrrown State Zip Code 508477-8877 S1623 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. 1 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 4-25-15 e3iispector'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 fut a und,r the same or different conditions of use. �, VU t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Citylrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. tank D Box and four chamber's. 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): [Sins•3113 Title 5 Official Inspection Form:Subsurface spedi Sewage Disposal System•Page 2 of 17 I r Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 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 upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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 emeopmal is less than 6" below invert or available volume is less than %day flow &4('//ilv G t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r< 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owners Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 Olfiaal 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 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owners Name information is Centerville MA 02632 4-20-15 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): I t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 gallon precast tank D box and four 500 gallon chambers. Number of current residents: 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 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: presentDate Commercial/lndustrial Flow Conditions: Type of Establishment: office Design flow(based on 310 CMR 15.203): 330 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): sq. ft.. 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: NA 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 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owners Name information is required for every Centerville MA 02632 4-20-15 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: 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 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: 2009 Were sewage odors detected when arriving at the site? ❑ Yes Z No BuildingSewer locate on site plan): ( P ) Depth below grade: 2'feet Material of construction: cast iron El cast ®40 PVC El other ex lain ( P ) Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Piping 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 2'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 Gal. Precast Tank. Sludge depth: 1" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sew Disposal S age sposa System-Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Citylrown 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 29" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Tape-Plan Past Report Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping, tank at 2'below grade w/steel cover at grade,Two inlet tee's outlet tee. No sign of leakage or over loading. 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-3113 Title 5 Official Inspec Uan Forth: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 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 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: 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•3113 Title 5 official Inspection Form-.Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments x� 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 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 No 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 is new 2009. Box is clean and solid w/steel cover at grade. No sign of over loading or solid carry over. 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owners Name information is Centerville MA 02632 4-20-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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 is four 500 Gal.1-12O chambers w/3'stone, steel covers at grade chambers are Tbelow grade. Leaching has 2"water, no high stain lines. No sign of over loading or solid carry over. 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 Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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.): 15ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 1 Y a I Lot I 1.6 AC I-EX1S77W TO BE z Map 20-9 A ND FILL, - - Parcel 86 � 8 Benchmark. Set ! Magnetic' nail �set 4 EL -101.45 (Assumed) - - .- Y5 { ' e)/F� �� � 1X -�- •e'er � t 9,:�' 5 � OF- Bldg. 'JA" ' :�;� # r - � `� fY •'�/' . ri"`l are or -- ? / / CPQ.v ,-i,- i, Lt[if 0 JA i` jj'�\ ell 0 0 0 =; f 3 t ..y�'f f L `'"'"�ms� T.�5+. ^�'.,'^X fit • �� '� n'"� � �� 0 k t� y� PROPOSED Q ' wM _ C v > i ve t - /6'ftA4 COS 4 � G. AN NQj e ,. �, oa �navernenc W W ALL CHAMBERS CD/DW/FND Gfltje of pGYa.-?'3C'-?� crkin g � + 9 ' �- BASIN - . - r Commonwealth of Massachusetts Title' 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 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: 11+ 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: 7-2-09 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: T.H. on Design Plan 7-2-09 BLDG B no G W. at 11'. Bottom of Chambers at 5'+above T.H. depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 16 of 17 V Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. B Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-20-15 required for every page. CityrFown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. F Property Address - .3�Tn Bayberry Square Owner Owner's Name 'l information is required for every Centerville MA 02632 4-20-1 W_ page. City/Town State Zip Code Date of Irisp'ection .J ff 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 �C� � \\\�►Ittulllnrl////�� on the computer, L J In 95 ������\�,�H CF!Hgs use only the tab 1. Inspector: key to move your p a o? SG cursor-do not JAMES James D.Sears = m=_ use the return Name of Inspector ;r„= �U: key. Capewide Enterprises,LLC o o. Q Company Name �%,�j!,e� TTP`. . 153 Commercial Street i'F S 1 N SPEG````��� /HIIII II I II I�t1\ Company Address r� k. Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-25-15 nspector'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 conditiorisofuse at that time.This inspection does not address how the system will perform in the 6uture,u er 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 . page. Cityfrown 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 system is a 1500 Gal. tank D Box and three chambers. 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-3113 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 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ 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 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4-20-15 page. Citylrown 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 esespeol is less than 6" below invert or available volume is less than %day flow /-£,4e1)1,vC 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 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w yt 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1500 gallon precast tank D box and three 500 gallon chamber;s Number of current residents: 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 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: office Design flow(based on 310 CMR 15.203): 489canons per day(gpo) Basis of design flow(seats/persons/sq.ft., etc.): 6525 sq. ft.. 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: NA t5ins•3/13 Title 6 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 , 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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-3f13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owners Name information is required for every Centerville MA 02632 4-20-15 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: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Piping is cast iron and PVC, cast iron into tank. Septic Tank locate on site plan): P ( P ) 18" 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 1500 Gal. Precast Per Past Dimensions: Report. Sludge depth: 2" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Note:Outlet cover under black top. Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tape plan past report. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping, tank at 18"below grade w/inlet cover steel at grade,inlet tee. No sign of leakage or over loading. 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 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Citylrown State Zip Code Date of Inspection D. System Information (coot.) 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-3113 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 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town 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 No 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 at 2' below grade w/steel cover at grade. Three lines out. Box is clean and solid, no sign of over loading or solid carry over. 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•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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 is new 2006, three 500 Gal. H-20 Chambers w/4'stone,side-ends 2'stone between chambers 2"water. No high stain lines. No sign of over loading or solid carry over. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown 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 w ' 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityfrown 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-3/13 We 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 TO BE ABANDONED--� EXISTING LEACHING PI m To c BE PUMPED ANE)FILLED WITH CLEAN &iD -� f x44A r X44 .3 3 LID EYJSTING CATCH BASIN TV t EXISTING LEACHING Pri-To BE PUMPSO"AND FILLS f TH CLEAN SAND zoo- PPXPOS A' H-20 LEACHING CHAMBERS vy G 1 MXQ 209 PROPOSED "D-80)c „ { PARCEL 85 EXIST. I+#F t:I 9I't ORING �rT P 1 WELL P.) j� TO ' E �� 46X4 j t CONTRACT-OR TO CUT , } - RESET"MW TO SURFACE EXIST— PARK PRCPQSEC+ 4 " . VENT-- / L s, z[ t tt f t } �o S o l d 314-L ON-1vim v, � ; j S83-1 39.�.ON`t tYj4S 3C �3 14SINIA dC���� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells NO 11'+' Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 7-2-09 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: T.H. on Design Plan 7-2-09 BLDG B no G.W. at 11'+ Bottom of Chambers at 5+'above T.H. depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road Bldg. F Property Address Bayberry Square Owner Owners Name information is required for every Centerville MA 02632 4-20-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 f (� r " I� Commonwealth of Massachusetts ( Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, GF Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 F page. City/Town State Zip Code Date of Insd ion 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 A. General Information the out r I G /v ��ttuuinnNui onn the computer, �. `������ASH OF 44��/i/,� use only the tab 1. Inspector: key to move your cursor-do not =�. JA M ES N use the return James D. Sears =�: key. Name of Inspector apewide Enterprise LLC X o- o� Company Name ' �,,T�`--A�uVQ S` 153 Commercial Street i,,�i�,F 5 I N Spy Company Address Mashpee MA 02649 CitylTown State Zip Code 508-477-8877 S1623 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-25-15 spector'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 futur un r the same or different conditions of use. t5ins•11H0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of f� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-20-15 required for every page. Citylrown 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 system is a 1000 Gal. Tank and pit. 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•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-1 5 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 11110 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 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-16 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Wealth(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 &A- ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than %day flow R 7' t5ins•11/10 Title 5 Official Inspection Form:Subsurface pecli Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner owner's Name information is Centerville MA 02632 4-20-15 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. ❑ ® 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. €) 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-11/10 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 < 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 gallon tank and pit. Number of current residents: s- Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment: office Design flow(based on 310 CMR 15.203): na 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: NA t5ins•11110 Title 5 Offiaal Inspection Form:Subsurface Sears Disp osal posal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner owners Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, le 1 lim, ho, 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 34"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipe is 4"PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 2'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 Gal. Sludge depth: 2" t5ins•11110 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4-20-15 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 28" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-TapeSludge Judge 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 at working level. Tank at 2' below grade w/cover's at grade. In and out let baffles. No sign of leakage or over loading. 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 tsins•11110 rme 5 Official Inspection Forth:subsurface Sewage Disposal system•Pap 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-20-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑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 !Sins-11/10 Title 5 Orfidal 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 �< 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town 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 No Box 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.): I 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 5' Precast Pit w/steel cover at grade. 2"water in pit w/stain line at 20". No sign of over loading or solid carry over. No high stain line. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 l ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner owners Name information is required for every Centerville MA 02632 4-20-15 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Wl MINE,- igo. iO R o-UIMM m- M 21 E- Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owners Name information is Centerville MA 02632 4-20-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 11'+ Estimated depth tolhigh ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 7-2-09 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: T.H. on Design Plan 7-2-09 BLDG B.no G.W. at 11'. Bottom of Pit at 4+'above T.H. depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Tittle 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 1645 Falmouth Rd, BLDG, G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityfrown 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•11/10 Tifie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. ( 2. T�� 1�7/(� Fee THE COMMQNWEAkTJi OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Y Wnation for BI8tl08al *pstrm Construction VPrmit Application for a Permit to Construct( ) Repair 0<_Upgrade( ) Abandon( ) ❑Complete System � ndividual Components Location Address or Lot No. t 4,Lj5- r,*I,,. Z D Owner's Name,Address,and Tel.No. c,e_.tr'6 ems,t C. d, Assessor's Map/Parcel Zoe 8 C. Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. —p U 2-1 3 3,"1 Type of Building: Dwelling No.of Bedrooms �r Lot Size 7 sq.ft. Garbage Grinder( ) Other Type of Building Uo yta4-- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date S (L Zo 1-- Number of sheets Revision Date Title t31�L� C 7 & � Size of Septic Tank a r ]` 7 Type of S.A.S. Description of Soil n << � Lt2 Nature of Repairs or Alterations(Answer when applicable) l} _Zv ��� �''a- � ��✓S 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 Bo. d of Health. Siped Date -5'— 13 Application Approved by Date __ 1,3 2e1 J Application Disapproved by Date for the following reasons Permit No. �,37 7 Date Issued O y t''tom' I ( 'LPG 1/ J(2.. Fee t Entered in computer: THE COMMQNYE ,FL .MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN BARNSTABLE,�`MASS�ACHUSETTS Application-for Mispos t 6pstem Construction 30ermit Application for a Permit to Construct( ) Repair 04 Upgrade( ) Abandon( ) ❑Complete System v ndividual Components Location Address or Lot No. /(o yraia„ Owner's Name,Address,and Tel.No. e,e. irE2� .l Assessor's Map/Parcel Z o.11 s,G p Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. CQ•�PM/tW {(/�✓•��! fi�.�.- �- �hfjlFR ,.ht ��(� 9 2--7 3 7-1 Type of Building: / r Dwelling No.of Bedrooms rill Lot Size 7 J�O oG sq.ft. Garbage Grinder( ) Other" Type of Building Cv h a cD No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date d 0 t� 2_o 1-L- Number of sheets / Revision Date Title C -11) L', r Size of Septic Tank a ? .r -11 Type of S.A.S. _ Description of Soil Nature of Repairs or Alterations(Answer when applicable) ( Q 5�, -n L,S 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 Bo,d of Health. I � Si I Date ��" 13— 10 1_) Application Approved by W/ p Date Application Disapproved by Date for the following reasons Permit No. 2 0 17 Date Issued ----------------------------------------- TH E COMMONWEALTH OF MASSACHUSETTS S C� � F r BARNSTABLE,MASSACHUSETTS I certificate of Compliance THIS IS TO C�aERTIFY,that the On``-site Sewage Disposal system Constructed( ) Repaired� Upgraded( ) Abandoned( ) �,t at �o'l5 R o u t 2 G } .k-Z VL7 has been constructed in accordance �- ? with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 UI 7-17 Y dated Installer Cimk,,,;;IJL*- r- n �e,( Designer 5•4_ f. ., #bedrooms VV l A- Approved design flow �,yC1�9. lD gpd The issuance of this permit ts�shall' not be onstrued as a guarantee that the system wil\ ctio ds designed. _ Date Cp �/ Inspector V ------------------------------------------------------------------------------------------------------------------------//=-------------- No. 2 0 �— + 7 l' Fee Jou THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Vermit Permission is hereby granted to Construct( ) Repair() Upgrade ) Abandon( ) System located at Y+�( Ft, ,a cl (� {^t �• -P_j/Ull�'� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructioh must be completed within three years of the date of this permit.Date //' Approved by G VIA, 4;, a• FTHE Tp r Town ®f Barnstable Barnstable Board ®f Health �a� � 4-.I.BARN E.) c. , �o MASS. m 200 Main Street, Hyannis MA 02601 m �e e °,r fD=AiA� 2007 i i i Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi November 7, 2012 Mr. Michael Pimentel, E.I.T. JC Engineering, Inc. 2854 Cranberry Highway East Wareham, MA 02538 RE: 1645 Falmouth Road, Buildings C, D, & E, Centerville A = 209 — 086 Dear Mr. Pimentel, You are granted a conditional.variance on behalf of your client, Bayberry Square: Condominiums, to construct an onsite sewage disposal system at 1645 Falmouth Road, Buildings C, D, & E, Centerville. The variances granted are as follows: 310 CMR 15. 221 (7): To install the soil absorption system with 8.5 feet of coverage, a waiver of 5.5 feet from the maximum allowable coverage of three (3.0) feet. 310 CMR 15. 221 (7): To install the distribution box with 7.93 feet of coverage, a waiver of 4.93 feet from the maximum allowable coverage of three (3.0) feet. 310 CMR 15.223(1)(b): To use one septic tank, with a minimum effective liquid capacity of 100% of the design flow of 619.6 GPD, in lieu of providing a second tank in a series, as required. Section 360-38 of the Town of Barnstable Code: To use a standard on-site disposal system in lieu of the requirement to install an innovative/alternative septic system capable of nitrogen removal for a residential-condominium development with a flow of 1,650 gallons per day or greater. Q:\WPFILES\1645 Falm Rd Cent Sep2012.doc d l . e / J4 [ This variance is granted with the following conditions: (1) The septic system shall be installed in strict accordance with the engineered plans dated. September 4, 2012, revised to include the 1650 variance on the plan. (4) The applicant must receive the approval of DEP prior to the in tallation of the septic system due to the variances requested. S 1� / (5) _ The designing engineer shall supervise the construction of the onsite G� ( , c/ sewage disposal system and shall certify in writing to the Board of Health o�P that the system was installed in substantial compliance with the plans dated September 4, 2012, revised to include. the 1650 variance on the plan. This variance is granted because the proposed plan appears to meet the design standards contained within the State Environmental Code, Title. 5 and local Health Regulations. Sin rely yours, f,ry, Vll ve,1. Wayn filler, M.D. -Chair an J QAWPF115ES\1645 Falm Rd Cent Sep2012.doc r - e 6/18/2013 01 :34 5082730367 tt2222 P. 001/001 ■ r . ti• Town of Barnstable Regulatory Services Thomas F.Geiler,Director M A99. , MA89. • Public Health Division 0rr�` Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office- 508.862-4644 Fax: 508-790-6304 Sewage permit# Zp 13-1 7YAssessor's Map/Parcel C 9 S 6 D0 5 Installer&Designer Certification Form Designer: Installer: Cdeew"&_ emererese.s Address: 2954 C(•canhecry A_:kqw� Address: 1,55 116), ,,W G1 :o6-273"0377 On 13 )-L,1 C pew,de 6"kirei)6J was issued a permit to install a '(date) �! (installer) septic system at I(o51.5 F41,rv►00* (ald� c,o,e) based on a design drawn by (address) dated Sokem%w y, 2012 (designer) 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as 14teral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required) ected and the soils were found satisfactory. tx OF JOHN L. CHURCHILL (In ler's Sig ture) R. 4180 esigner s Signature (Affix De gn Here P ASE RETURN TO ARNSTABLE PUB C-REAL DIVISIO CERTIFICATE OF COMPLIANCE WILL NOT ,�E ISSUED UNTIE_BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BAR STABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice Iormsldcsisnercertification form.doc �� s� lour, aov 3M PAGE '244 in the case of each unit owner or occupant are incidental to the maintenance of such purposes and offices by that owner or occupant in one or more units such as , but not limited to, a low-traffic retail store compatible with professional use as would be allowable in a limited business zone surrounded by residential use, banking, brokerage, travel agency, limited restaurant with seating of less than twenty--five persons for breakfast and lunch type food, but no MacDonald or. other franchise type restaurant or fast food .restaurant, newsstands, barbershop, health and fitness store and/or clinic, medical office, dental office , lawyer, accountant, architect, and similar type professional offices , however, no use, including without limitation, any office use or retail use shall 'be permitted which in the opinion. of the Trustees is inconsistent with the maintenance of the general character of the condominium development as a limited retail, professional business complex of the first class , in the quality of its maintenance, use and occupancy. In addition, the use of the property shall be limited in accordance with - the following provisions : A. The units and common elements shall be used only for purposes consistent with their design. B-. Each. unit shall be used only for such purposes and to such extent as will not overload or interfere with any common element or the enjoyment thereof by the owners of other units. C. No nuisances shall be allowed on the property nor shall any use or practice be allowed which is in violation of the By-laws or Rules and .Regulations of the Association or which unreasonably interferes with or is an unreasonable 12 • L A2 aooK�i�� p g[ ;dqo the basement, ,where applicable, the interior surface of the concrete walls; as to the roof skylight, where applicable, the 1. exterior surface of the skylight. E. Chimneys : Within the boundaries of the units are part of the common areas and facilities of the condominium. 9 . MODIFICATION OF UNITS. The owner of any unit may not at any time make any change or modifications of the exterior of said unit or any interior changes that would affect or in any way modify the structural or supportive characteristics of the building or its surfaces; however, such owner may at any time and from time to time change the use and designation of any room or space' within such unit, subject always to the provisions of this Master Deed, and the provisions of the By-laws of the Association including the Rules and Regulations promulgated thereunder. as the same may be amended from time to time. Any and all work with respect to the foregoing shall be done in a good and workmanlike manner pursuant to a building permit duly issued by the Town of Barnstable, where required, and pursuant to plans and specifications which have been submitted to and approved by the Trustees or managing agent, as the case may be, of the Association. Such approval shall not be unreasonably withheld or delayed. 10 . RESTRICTIONS ON USE OF UNITS. No unit is intended or designated for occupancy for residential purposes. Each unit is hereby restricted to limited commercial use, as hereinafter defined, and/or profes- s ional use, by the unit owner (thereof) . No unit shall be used for any purpose other than the maintenance of . limited retail and professional purposes and offices therein and purposes which 11 - I AsBuitt Page 1 of 1 TOWN OF BARNSTABLE LOCATION i(45 "FgJm -(Jk.K4 f{yi ld',q tAt SEWAGE# Z.013- 1 7`f ,r VILLAGEC entenyl Ne- ASSESSOR'S MAP&PARCEL Z INSTALLER'S NAME&PHONE NO. w C, 1-J; SEPTIC TANK CAPACITY o1 5 OO G 4 I LEACHING FACIIdTY:(type) 4(5t bkta,�,►�e�_ (size) y'X 5*1.0 NO.OF BEDROOMS 8�]6 i S.P. cJ4T'c.e, SPace OWNERRc (er4�)z Sqg;c,.re. Coe,dnm;n;,i m z PERMIT DATE: f 3 Z-,7 COMPLIANCE DATE: 7 Separation Distance Between the. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility &qa Sfa A G�FeFeet Private Water Supply Well and Leaching Facility(If any wells exist on 'W site or within 200 feet of leaching facility) N/A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within J 300 feet of leaching facility) A11A Feet ! FURNISHED BY GAOC(,J! e Ehfu paj CS &e-c I d I.cMP 0 Sao ,,s n d{. � M In f `� Q Q Q �4 C� lo � tJrJ http://issgl2/intranet/propdata/prebuilt.aspx?mappat=209086AO I&seq=2 7/11/2017 4 Town of Barnstable RECEIPT NAMSAPMABLt ' 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: TB-17-1940 Date Recieved: 6/20/2017 Job Location: 1645 UNIT 2E FALMOUTH ROAD/RTE 28,CENTERVILLE Permit For: Building-Addition/Alteration-Commercial Contractor's Name: JOSHUA X KOURI State Lic. No: CS-074660 Address: CENTERVILLE, MA 02632 Applicant Phone: (508) 776-5306 (Home)Owner's Name: KASL LLC Phone: (Home)Owner's Address: 22 JACKSON DRIVE, ACTON,MA 01720 Work Description: tenant fitout for chiropractic office-Alexis Hrynko-Kouri Chiropractic. New flooring and painting Total Value Of Work To Be Performed: $2,000.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor, subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued, it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code, ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: JOSHUA X KOURI 6/20/2017 (508)776-5306 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $2,000.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $75.00 6/20/2017 $75.00 i 5233 Check Total Permit Fee Paid: $75.00 THIS IS NOT A PERMIT Commonwealth of Massachusetts Ulm Title 5 official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments- 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-30-12 page. Cityrrown State Zip Code Date of inspection Inspection results must be submitted on this form.Inspection forms may not be altered In any way.Please see completeness checklist at the end of the form. Important:When A. General Information on 4 the computer, �j \``���NO kA OF IAtigss use only the tab 1. Inspector key to move your pact cursor-do not Jams Q.Sears g�. JA M E S R, use the return - -' Name of Inspector = key- Capewide Enterprise, LLC mp Company Name I N SP�G 153 Commercial Street Company Address ram, Mashpee NIA 02649 Cityrrown State Zip code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Gasses ❑ Conditionally Passes ❑ -611S ❑ Needs Further Evaluation by the Local Approving Authority y$y$ 1 k�R 1 ♦ 0 d 4-30-12 I `' peaor's Signature Date r�9 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. csins•cvco (/ V T1Ue Lf f'onre SubsuAace Disposal Sys •Page t or 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage.Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner owner's Name information rewired for every Centerville _ . .._.. ._ . . w,.,.w.. . MqT- 02632 430=12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/ahvays complete all of Section D A) System Passes: I have not found any information which indicates that any of the faifufe criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes, ❑ one or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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-faiture-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): t5ft•11/10 Title 5 Affi W htspection Form:Subsurface Sewage Disposal System•Pap 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage[Nsposal System Form-Not for voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Name information is _ ___... .. __y r� for every Centerville MA 02632 4-30-12 page. Citylrown State Zip Code Date of tnspeation B. Certification (cost.) B) system Conditionaily Passes(cunt.): ❑ 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 [3 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 CNIR 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 t5tns•t t/f0 Tide 5 Offtctal Insped7on Form:3uDswface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface-Sewage Disposal System Form-Not for Voluntary Assessments. 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville �r _.. ._ ._.. _.. _ _ MA''._ 02632 4=30-12 . ... page, Cityfrown State Zip Code Date of Inspection B. Cerfification (cunt.) 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 _. r ❑ ® 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 Cl ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5tns•11/10 Tits 5 Official inspection Form:Subsuttaee Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville _ _. ._ _._ ___.__._ MA`- 02632` 4-30-12 page. Cityfrown state Zip Code Date of inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year MOT 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. ❑ 0. 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 flaw of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition.to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection ❑ ❑ Area-IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in 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 Department.- t51rs•11110 Tide 5 Of ft hspecdw Farm:Subsurface Sewage Disp M System-Page 5 of 17 Commomveatth of Massachusetts I f UTitle 5 Official Inspection Form Subsurface.Sewage-Disposal System Form Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Name information is W for every Centerville __ _ MA 02632 4-30-12 o page. Cityr own 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 0. ❑ Pumping information was.provided by the.owner, occupant, 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? 0. ❑ 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)1 D. System Information Residential Flow Conditions: Number of bedrooms(design); Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5fns•11/10 Title 5 Official inspection Farm Subsurface Swap Disposal System•Page 6 of IT Commonwealth of Massachusetts Title 5 Official inspection pawn Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Name information is _ . squired for every Centerville - -u _ MA _ 02632 ____ 4-30-12 _...._._..__.. ... _ .. page. City/Town Siate Zip Code Date of Inspection D. System Information Description: The system is a 1500 gallon Precast Tank D Box and-three 500 Gal H2O Chambers. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] . ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: late Commerciallbndustrial Flow Conditions.- Type of Establishment: office Design flow(based on 310 CMR'15.203): 489 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 6525 sq.ft. Grease trap present? ❑ Yes ® No Industrial waste hoiding tank present? ❑ Yes 0 No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: NA t5ats•t rlrQ Trde 5 OffidW ftv"cdcm 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: 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Name information is required for every Centerville AAA 02632 4-30A2 - page. Cityrrawn State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date — Other(describe below): General Information Pumping.Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gale How was quantity pumped determined? Reason for pumping: Type of System: Septic tank,distribution boas,sell 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 o i inspection of the UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. Other(describe): t5ins•11/10 Title 5 Offldal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Dl$pmal Sytene Fom-Plot for Voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Name information is. Centerville MA 02632 4-30=12 _ , .. .. d _..,.._. . every page. CitylTown State Zip Code Date of inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of in€ormation: 2009 Were sewage odors detected when arriving at the site? 0 Yes 0. No Building Sewer(locate on site plan): Depth below grade: Xf feet Material of construction: cast iron ED 40 PVC 0 other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Piping is cast iron and PVC,cast iron into tank Septic Tank(locate on site plan): 18" I Depth below grade: feet Material of construction: ®concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: yurs Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) Yes 0 No Dimensions: 1500 Gal Precast Per Past Report 1« Sludge depth: t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-#dot for Vokmtary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Flame information is mquired for every Centerville - .. MA `...,_ 02632-:..- 4-30-12 page. Cityrrbwn State 210 code Date of Inspection D. System Information (cons.) Septic Tank(cant.) Distance from top of sludge to bottom of outlet tee or baffle Note: Outlet cover under black top Scum thickness, 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA HOW were dimensionsdetermined? Tank pumped at inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Yearly pumping, tank at 18n below grade wrinlet cover steel at grade, inlet Tee No sign of leakage or over loading 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 Wbottom-of-outlet tee or baffle- Date of last pumping: Date t5ins•11/10 Titte 5 Official►rtspection Forth:subsurface sewage Disposal system•Page W of 17 - J Commonvvea#th of Massachusetts- Title 5 Official Inspection Form Subsurface.Sewage.Disposal System Forth-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Flame inforrnation is Centerville regt�irert for every MA """"�" 02632`.......... 4-30-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) 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: Mann 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•t tf t 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page i i of 17 Commonwealth of Massachusetts `title 5 official inspection Form Subsurface.Sewage.Disposal System Form Not for voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Name ition is e*ik dfor very Centerville r.w a.._ MIA 02632_ 4-30-12 page. CityrTown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan:): Depth of liquid level above outlet invert No 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 at 2' below grade w/steel cover at grade Three lines out Box is clean and solid, no sign of over loading or solid carryover _ . .. _. Pump Chamber(locate on site plan): Pumps in wonting order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain why: Mis•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 P Commonwealth of Massachusetts 1VTitle 5 Official inspection Form Subsutlface Sewage Mpmal System Fom-Not for Voluntary Assessments 1645 Falmouth Rd. SLDG.F Property Address Bayberry Square Owner Owner's Name information is mquirw for every Centerville _ MA '" 02632 _ 4-30-12 page, Cityf own State Zip Code. Date of inspection D. System Information (coot.) Type: ❑ leaching pits number: teaching chambers' number ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dknensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of sal,signs of hydraulic failure, level of pond ng,clamp soil,condition of vegetation, etc.): Leaching is new 2006,Three 500 Gal H-20 Chambers w14'stone, sides-ends 2'stone between chambers 4"water -No high stain'line, No sigh of over loading or solid carry over cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer I ' Dimensions of cesspool Materials-of construction- Indication of groundwater inflow ❑ Yes ❑ No . t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owners Flame information is requirned for every Centerville MA 02632 4-30-12 page. Cityrrown State Zip Cade Date of inspection D. System Information (cunt.) Comments(note condition of sail;signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): i Materials of consbuction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5irts-t tf 10 Tilt 5 Official hWection Fomr.Subsarface Sewage Disposal System•Page 14 of t7 c Commonwealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Flame inform is Centerville MA 02632 - 4-30-12' r�►ffred for every 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 t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Pap 15 of 17 . • g - qg Y i a ` ^4 yyyS...ggg'���...+���"...,,C 2.4-5�•'�'.�..� Imo.� �m7� �- zu z r �W f it I�u 'IT{,# s'It'- �.' ' inn + 1q+ ca MEMO r ���e `�.ga���3'4 .�l�1„t'''�'Crh `s. � F E'✓�^C ;,:4m'r� ; �F�'f1 .a�. .ct� ,>�,r. Commonwealth of Massachusetts Title 5 Official inspection Farm Subsurface Sewage f"sposal System Form-idol for ltoluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owner's Fume information isrequired ' W every Centerville w ..., MA""- 02632 4.30-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope . Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water. Bottom of leaching 11+4` teat Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record If checked, date of design plan reviewed: 2006 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) 0 Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used: USGS Observation Well Data USED: Technical Bulletin 02-0001 plate 92 annual ranges of groundwater.elevations Perpast.Report and-Design Plan Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5irs•11/10 Tits 5 Offidal hspec im Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official inspection Form SuWurfat: &n"ge,D%posal system Fora-Alot for voluntary Assessments- 1645 Falmouth Rd. BLDG.F Property Address Bayberry Square Owner Owners Flame information isrequired for every Centerville MA 02632 4-30-12 pne, Cityfrown 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 t5ats-11/10 Title 5 Orfidat kq7ecdon Forrrr.Subsurface Serge Disposal System•Fags 17 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface-Sewage Disposal System-Form-Not for.Voluntary Assessments- 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name Information Is required for every Centerville MA 02632 4-30-12 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 forth. Important:VVhen '0uu % forms A. General Information ftlling out forms OF A4AIS �4 on the computer, ``��...••.. ......q G use only the tab 1. inspector: key to move yourI l = JAM ES •u' cursor-do not J — ' ames D. Sears _ _0: SEARS _ use the serum key. Name of Inspector Capewide Enterprise, LLC Company Name INS? 153 Commercial Street Company Address Mashpee MA 02649 Citylrown State Zip Code 508-477-8877 S1623 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, inspection was performed based on my training and experience in the proper function an' riiaintenar of site sewage disposal systems. I am a DEP approved system inspector pumuantto Section_5.346of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ 'Fails r Needs Further Evaluation by.the Local Approving Authority ' 4-30-12 spector'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. tsins•1 vi o Tide 6 oftei eFSWmdece Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments - 1645 Falmouth Rd. BLDG.G ' Property Address Bayberry Square Owner Owner's Name information is a for every Centerville'` _ - _ ___ ____�___ MA-._-- 02632 __.__ 4-30A2w___,__ .._._....•___..._.__..-_.__..-- page, Cityrrown 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: l have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: . one or more system components as described in the"Conditional Pass"section need to be. replaced or repaired.The system; upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yeses;"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): MIS•11110 Titre 5 Offidal inspection Form:subsurface Sewage U7sposai system•Page 2 of 17 Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface.Sewage.Disposal System Form Not for Voluntary.Assessments. 1645 Falmouth Rd. BIDG.G Property Address Bayberry Square Owner Owner's Name information Is required for every Centerville ____ _._ _. _�___ __.__ — MA'— 02632 `-- 4=30-12`` pa". Cityfrown State Zip Code Mate of Inspection B. Certification (cunt.) 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 MIS•11110 Tdo 5 Of dW kwpec ion Fonw Subsurface Sewage Bisposat System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface.Sewage DisposalSystem Form-Not for Voluntary Assessments. 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville - _____._.__. Y __---__- MA _._._ 02632-.___._. 4_30A 2 page, Cityfrown 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: Dj 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.._ n ® 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 ` t5ins•11110 TWe 5 Ofrrdal kWedion Form:Subautaw Sewage Disposal system•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments. 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is rewired for every_ Centerville ___.._ . ._.. _._ MA— 02632 � 4-30-12 page. Cityrrawn state Zip.Code Date of itispedion 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: ❑ 0 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. Z. 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 collform 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"non to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection ❑ ❑ Area-iWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in 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-11110 Ti9e 5 O fidal knpecfian Famr.Subsurface Sewage Umposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments- 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for every Centerville_-- MA 02632 - page. Citylrown 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 note 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? ® ElWas the facility owner(and occupants if different from owner)provided with information ort 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)1 D. System Information Residential Flow Conditions: Number of bedrooms(design); Number of bedrooms(actual), DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): iSins•i U10 , Tide 6 official inspection Form:Subsurface Sewage Dispose{System•page a of 17 I y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage.Blsposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is requirreed for®very Centerville MA, 02632 4-30-12 page. Cityrrown State Zip Code Date of inspection D. System Information Description; The system is a 1000 gallon septic tank and leaching pit Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required]. ❑. Yes ❑. No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commerciallindustrial Flaw Conditions: Type of Establishment: office Design flow(based on 310 CMR 15.203): 330 Gallons per day(gpd) Basis of design flow(seats/personslsq.ft., etc.): 2000 sq.ft 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: NA t5irts•t f/10 Trite 5 of cW Irmpedion Pom:Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachuseft OF Title 5 Official Inspection Form Subsurface.Sewage-Disposal System Fomt-Not for Voluntary Assessments - 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name ienterve _._ ._�..._. .. _ �_. MA 02632 4430-12 required information uiredired Centerville,for every .......— page. Cityrrawn State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Bate Other(describe below): General Information Pumping_Records: Source of information: Was system pumped as part of the inspection? Q Yes Q No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: �- Septic tank" ' soil absorption system ❑ Single cesspool Q Overflow cesspool ❑ Privy Q 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•11/10 We 5 l)tfidal lemon Form Subwftoe Sewage Ulsposal System•Page 8 of 17 Commonwealth of Massachttsetts Title 5 Official Inspection Fora Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is Centerville -� r...... v_.- _..__ .. ..�__..... �._� _. required for every MA 02632 4-30-12 page. cityrrown state Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components,date installed(if known)and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: �}cast iron 0.40 PVG ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage;etc.): Pipe is cast iron and pvc Septic Tank(locate on site plan): Depth below grade: 21 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 Sludge depth: 0 t5ms-11110 Tft 5 otfidal hSPeofion Pome Subsurface sewage Olsposal system-Page 9 of 17 Commonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name kv information is _. .._�. ._ .. rewired for every Centerville' ~- _. . -._ _ _. _-... MA 02632 4-30-12 page. Cityrrown State Zrp Code Rafe of Inspection D. System information (cons.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tape and Past Report Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping,tank at 2`below grade wrniet cover at grade in grass area, inlet baffle No sign of leakage or over loading Grease Trap(k)cate 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-baffie Date of last pumping: Date t5ins•1 ill 0 Titre 5 official inspection Form:Subsurface Swage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage.Disposal System Form Not for Voluntary Assessments 1645 Falmouth Rd. BIDG.G Property Address Bayberry Square Owner Owners Name information iss for every Centerville _.._._.. MA 02632 4-30-12 ..required page. City/Town State Zip Code Date of inspection D. System Information (cons.) 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 blow 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.). . W *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No tfiim-11/10 title 5 Offida<Uspecdon Force Subsufiace Sewage Mposat System-Page 11 of 17 Commonwealth of MassachCommonwealthus etts Title 5 Official inspection Form Subsurface.Sewage Disposal System Form Not for Voluntary Assessments. 1645 Falmouth Rd. BIDG.G Property Address Bayberry Square Owner Owner's Name information Is required for every Centerville - MA- 02632.v_.r 4-30-12 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 Comments(note if box is level and distribution to outlets equal;any.evidence of solids carryover,any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: 0 Yes ( No Alarms in wonting order: p Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): v Soil Absorption System(SAS)(locate on site plan, excavation not required). If SAS not located,explain why: tskm•t uto TWO 5 orrmw hwechm Fww.Stbudaw Sewage DmposW Systm•Pap 12 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface.Sewage.Disposal System Form-Not for Voluntary assessments 1645 Falmouth Rd. BIDG.G Property Address Bayberry Square Owner Owners Name information Is required for every Centerville` _ __._ MA 02632 ` 4-30-12 page. Citylrown State Zip Code Qate of Inspedion D. System Information (cont.) Type: leaching pits number: 1 ❑ leaching chambers number:. ❑ leaching galleries number ❑ leaching trenches number, length:. ❑ leaching Melds number,dimensions: ❑ overflow cesspool number: ❑ innovative/attemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is one 1000 Gat Precast pit; Pit at 19"Below grade w/steet cover at grade 4" Water, stain line at 1', No sign of over loading or solid carry over 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 f5i-•1 v10 Tits 5 Of dW ktspedion Form subsfaoe sewage Omposat sysr •Page 13 of 17 CommomeaFth of Massachusetti- Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BIDG.G Property Address Bayberry Square Owner Owner's Marne information Is required for every Centerville ..__ __._...- - . ._ .. _. MA ....,.. 02632"__'-- 4-30-12 _. ,..�.. ,. , ,_.n....._.._... page. Citytrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil; signs of hydraulic failure, level of ponding,condition of vegetat�n, 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.): t5ks•1Itio TWe 5 Offidat UnpecOm Fow..&tusface sewage Da posat system Page U of 17 Commonwealth of Massaohusetts 4 Title 5 Official Inspection Form Subsurtace-Sewage Disposal System Fo n-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information Is �. ....., r_, treq&ed for every Centerville MA`___ 02632 4-3©-12' _ J - page. Cityrrown State Zip Code Date of Inspection D. System Information (cone.) 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 allwells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below. rl hand-sketch in the area mellow ❑ drawing attached separately t5im•i irto riff 5 Off=W hgmcbm Famr.&bswf"Sags Deposal sYs+•Pays i 5 of 17 Map Page I of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® Zoom Out 'In K y r r t�. I S2.71 r 1 �j O S. Y N� i� }} w t 3+ .. ... ... ... M1 Set Scale 1" 20 § I Aerial Photos I MAP DISCLAIMER (:-n—inhf,m11F_)MA Tnwn of Rgmefahle MA All rinhfc meant, httn-//www tnum hnrnctahlP mn nc/arnimc/annaanann/man aenv7nrnnartvTT)=')0002A A 01,P, Al)Q/')000 v Commonwealth of Massachusetts a low Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary.Assessmentsu,p . 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is re uicecE f®r evegy Centerville _.._._. _..._. _ _. .._ _....-___..__ MA .__- 02632 4-30-12 page, Cityrrown State Zip Code We of inspection D. System Information (font.) Site Exam: ❑ Check Slope ❑_ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 12. T 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: 1985 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Amassed USGS database-explain: You mint describe how you established the high ground water elevation: Used: USGS Observation Well Data USED: Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations GW Past Report. Before filing this inspection Report,please see Report Completeness Checklist on next page. i&M•1 MO rMs 5 OrBdal Inspection Fow..subsurtaos sewage Qtsposal syd+n•Pap to of 17 Commonwealth of Massachusetts Title 5 Official inspection Fora Subsurface.Sewage.Disposals System Form-Not for Voluntary Assessments. 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is __ . _ _ ,r_ required for every Centerville _ MA' 62632 4-30-12 page. CiAyrrown State Zip Code Date of inspection E. Report Completeness checklist ® inspection Summary:A, B,C, D, or€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 t5im•11t10 Title 5 Of oW Umpecdw Fow Subswface Sewage OispasW System•Page 17 0117 r � t. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1645 Falmouth Rd. BLDG.1`3 Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code . Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key - to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 5 000 s 310 CMR 15. t ) The stem:Y , ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority -- W 4/28/2009 -ro7 '3-' -� Inspector's Sign re Date "' The system inspector shall submit a copy of this inspection report to the Appr ving Au�tl�ority*oard of Health or DEP)within 30 days of completing this inspection. If the system i a sharesystUm or has a design flow of 10,000 gpd or greater, the inspector and the system own r 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 � t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in hydraulic failure.New SAS should be installed. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 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 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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 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 '/z day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every 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-09/08 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 c�M 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityrrown 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•09108 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 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon septic tank,distributiob box and leaching pit. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 4/28/2009 Date Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 330Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Sq.Ft. 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: NA t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 4/28/2009 Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? measured Reason for pumping: Maintenance Type of System: z 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-09/08 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 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every 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: 1985 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.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank(locate on site plan): 2' 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: 1000 gallon Sludge depth: 0 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 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 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Citylrown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town 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 Yes Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is broken and half full of dirt. Wood placed over box for cover.Box needs to be replaced. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.System is in hydraulic failure.Leaching pit was full at time of inspection. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® ® Zoom Out 'In _ k w y i. "� tt 'b s ;i- t' t' Q Fee:t Set Scale 1" =.20 I Aerial Photos I MAP DISCLAIMER .................................. Cnnvrinhf 9MF_9MA T—un of P—IIOhlo KAA All rinhfc—ann h"://www.town.bamstable.ma.us/arcims/aDDaeoaDD/maD.asnx?DrODertvID=209086A0l&... 5/9/2009 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar . ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 12.5' 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: 1985 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGA Observation Well Data. USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 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 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is Centerville Ma. 02632 4/28/2009 required for every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE _'LOCATION �P SEWAGE# IG®q- 0 9 ILLAGE �_oft6L4V ASSESSOR'S MAP&PARCEL 'U3 - &J0 INSTALLER'S NAME&PHONE NO. (2gne wt J& f n. y Z�r c/U SEPTIC TANK CAPACITY SOCK l 2m LEACHING FACILITY.(type) �`�� f-U(� ��Zf1 (size) 11.`L Y Ya OWNER ��,Le,/(V SClu�4! 2 Conc�a f J��rc,✓1 PERMIT DATE: S- I y - Z�`� COMPLIANCE DATE: 10 o Z� O'� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility e Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ` Feet FURNISHED BY t �� � gtED I� Ls Ltd �-i �! QS L d h h� f _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the �J computer, use 1. Inspector: 314 ✓ I �Q only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name t� P.O.Box 763 Company Address Centerville Ma 02632 °f City/Town State Zip Code (.508)428-4028 S 14454 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 1I �-a 4/28/2009 C's , Inspe ors Signature Date ' I`ti,? The system inspector shall submit a copy of this inspection report to the Appro ing Authority (-oard of Health or DEP)within 30 days of completing this inspection. If the system is 3 sharecTsyste'm or has a design flow of 10,000 gpd or greater, the inspector and the system owne 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. L01 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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•09/08 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 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 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 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 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 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•09/08 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 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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•09/08 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 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. Citylrown 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. CitylTown State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1500 gallon septic tank,distribution box and three 500 gallon dry wells. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 489Gaiioris per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 6525 sq.ft. Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? El Yes ® No Water meter readings, if available: NA t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 4/28/2009 Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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•09/08 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 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every 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 leaching installed 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3.5' feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evide3nce of Ieakage.System vented through dry wells. 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: 1500 Sludge depth: 0 t5ins-09/08 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 M 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. CitylTown 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum-to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank tearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 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 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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-09/08 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 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has three outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number;dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Chambers had 4" of water on bottom at time of inspection with no stain line above this point. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 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.): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel ViewerIF Custom Map Abutters Map Size ® Zoom Outl jIn A IC R r I.i+�/l P A R 1!]I '\ / (R r, r1 ! o r ,r �V /w,40. .y. [v � � r•�,r,n � - Y' y" t Z � 1 A` f yt 8 } i � Set Scale 1" _;20 Aerial.... Photos I MAP DISCLAIMER _..._ .. .. _. .. . ... � f`nnvrinhf 9fVK_9MR T—un of R—cfahlo RAA All rinhfe racanu h ttn'/IVI mu tnxxm hn rn Qt`1 hI P. mn 11 Q/n roi m Q/A nnaPnnnn/mnn ACn'v7nrr Y1prKiTT)='•non RC%A 01 Rr ar)o/mno Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1645.Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 11.4' 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: 2006 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED'Technical Bulletin 92-0001 plate#2 annual ranges of groundwater.elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 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 °M 1645 Falmouth Rd. BLDG.F Property Address Bayberry Sruare Owner Owner's Name information is required for Centerville Ma 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 3 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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: A. General Information When filling out forms on the I � computer, use 1. Inspector: I v� only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 �R c ❑ Needs Further Evaluation by the Local Approving Authority ; �S ` 4/28/2009 ' Inspec or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving thority(8oarcr of Health or DEP)within 30 days of completing this inspection. If the system is a sha d system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall ubmit 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. " �e 5 9 �o t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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-09/08 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 °M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 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 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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 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 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consist of a 1000 gallon septic tank and leaching pit. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 330Gaiions per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 2000 Sq.Ft. 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: NA t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 4/28/2009 Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every 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: 1982 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.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank (locate on site plan): 2' 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: 1000 Sludge depth: 0 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.G Property Address Bayberry.Square Owner Owner's Name information is required for Centerville_ Ma. 02632 4/28/2009 every page. City/Town 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville. Ma. 02632 4/28/2009 every page. CitylTown 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 A Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (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 l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.G ` Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer —Custom Map Abutters Map Size Zoom Out, In tt ss: 3 .a s 52.77. {i } f r � r s } 5 P d SSA 9 � f e" t six r Set Scale 1° 20 I Aerial Photos I MAP DISCLAIMER (`nnvrinhf 9l1f1F_9fIf1R TMAIn of Rnrncfnhin KAA All rinhfc roenna http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=209086A0I&... 4/28/2009 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 12.7' 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: 1985 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data. USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 A Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.G Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable ,yof THE ( 10,ZZir Department of Health,Safety,and Environmental Services (�1N %�►/a Public Health Division y crass I " r -CO)• �}(�1 ' �o 1639' a�0 200 Main Street, Hyannis MA 02601 rF4 MAC Office: 508-862-4644 Thomas A. McKean, RS, CHO PAX: 508-775-3344 Director of Public Health June 24, 2016 Ms. Kristen Terkelsen Physical Therapy Solutions 1663 Falmouth Road Centerville, MA 02632 Dear Ms. Terkelsen, am in receipt of two additional letters from you dated June 23, 2016 and June 24, 2016 regarding the proposed nail salon and its wastewater discharge flow at 1667 Falmouth Road, Centerville. On June 21st, I responded'to your second letter and on June 171h I responded to your first letter. As indicated in both the June 17th and June 21st letters, the existing septic system has a capacity of 1,869 gallons at Centerville Plaza, 1661 through 1675 Falmouth Road, Centerville. In the past, 1,815 gallons per day (GPD) of discharge was permitted at this site. This site is therefore grandfathered; each unit is restricted so that the overall wastewater discharge flow does not increase beyond 1,815 gallons per day which is the maximum wastewater discharge allowed for this site. There is no extra capacity available above 1815 GPD due to the Saltwater Estuary Protection Ordinance which restricts wastewater discharge flows to 440 gallons per acre per day. The nail salon is restricted to 108 gallons per day maximum discharge as approved by Brian Dudley of the Massachusetts Department of Environmental Protection (DEP). This is based on two employees and 20 customers/pedicures per day. If this business expands into another unit with additional employees and additional pedicures/customers, the proposed wastewater discharge will have to be reviewed and recalculated in regards to the number of employees and pedicure customers by a professional engineer, prior to the issuance of an approval of a building permit. The wastewater calculations were not based on a washing machine nor were they based upon the number of pedicure chairs. The engineer's calculations were based on number of employees and the number of pedicures/customers per day. To the best of my knowledge, this will not be a public clothing washing business. The applicant informed us this will be a nail salon. If any other changes are proposed within this plaza (i.e. a new use, change of use, additional seating.at a restaurant), the proposed use would have to be reviewed by a professional engineer at the applicant's expense and the wastewater discharge flow would have to be recalculated prior to the issuance of an approval of a building permit. 2ioanivas cerely, McKe n Cc: Paul Canniff, D.M.D, Ed Pesce, P.E.. Q:IMPICenterville Plaza Terkelsen Jun2016 First Property Mgmt, 1046 Main St.,Osterville,MA YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. 1 DATE: 11L(O Fill in please: APPLICANT'S YOUR NAME/S: n SLY\, v\o BUSINESS YOUR HOME ADDRESS: /r�l 6 , ok Co' 11416 08 TELEPHONE # Home Telephone Number NAME OF CORPORATION: g-c,- C. NAME OF NEW BUSINESS .ten k ry 1 TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES jefN Cen- l�/MA �/�� ADDRESS OF BUSINESS r,rn u c-,e`/g oa63 MAP/PARCEL NUMBER CS V (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been infp4ned an r i equirements that pertain to this type of business. 1711 Aut riz4*1-bAnititure COMMENTS: 2. BOARD OF HEALTH This individual e of d of the per �requirements that pertain to this type of business. A th ized Signa ure* COMMENTS: 3. CONSUMER AFFAI (LICENSING THORITY) This individual h rm111 f the licensing requirements that pertain to this type of business. t a z @SZ tur ** COMMENTS: r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG,A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 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 `���1lutulnuruw� on the computer, -\ti10F use only the tab 1. Inspector: key to move your ' �? JA M ES• G cursor-do not _�, to use the return James D. Sears =�: ;m key. Name of Inspector =00 Capewide Enterprise, LLC l�l Company Name 153 Commercial Street �� St iN SP1EG���`��� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 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 4-25-15 spectors 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. i t5ins-11/10 Yale 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s� 1645 Falmouth Rd,_BLDG, A Pr@perfy Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) inspection Summary: Check A,B,C,D or E/always complete ail 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 system is a 1000 Gal. Tank.Two D Boxes and two 500 Gal.Chamber. 13) 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•11110 Tide 5 Offidal In spetdien Form:Subsurface Sewage Disposal System,Fage 2 of 17 l f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4=20=15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): El 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 L] 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•11/10 TWe 5 Offidai inspedon Form:Subsurface Sewage 01sposai System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 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 is less than 6"below invert or available volume is less than%day fl t5ins•11/10 Title 5 official inspection Form:Subsurface Sewage Disposal System Page 4 of 17 1 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments s 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner owners Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) - -- Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system ils. 1 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. Mina•11/10 Title 8 OHictat inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts RES Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? Z ❑ 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): Number of bedrooms(actual), DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Road,BLDG. A Property Address Bayberry Square Owner Owner's Name required fo is Centerville MA 02632 4-20-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank.Two D Box's and two 500 Gal. Chamber. Number of current residents: 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 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy Date CommerciaUlndustrial Flow Conditions: Type of Establishment: office Design flow(based on 310 CMR 15.203): 4408 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 3,702 sq. ft.. Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No i Water meter readings, if available: NA t5ins•3113 Title 5 Official Inspection ion Form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, A property Address Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection Q. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? Yes No If yes,volume pumped: gallons Now was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool 13 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): Mine•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts I uWTitle 5 Official Inspection Form Subsurface Sewage Disposal System Fern-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner owner's Name information is mquired for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: New leaching installed in 2006 Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building.Sewer(locate on site plan): Depth below grade: at feet Material of construction: ®cast iron 40 PVC other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): PVC piping 4"SCH 40 and cast iron. Septic Tank(locate on site plan): Depth below grade: 8.6'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 precast. Sludge depth: 2" t5ins=11/10 Tide 5 txfiaal Inspection Form:Subsurface Sewage Disposal System=Page 9 a117 Commonwealth of(Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 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 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Tape-Plan Past Report Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping, tank at 8'-6" below grade in and out let tees. Both cover's steel at grade. No sign of leakage or over loading. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 10 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foy-Not for Voluntary Assessments g< 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank tank must be pumped at time of inspection) locate on site plan): 9 9 ( P P P� )( P ) 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 thins•11110 Title 5 Mal Inspection Form:Subsurface Sewage Qlsposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4--20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No 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.): ?w'a_!'D Boxes existing, D Box at 7' below grade one line out steel cover at grade, Clean and solid. _ New Box from 2006 at 9'6" Below grade two lines out. Box is clean and solid w/steel cover at grade. /121jj sign of over loading or solid carry over. Rump Chambei(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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11110 Title 5 Offidel In spectlon Form:Sd'surfece Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 1645 Falmouth Rd, BLDG,A _ Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown 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.): Leaching is two 500 Gal Precast Chambers H2O w/4/stone on ends. Side and in between chambers. Chambers have 2"water no high stain line no sign of over loading or solid carry over. chambers are 9' below grade w/steel covers at grade, 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•11/10 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments s 1645 Falmouth Rd, BLDG,A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown 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•11110 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 1645 Falmouth Rd, BLDG, A Property Andress Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4-20-15 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 t5ins•11/10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 15 of 17 Vh 1� INDEX - At MAP 209 MAP 209 PARCEL 87-1 BUi L€3ING A01 ti=OACEY 2 rtOPIOSE0 PVC VENT PIPS(LOCATION TO 4r ISTING 1,000 GALLON SEPTIC TANK , .. €STING g OXO TO BE UTILIZED A t r;' #1M SLUG.A STlI L EAOIiPl PIT TO BE P E)USTINN 3 c e E IA-1ROPOSE BUILDING r �7 S.F. TOTAL) POSED —600 GALL( t5 - Nsr � '' TIP f S g6 /��"" - t = t` cs.. ng `y �1 ss' gg •. MSS _ .-46— �! Nail in U.P.88 GOAD { a. o' Npm U s GS3 1j1Y1TE 'LAN Y:. SCALE. 1''--2e° I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments r< 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells No 11'+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record Y 9 If checked, date of design plan reviewed: 7-2-09 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: T.H. on Design Plan 7-2-09 BLDG. B.no G.W. at 11'+ Botton of Chambers at V above T.H. depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Meal Inspection Foffrr Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 1645 Falmouth Rd, BLDG, A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityfrown 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•11l10 19tle 5 Me!Inspedon Form Subsurrm Sewage Disposes System•Page 17 of 17 I Commonwealth of Massachusetts 9 --® �� ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _ p' zk 1645 Falmouth Rd, BLDG, CAE Property Address >.. Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Insp� on 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 C) o��uuwuuur�i on the computer, e J`�p\ ��H OF Mqgy 'SS use only the tab 151 key to move your 1. Inspector: `�`o�:• :9�yG cursor-do not _�: JAMES James D. Sears =�: cP, use the return Name of Inspector key. Capewide Enterprise, LLC o o. t�l Company Name 153 Commercial Street ���i��l/115�iNS?f'- Company Address Mashpee MA 02649 Cityrrown state Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 1 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 I 4-25-15 spector'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 coridi 'ons of use at that time.This Inspection does not address how the system will erform In the fu re under the same or different conditions of use. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown 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 system is a 2500 Gal. Tank D Box and 4 Chambers. 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•11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner owners Name information is required for every Centerville MA 02632 4-20=15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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): 8 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•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection. B. Certification (cont.) 2. System will fail unless the Board of Wealth(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 is Jess than 6" below invert or available volume is less than Y2 day flow /- EW C1111u (' t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy Is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system falls. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 2500 gallon precast tank, D box and 4 chambers.. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: once Design flow(based on 310 CMR 15.203), 440 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): approx 5000 sq.ft. 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: NA t5ins-11M 0 Title 5 Olfidal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 L-- i Commonwealth of Massachusetts Title 5 Official Inspection Form . a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, C,D,E Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Tdle 6 OrBdal inspection Form:Subsurface Sewage Disposal System•Page 8 o117 a' Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: New D Box and leaching 2013 Permit#2013- 174. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 8'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4"pvc sch 40 Septic Tank(locate on site plan): Depth below grade: 7'tsar 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: 2500 Gal. Sludge depth: 2" t5ins-11110 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town 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 NA Scum thickness 2" - — -- - - Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tape-Past Report Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping, 3 inlet tees, Outlet Tee Tank at working level. Tank at 7' below grade wlsteel cover's at grade in black top lot. 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-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4-20-15 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: 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•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is S' below grade w/steel cover at grade. Box is clean and solid w/4 line's out. 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts lugTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number. 4 ❑ 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 is four 500 Gal Dry well chambers. Chamber's are 8'-6"below grade w/4"water wall's are clean. steel cover's at grade No sign of over loading. 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•11110 Title 5 Official lnspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, C,D,E Property Address Bayberry Square Owner owner's Name information is Centerville MA 02632 4-20-15 required for every — page. Cityrrown 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.): t51ns•11110 role 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner Owners Name information is required for every Centerville MA 02632 4-20-15 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 t5ins•11110 Ttt{e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r r 1 9 d L891 -ON Ndbl -1 SIDE `! `��1� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal-System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, C,D,E Property Address Ba be Sq uare e � RY q ua Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells �6 Estimated depth t 11t p high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 7-6-12 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: T.H. on Design Plan 7-6-12 BLDG C-D-E no G.W. at 14'+ Bottom of Chambers at V above T.H. depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG, CAE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-20-15 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file �I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 , r Number Fee 1005 THE COMMONWEALTH OF MASSACHUSETTS $loo.00 Town of Barnstable Board of Health This is to Certify that Anderson Hardware 1644 Falmouth Rd., Centerville,MA 02632 Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. ------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 6/30/2014 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 6/30/2013 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Tow. of Barnstable o�,;4E Regalatory Services nom-A Y Ge3ex,Directar ian McKean, r 2DO t�i�Stz-4 EY=IdS,1 02601 ' F� 508-790-631k-'. OE, cE_ 50846274644 i Appiica-fion Fee. VOUAC A�SESSflRS�iAP A T PARC-L NO, DATEATPLiCATIO-N ATPL CA T IO-N FOR PEPIN T TO STORE AND/OR UT MORE 111 G_ALLnN,q ®F -FAZ RDOUS A.TERIALS Fr - OF APPLICANT.' LI1'v A1�, O A OF ESTABT 'I' 91 � ,.�~� � '0 ,�=R-ESS OF EST_ABLLS�/fL%TT �. �C`-�/` SOLE 0 �: YES NO w �' L�+ APPLICA�I'T IS A PART,. ANC HOlyIE ADDRESS OF ALL Ze 9 p i APPLICANT IS A Cop PQB ATION: ==D L DDEN=CA=GN�ti a STATE OF Il iCORPOB.ATION / ` 'v �TA.�E AN1�HOi�E ADD1�E OF: CT�= SIGNATURE OF ATTidCA-l'T �� HOIN� ADDRESS 1,�,S=cnOIN& HO��ff T=UH01"1E# �' i YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate,, You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to [lie Town Clerk's Office, 1 st FL, 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: I Fill in please: APPLICANT'S YOUR NAME/S: gusse<i `% obt; a„r BUSINESS YOUR HOME ADDRESS: 0'571ery1/lc .il'!4 02 65 TELEPHONE # Home Telephone Number Co/-7 S/o aQ p piq NAME OF CORPORATIONS NAME OF:NEW BUSINESS rc „ sS�knr TYPE OF BUSINESS IS THIS A;'HOME-OCCUPATIONS YEAS NO / ADDRESS OF BUSINESS G.Y AP/PARCEL NUMBS When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING C MMIS ONER'S O CE This indi idual s b era-infp m f an per it re uirements that pertain to this type of business. thoriz d Signatur COMMENTS: - 2. BOARD OF HEALTH This individual has tbeenrird r orl-of the permit requirements that pertain to this type of business. Authorized Signature COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. COMMENTS: Authorized Signature** ,a a Town of Barnstable Barnstable BOARD OF HEALTH m"aC I 9 na MASS. 0 1 200 Main Street, Hyannis MA 02601 1639. �ArE0 MAt p�m 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi CERTIFIED MAIL# 7011 0470 0001 4525 7192 June 13, 2012 Bayberry Square, Bldg C,D&E 1645 Falmouth.Rd/Rte 28 Centerville,MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located Bayberry Square, 1645 Falmouth Rd/Rte 28, Centerville, MA was last inspected on 4/28/2012, by James L. Sears, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5(310 CMR 15.00); due to the following: • System is in hydraulic failure You are ordered to repair or replace.the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health QASEPTICIL.etters Septic Inspection Failures or Future Eval\Regulatory Authority.doc 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the 3 computer, use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address' Centerville Ma 02632 ter" City/Town State Zip Code (508)428-4028 S14454 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: t ® Passes ❑ Conditionally Passes ❑ Fails t t / ❑ Needs Further Evaluation by the Local Approving Authority F� 4/28/2009 — " Inspector's Signature Date ©i -:, The system inspector shall submit a copy of this inspection report to the Appr 'ving Authority(,Board of Health or DEP)within 30 days of completing this inspection. If the system i a shar d system or has a design flow of 10,000 gpd or greater, the inspector and the system own r shall submit the report to the appropriate regional office of the DEP. The original should be set e t to the—*steramjowner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I jisposal t5ins•09/08 Title 5 Official Inspection Form:Subsurface System•Peg 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 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 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 2500 gallon septic tank,distribution box and two leaching pits. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes'❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: office Design flow(based on 310 CMR 15.203): 440 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): approx 5000 sq.ft. 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: NA t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 4/28/2009 Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: _ 2500 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 8' . Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank (locate on site plan): 71 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: 2500 gallon Sludge depth: 0 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. t 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-09/08 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 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. City/Town 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.First leaching pit was full at time of inspection.Second leaching pit water level was 34" below invert with no stain line higher. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. Cityrrown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer I Custom Map Abutters Map Size NNE Zoom Out ,In A K 1()1 ' .. 3 `k4y 5 i V i aO ab 1> t ?10 b5 ti it oc is f: 52.62 , 1 20 Feet E _. _...._ ..... ......... Set Scale 1" = 20 I Aerial Photos '. I MAP DISCLAIMER (`nn„rinh}9()1F_OMA Tnum of Pornefohlo xAA All rinhfc roconi; httn•/Axnxnu trnxm harnetahla ma A 01 P. A/1)0innnn Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 10.4' 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: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USEWD:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.C,D,E Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma 02632 4/28//2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645.Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville ,, MA 02632 4-28-12 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 ``,��� SN pF Mq Oi,G on the computer, use only the tab 1. Inspector: key to move your (l f� I11n o : '••yc JAMES m cursor-do not James D. Sears =o! SF A RS use the return r� key. Name of Inspector *; a Capewide Enterprise, LLC '>' °F T 1 ��°:oQ sr1t--� -T.., � Company Name ,F 153 Commercial Street ''�rr/nn11111 Company Address Mashpee MA 02649 City/Town State Zip Code 508477-8877 S 1623 Telephone Number License Number B. Certification 1 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 and0aintenanoeof on-slte j sewage disposal systems. I am a DEP approved system inspector pursuantA6 bection,15.3405 Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails. or ❑ Needs Further Evaluation by the Local Approving Authority f � t) 4-28-12 spector'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•11/10 Witis Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owners Name information is required for every Centerville MA 02632 4-28-12 page. Cityrrown 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: 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): i t5ins•11/10 Tide 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 p 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): ❑ 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•11/1 0 Title 5 Official inspection Form:Subsurface Sawage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °Y 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owners Name information is required for every Centerville MA 02632 4-28-12 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 O ® 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 t5ins•1 ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 at 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4-28-12 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 ❑ 0 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a•significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 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 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 page. Cityrrown 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11/10 Us 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4-28-12 page. CityrFown State Zip Code Date of Inspection D. System Information Description: The system is a 2500 gallon septic tank,distributionbox and two leaching pits. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: office Design flow(based on 310 CMR 15.203): 440 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): approx 5000 sq. ft. 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: NA t5ins•11/10 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 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 4-28-2009 Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool . ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page S of 17 Commonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-28-12 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 8' feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): — — Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 7'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: 2500 gallon Sludge depth: 0 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 page. City/Town 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 NA Scum thickness O Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? TAPE-PAST REPORT Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping, 3 inlet Tees, Outlet Tee Tank at working level, Tank at 7' Below Grade w/steel covers at Grade in Black top lot 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Insp ection dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 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 No 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 is 8' Below Grade w/steel cover at grade in black top lot, Two lines out walls on Box are Gone, Need to replace D Box 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.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology- Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is Two Precast Pits, Pits are 10'below grade w/steel covers at grade in Black top drive Leaching is failed, one pit Full other pit water level 4" Below inlet line. Need to replace leaching. 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 I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface pec6 Sewage Disposal System•Page 13 of 17 I • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28A2 page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 114 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 I t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 TN RA It Sk �-;a• ^�� ''��,--�' �, �c�� � ,� �- r a ^w Kc,M'" *3✓.Ei" 's+,sw...:-� `^'cF 7r VMS'„ mart �x.._ --------------- �r - I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 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: Bottom of leaching 10.4'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used: USGS Observation Well Data. USEWD:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Note: GW taken off past report Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG. CDE Property Address Bayberry Square Owner Owner's Name information is required for every Centerville MA 02632 4-28-12 UV page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Me 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 c - J No. O Fee �f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yte PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpYication for Misposal 6pstem Construction 3oermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon 0 XComplete System ❑Individual Components Location Address or Lot No. /LD Owner's Name,Address,and Tel.No. "t aig S C4; is Assessor's Map/Parcel 0 o 13 i G 3 9 FA fr�+ov�4 /load Foot( ^ -,rf Installer's Name,,g,d ass✓d � Designer's Name,Address,and Tel.No. e � � Type of Building: Dwelling No.of Bedrooms / Lot Size >4c-reS sq.ft. Garbage Grinder( ) Other Type of Building FT-�od ! !r I oC-,er 4 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �! 9 2, 7 gpd Design flow provided q S"57 Z gpd Plan Date GV-4 1-3,y f) Number of sheets 1 Revision Date Title 094,n r Size of Septic Tank l i a°D/ CM AV-h coe_ Type of S.A.S. q,OtF 40ne �• �Seo /rdn C�ai+r�s Description of Soil (j— fC,'f! , ��Z�l Ak La yv,� Ce Sa n� Lv�Co n®w Y-- $ t' lLD e (�oi✓or COsci!'fc ,'s {ray.-vim 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 Board of Health, A4 ig ed 1° Date Application Approved by Date Application Disapproved y Date for the following reasons Permit No. Date Issued — .,,:.tici .c�'ye..,-.it,..,...� �... .,.-...:�„r..._.,-,...._..,.R,s,,,..s.rw•^.-,.^^«r�.v......_.._.�, .' � d{�_°+�...,.�,_ _ ..- .... --,..v--..n�-.. �-u•---r + fI'No. " .� /: _ i` l Fee ZW i r,. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS TAppY%cation for disposal Opstem Construction Permit Applicati 'for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon�f(� Pd Complete System ElIndividual Components Location Address or Lot No j `3 8~t=u�ihov 1, /Loa w dwner's Name,Address,and Tel.No. `-t e°dc1 5 c 's Assessor's Map/Parcel 1©9'lo r'3 Installer's Name,Address,and Tel.No. *;, Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size 4I C Ac r e5 sq.ft. Garbage Grinder( ) -N-.�Other Type of yp Building �;r, ,(l o 6-F r,,/' No.of Persons Showers( Cafeteria( ) Other Fixtures r Design Flow min.required) 3 2 2, 7 , Z ( q ) gpd Design flow provided S'�5 gpd `Plan Date (,ep-f /3, 201 Number of sheets Revision Date I• YTitle S 4e 091r/1 S c eo-t,C if PiJQ r Size of Septic Tank / S 0V yGoIG-M v2 cc,r,P Type of S.A.S. 'Pof S fvi7c t�, ;-TcApc-s,&^ Cxrrtj jers Description of Soil 0— $ S a- c,.. r o GG f A 2- `/--y0 73 Lam. SQn /C a fi Y!/�oG✓ `/a lL G (f -"'11�/' C'm�r I C SA�e k�-f✓��a.. 5 o�,. r IF 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 Board of Healt AIE�4,1-)ty d ��\ C v Date Application Approved by v. s Date Application Disapproved byy / / / r \ v v Date for the following reasons Permit No. Date Issued ----------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS ` Certificate of Compliance '._ THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(V) Repaired( ) Upgraded( ) Abandoned( )by �( ,flr,J�( +� at 14,-3<Z ►-A I ut a 4 v�� 2 .. Q .l t-tna� has been const��cted in l ado .61 ce with the provisions of Title 5 and the for Disposal System Construction Permit No. ated Installer ,a. (Q, Fvi �l"� r 5`S Designer sv k k,-kf� (:; t r t #bedrooms Approved design flow y'S Z gpd The issuance o this permit shall not be Icon/sltrue/dlas a guarantees iliatt the system w�function?as designed?11, �° Date I, 6 0�� �,�i rl. '{i� ��G�. 1 // �/r �;t/ f/; ,t2Inspector------------------ /�I,'t --' - - - ----- ----- ----2pf/� _�_ No. �. r + - Fee /( (/ f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Nsposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon System located at !L 3 Q 4-=OSIt--t-aviI-1 XeIA--d / -�QA, �f- ✓ 1 A and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 I 1 ���I \ Approved by_ I _ (______ t . 11 27/j013 14:42 FAX 5084283928 CAPEWIDE Z 002:%002 TOWN OF BARNSTABLE LOCATION 1639 Eatmw _SEWAGE# 2 ® ' VILLAGE. f✓— ASSESSOR'S MAP&PARCEL o' � INSTALLER'S NAME&PNOINTE NO. CQ 4t, SEPTIC TANK CAPACITY �� �aa � C, P,..�a:dno � 1Y�C� ���sr�f G-tot,l� _ � . LEACHING FACILITY:(type) 6JLeo01 .CA*Jt j size) J-0 �s N-a® NO, OF BEDROOMS J.7k C,.f.� \ PERM f LATE: t t : ' Zq t 3 COMPLUNCr DATE: Separadun Distance Between the: .tlo f vurK tu+� Ma simaac Adiusted Cnoandwaler Tahie to the Bottom—of 1-Mc3 ing Facility rr.G' I e a_ Feet Private Water Snppl 01 and Leaching Fac lity(If any wells exist an / a site or within 200 feet of leaghiag facility) AFeet Edge of Wetland and L.oaching Fac.114y(If any wetlands exist within 300 feet of leaching facility) R'Jkt lsh,rEDBY FocA WS u ' r� cr 64,E 4 d -i�78 A-4= 11� ' 13-7p 37il I31. A If " a �,..- r $ Town of Barnstable i Regulatory Services Thomas F. Geiser;Dirrectoc Public Health Division Thomas McKean;`Director 200 Maio Street.Hyannis;MA 02501 Office:508462-4644 Fax:508 790-6304. --.Installer 8r Designer Certication '®rnm Date:'II 2 1-2Zal3 Seabe Pe:ra�aatY . Assessor's 1Vlap�nrces a 9 of 3 , . v T'€i2 P2�S ES L�� S �Ng� r`n��l':'a+ . Iaistaiser: �A�E Designer' - L _7 Pat 9{et° 2 mS �6,'7/e 1$ 3:Cow%�v�nKC.tA�.. PO . Tao Address. x s q Address: ttc_.was issued a permit to install a. On (date) (installer) septic system at .1�39' FQ ` -based on a design drawn by (address) (designer) I certify that the septic:system referenced above was installed substantially according to.the design; may-include minor approved changes such m. lateral.relocation of the disinbutzon box and/or septic tank i -- the"septic="em referenced-abovemas installedwith-manor changes I certify that (�e:greater than 10' lateral relocation of the SAS or any vertical relocation of any component:of the se tic stem but in accordance with State&Local - Regulations Plan revision or c,wtru � � o f��llowo PETER Z�?rlSi e) { ` SULLWAN No..29733 h Y ..� •4. F :�\ esi er's Si tune (Affix.Designer'.s Stamp.Here) r .� Sn 1 ) � i. g ILBLIG HEAT TH DryTSION, CERTIFICATE OF COMPLIANCE WILL, - P "NOT BE.I,SSUED UNTIL BOTH THIS FORM AND AS-B�T CARD AREA RECEIVED BY THE BARN TABLE PUBLIC HEALTH DIVLSION.THANK YOII. � Q:Health/SepticlDesigner CertificationForm 3-26-04.doc �. fT��OWN OF BARNSTABLE LOCATION I�45 6a1eh-U1N.Ro( 13us IGN i�� SEWAGE# Zo%3- 1 71 f VILLAGEC—enf er-vi Ile, ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. w' C. . -O-W77 SEPTIC TANK CAPACITY o1 5_00. G LEACHING FACILITY.(type) 00 GJ amtjes ' (size) Ia.j'K SI.0 e -o NO.OF BEDROOMS &-, 6 i S,�, W c*a c e Sauce OWNER aTARrj.y SgL-are PERMIT DATE: 5��3 13 COMPLIANCE DATE: 9 /7 Separation Distance Between the: Sfi�nc4de Gett�ne{ur� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility y){eeft,l ��- Feet Private Water Supply Well and Leaching Facility(If any wells exist on b2d' site or within 200 feet of leaching facility) Al A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY G4gAUIl CIG 0I f-6'On3 e3 &CC- f 1 i 1 r7 O rlr en u b 0 M IJ il) it �t �Q � C? c� � � n i A DATE: FEE. EMNSUBM nrARM s"q,A�� REC. BY Town of Barnstable SCHED. DATE: Board of Health Q 200 Main Stlee,Hymnis MA 02001 Office: 508-862 4644 Susan G.Rask,PLS. FAX: 508-790-630.4 Sumner Kaufman,M.S.P.H. Wayne A-Miller,M.D. VARIANCE REQUEST FORM LOCATION FAL Property Address:i l� �'�W' /uLl t-�(/�+-CO�7� Assessor's Map and Parcel Number. Do Size of Lot: Wetlands Within 300 Ft. Yes Business Name:.4Y&IFIZAy Sit" c 1=. No {{��, Subdivision Name: ,,nn APPLICANTS NAME:, �,� f 7C ,y Phone �—igo-,Zq t Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S t /NAi NAME CONTACT PERSON a j , �. . Name: 6���lV f�� 1 TA �E Name Y 1l IAST � f s T, AEnU15 d-aSSOD. Address: 3z F*141s(v 1'*/W Address: qS1 kPI/I `t (�, )W 6 i\, !� �EiV (�ClJ�J kyk i MA Da360 Phone. Phone: - X3- a2oro O VARIANCE FROM TION(List R.&) REASON FOR YARIA&CLE(May attach if more space needed)me,[U% -- 6 s web ry NATURE OF WORK House Addition 0 ????? House Renovation 0 Repair of Failed Septic System Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate completed sets . _ Four(4)copies of the completed variance request form _ Four(4)copies of engineered plan submitted(e g.septic system plans) _ Four(4)copies of labeled dimensional floor plans submitted(eg.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) C:\Documents and SettingsWecollik\Local Settings\Temporary Internet Fi1es\0LK3\VARIREQ.D0C Cab. Town of Barnstable Barnstable pFTNE_p� ` Board of Health "�°'�'"��"� I RAILYSiAI3LE)' 200 Main Street, Hyannis MA 02601 NASS. Q opA`les9. `e 2007 if)MAC a. Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi November 7, 2012 Mr. Michael Pimentel, E.I.T. JC Engineering, Inc. 2854 Cranberry Highway East Wareham, MA 02538 RE: 1645 Falmouth Road, Buildings C, D, & E, Centerville A = 209 - 086 Dear Mr. Pimentel, You are granted a conditional.variance on behalf of your client, Bayberry Square Condominiums, to construct an onsite sewage disposal system at 1645 Falmouth Road, Buildings C, D, & E, Centerville. The variances granted are as follows: 310 CMR 15. 221 (7). To install the soil absorption system with 8.5 feet of coverage, a waiver of 5.5 feet from the maximum allowable coverage of three (3.0) feet. 310 CMR 15. 221 (7): To install the distribution box with 7.93 feet of coverage, a waiver of 4.93 feet from the maximum allowable coverage of three (3.0) feet. 310 CMR 15.223(1)(b): To use one septic,,tank, with a minimum effective liquid capacity of 100% of the design flow of 619.6 GPD, in lieu of providing a second tank in a series, as required. Section 360-38 of the Town of Barnstable Code: To use a standard on-site disposal system in lieu of the requirement to install an innovative/alternative septic system capable of nitrogen removal for a residential-condominium development with a flow of 1,650 gallons per day or greater. Q:\WPFILES\I645 Falm Rd Cent Sep2012.doc This variance is granted with the following conditions: (1) The septic system shall be installed in strict accordance with the engineered plans dated September 4, 2012, revised to include the 1650 variance on the plan. (4) The applicant must receive the approval of DEP prior to the installation of the septic system due to the variances requested. (5) The designing engineer shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the plans dated September 4, 2012, revised to include the 1650 variance on the plan. This variance is granted because the proposed plan appears to meet the design standards contained within the State Environmental Code, Title. 5 and local Health Regulations. Sin rely yours, 1Nayn iller, M.D. Chair an QAWPFILES\1645 Falm Rd Cent Sep2012.doc - � 1 Excerpt from Board of Health Meetin;?Minutes on 9/18/12: I. Variance — Septic (New): A. Michael Pimental, JC Engineering, representing Bayberry Square Condominiums, owner— 1645 Falmouth Road (Buildings C, D & E), Centerville, Map/Parcel 209-086, 1.68 acre parcel, three variances requested. Michael Pimental, JC Engineering, was in attendance and presented the plan. Mr. McKean said the staff had no issues with the requested variances. They are not increasing the flow. Theyy.-reque-stitrg a-varian-ce fratn_DEPa.requirement of providing a second tank Upon a moti (dye by Dr. Canniff, seconded by Mr. Sawayanagi, the Board voted to appe condition that he put the variance from the 1650 regulation onlan. (Unanimously, voted in favor.) I Q:\MINUTES\EXCERPT OF MINUTES\Excerpt BOH Sep 2012 1645 Falmouth Rd Cent.doc LETTER OF TRANSMITTAL 777 JC Engineering Inc. Civil&Environmental Services 2854 Cranberry Highway Telephone: 508-273-0377 E.Wareham,MA 02538 Facsimile: 508-273-0367 TO: Town of Barnstable DATE: 09/04/12 JOB NO. 2255 Board of Health RE: BOH Variance Package 200 Main Street Buildings C,D,&E Hyannis,MA 02601 1645 Falmouth Road Centerville,MA 02632 WE ARE SENDING YOU: X Enclosed Under separate cover via X the following: Report Prints Brochures Shop Drawings Specifications Copy of Letter Change Order Forms Please find enclosed the following for your review and approval: 1 four copies of an executed variance request form 2 )four copies of a septic system design plan dated September 4, 2012, 3.) a signed representation authorization letter, 4)four labeled existing building floor plans, 5.)one executed Soil Suitability Assessement for Sewage Disposal form 6 ) an executed check list 7.)a High Ground-Water Level Computation work sheet and 8.)one check for$95 (variance request fee). THESE ARE TRANSMITTED as checked below: X For Approval Resubmit Copies for Approval For Your Use Approved as Noted Copies for Distribution As Requested Returned Approved as Submitted Returned For Review and Comment For Your Information REMARKS Should you have any questions please feel free to contact our office. l COPY TO: File(1),Andy(2) SIGNED: Mic ae Pimentel, I.T. 5 bm�t by Emai� HIGH GROUND-WATER LEVEL COMPUTATION Date: August 31, 2012 Site Location: 1645 Falmouth Road, Centerville, MA Permit: Owner: Bayberry Square Condominiums Phone: Contractor: To be determined Phone: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. (depth is in feet below land surface) Date: 8/30/12 27.40 mm yy feet below is STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well MIW-29 B) Water-level range zone D STEP 3 Using monthly "Current Water Resources Conditions" determine current depth to water level for index well. 08/29/12 9.32 mm/yy STEP 4 Using Table of Potential Water Level Rise for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level adjustment. 6.20 STEP 5 Estimate depth to high water by subtracting the water-level adjustment (STEP 4) from 21.20 measured depth to water level at site (STEP 1). NOTE* Tables 1-9 "Potential Water-Level Rise" are attached as worksheets to this file. monthly index well data: www.capecodcommission.org/wells.html DATE: o� � FEEJ. BARNSrABLE , ' REC. d ! 39. Town of Bar nstable I SCHED. DATE: Board of Health 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Wayne A.Miller,M.D. FAX: 508-790-6304 Junichi Sawayanagi Paul J.Canniff,D.M.D. VARIANCE REQUEST FORM LOCATION Property Address:_1645 Falmouth Road(Buildings C D.&E),Centerville,MA_ 02632 Assessor's Map and Parcel Number: _Map 209,Parcel 86_ Size of Lot: 1.68 acres Wetlands Within 300 Ft. Yes Business Name: Baxberty Sguare Condominiums No X Subdivision Name: N/A APPLICANTS NAME: First Property Management Phone 508-420-0299 Did the owner of the property authorize you to represent him or her? Yes X_ No PROPERTY OWNER'S NAME CONTACT PERSON . Name:Bayberry quare Condominiums.c/o Andrew J.Witter . Name: Michael Pimentel E.I.T.UC Engineering.Inc.) Property Manager First Property Manaeement �� Address: 1046 Main St Suite 11 Osterville,MA Address:2854 Cranberry Highway.E.Wareham.MA S Phone: 508-420-0299 Phone: 508-273-0377 VARIANCE FROM REGULATION (List Reg.) REASON FOR VARIANCE (May attach if more space needed) See attached Appendix A NATURE OF WORK House Addition 0 House Renovation 0 Repair of Failed Septic System 0 I Checklist(to be completed by office staff=person.receiving variance request application) Please submit copies in 4 separate completed sets. _ Four(4)copies of the completed variance request form _ Four(4)copies of engineered plan submitted(e.g.septic system plans) _ Completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or registered sanitarian _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) _ Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/lessee only], outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) _ Variance request submitted at least 15 days prior to meeting date Wayne Miller,Chairman VARIANCE APPROVED NOT APPROVED Junichi Sawayanagi REASON FOR DISAPPROVAL Paul J.CannifF,D.M.D. C:\\users\\decollik\\AppData\\Local\\Microsoft\\Windows\\Temporary Internet Files\\Content.0utlook\\BAJ9P9B7\\V X ENGINEERING Inc. { u Civil & En ronmental Engineering 2854 Cranberry Highway East Wareham, Massachusetts 02538 Ph. 508-273-0377--Fax 508-273-0367 APPENDIX A Due to the depth of the existing buildings' sewer plumbing and 2,500 gallon septic tank,the following variances are requested: The following variances are requested from 3.10 CMR 1.5.221(7): (1.) A 5.50'variance (3.00 - 8.50) for the maximum cover over the leaching facility. (2.) A 4.93'variance (3.00 - 7.93')for the maximum cover over the distribution.box. The following variance is requested from 3.10 CMR 15.223(1)(b): (1.) A variance from providing a second tank in series with a minimum effective liquid capacity of 100% of the design flow of 619.6 gpd (i.e. no second tank provided). s , JC ENGINEERING, Inc. Civil & Environmental Engineering G 2854 Cranberry Highway. East Wareham, Massachusetts 02538 Ph. 508-273-0377—Fax 508-273-0367 October 8, 2012 .r Mr. Thomas McKean, R.S., CHO Barnstable Board of Health Agent 200 Main Street Hyannis, MA 02601 RE: Bayberry Square Condominiums ( 1645 Falmouth Road, Centerville, MA 0263 Dear Mr. McKean: As required by the Board of Health during our public hearing with them on September 18, 2012, we submit two (2) revised septic plans adding the local variance request from the town of Barnstable's Innovative and Alternative Systems regulation (sections 360-36 through 360-42) (i.e. 1,650 gpd rule). This plan revision was a condition of the approval granted by the Board of Health during this public hearing. Also, the second condition of the approval was for us to submit the variance requests made on this project to the Department of Environmental Protection (DEP) for their review and approval. However, in order to complete this variance request, DEP requires a copy of a signed letter from the Board of Health granting the requested variances to be provided to them as part of their variance request application (i.e. BRP WP 59b—MassDEP Approval of Variance Granted by Board of Health). Please provide us with this signed letter so that we can finalize our application to the DEP. If you have any questions or comments, please do not hesitate to contact our office. Sincerely, Michael Pimentel, EIT, CSE Project Manager Enclosure - :n Cc: Andrew J. Witter & File JC ENGINEERING Inc. Civil & Environmental Engineering �p 2854 Cranberry Highway. East Wareham, Massachusetts 02538 Ph. 508-273-0377—Fax 508-273-0367 August 27, 2012 Mr. Thomas McKean, R.S., CHO Barnstable Board of Health Agent 200 Main Street Hyannis, MA 02601 RE: Extension Request Bayberry Square Condominiums 1645 Falmouth Road, Centerville; MA 02632 I" Dear Mr. McKean: On behalf our client Andrew J. Witter, president of First Property Management and agent for the Bayberry Square Condominium Trust,this letter is request an extension to your order letter (attached) dated July 5, 2012 to repair or replace the septic system located at Bayberry Square, 1645 Falmouth Road, Centerville, MA for buildings C, D, & E. In the process of preparing the septic system upgrade plan, we discovered that variance requests were needed for this project. We are making an effort to complete our packet and submit it to your office so that we can be placed on your September 18, 2012 agenda. If you have any questions or comments, please do not hesitate to contact our office. $incy, +' CJ C" � Churchill PE, PLS, CSEt JLC/mcp " Cc: Andrew J. Witter& File y T � n ar -ma { yoF.IHE r ti Atez QARD 200 Main Street,Hyarni5 MA 02601 jV 9i NAS'S. 2(1(1i rfD MAt Utticc 50$ $G� 3Fi44 ��sync t��iller,l�':D. F:1h: 5Ob=390-G3o4 Paul Caiuui!',D.TI D. lunichi'Sa��ayanagi i CERTIFIED MAIL#k 701 l 0470 0001 4525 73 14 fuly 5 2012 Firs Propet.; Ma:tgeinett J. 46 MainiStrect#11 Ostcrville, iM 02. 55 RE' T3AYBERRYSQUARE C ONDOMINTUMS ORDER TO CONTPIA WITH STATE ENVIRONMENT�►L CODE, . LE 5 1. The septic system.locate;.at Bay erry Square,1645 iilmouth Rd/Rte2$, Centerville, . ti1A for Buildings C,,. & E, vas last inspected on 4/28/20I2,by James L.Sears, a certified septic a`spector for the State of Massachusetts. The uispectron of the septic system showed that the system"�'aiis" under;the guidelines of the 199 TITLE 5(310 CM15.00);due to the following; • System iS m hydraulic failure Yau are ordered to repair or replace th,Septic 5ystem within s►xty;(GU) days from the date you receive this laotifrcation. Failure to repair; eplaceithe septic system withU the deadline period till rtasult in future enforcement action. . . PER ORDER OF THE BOARD OF HEALTH That 1as i\1cKcan, R S CFIO Agent of.the Board of Health Q.'SFP I IC,Lcitcrs Segue InspLctiot Failures or huture Eval\1G45 Falmouth Rd Cent.doc ......__........ _..i. ' First Property 1Vianagement 1046 Main Street, Suite t 1 Osterville,NIA 02655 0-099H5082 1. August 27,2012 Board of Health Towm of Barnsta11 ble 200 Main Street Flyannis MA 02601 Re: Declaration of Authorization 1.645 Falmouth'Road, Buildings C; D & E Bayberry Square Cond�m3mums,Centerutlle MA Dear Members of tI.he Board: .,-- . , .I :v. - m Let it be known that I,Andrew T.Witter,property manager with authority t.o act on behalf of the owners of Bayberry Square Coiadominiums,do hereby authorize JC Engineering, -iE Inc.of East Wareham,MA 02538 to represent our interests regarding the upgtade;ofthe sewage disposal system located at 1645 Falmouth Road,Buildings C,D,&E In Centerville, Massachusetts in meetings both public and private. \Sincere]y, ,1. ndr fitter. Press ens II. First Prope y Management Agent for Bayberry Square Condominium Trust I Town of Barnstable P# oa t"e ta,. Department of Regulatory Services r • BARNSTABIE, Public Health Division Date MABB. %679. `0� 200 Main Street,Hyannis MA 02601 r�. Date Scheduled_�� O� Time / / Fee Pd. ®v ` Soil Suitability Assessment for Sew isposal Performed By: l(Y12Y1 i e`,61 I. Gs& Witnessed By: LOCATION&,GENERikL:INFORMATION t Location Address 1104j.5 Owner's Name G Address �Mbit 1 tSt' a-Eel it R,��Fe�i�l��1 rl IrkCeaifecvtllel H f} v2632 Assessor's Map/Parcel: M 4 p Z q {� Engineer's Name `S E A,5CVle ec C"J t nG, NEW CONSTRUCTION ( REPAIR Telephone# 5 0 9-2 7.3-0 3 77 Land Use G F(tCe_ G1&5slopes(%) ( `-2 Surface Stones Distances from: Open Water Body — ft Possible Wet Area ft Drinking Water Well I A- ft Drainage Way ft Property Line -7(0 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) See cw�kaches� eicin 1 r:s A4 _73 Zf 73 Z , Parent material(geologic) dill Depth to Bedrock _ Depth to Groundwater: Standing Water in Hole:T,y'(dbS,We(``� I Weeping from Pit Face cn^ C Estimated Seasonal High Groundwater 21.Zt ac�(JS�ed f ObS. �� iJSed 17, C5 t �OC Cedl3ertK}lUeiltQ5S DETEFMNNTION FOR SEASONAL HIGH WATER TABLE' Method Used: CC O6 S-wa k I� _ Depth Observed standing in obs.hole: A Depth to soil mottles: in. Depth to weeping from side of obs hole: in. Groundwater Adjustment - ,20 ft. I Index Well,# HIly21;Reading Date: 6`-29i2. Index Well level P_�2 Adj.factor ,20 Adj._Groundwater Level�'(,Z `6�os.L,4"i U 1� . - .. C3S26(l •17..� ('(u-E�Se•ticlluevlQSS ,PERCOLATION.TEST - Date :I�br(1 Time Obsgrvatlon.i, -,t,�.,.,:.�- �,:j;•''..� .",I,..,,,5:i iiµ. ;;r.',., «,,.., .,I. _.)t. ue> s?:;i� r.r.iil;:, i.r•.,wirT-C'i71 r-J: w^:. . Hole# Time at 9" 4 v _ Depth of Perc q -60 Time at 6" Start Pre-soak Time @ 11.03 A)-1 Time(9"-6") End Pre-soak Rate Min./Inch a Site Suitability Assessment: Site Passed �US Site Failed: v Additional Testing Needed(Y/N) N Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC '?r DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. . Consistency,%Gravel b�1 04 qt L S 2.5 Y V4 DEEP OBSERVATION HOLE LOG. Hole.,# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) - "rMunscll) Mottling (Structure,Stones,Boulders. Consistenc %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes_. Within 500 year boundary No— Yes Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervinns:material exist in all areas observed throughout the area proposed for the soil absorption system? -To k!,Qe`ffteA " lO E:G. 2.%go a {(Me 0C M%s (ocVcv) (See elan) If not,what is the depth of naturally occurring pervious material? Certification I certify that on Jb-Z7-9 1 (date)I have passed the soil evaluator examination approved by the F Department of Environmental Protection and that the above analysis was performed by me consistent with the:required training,expertise and exp 'ence described in 310 CMR 15.017. Signature Date 8-31-(Z / Q:\SEPTIC\PERCFORM.DOC oFT�ro Town -of Barnstable Barnstable BOARD OF HEALTH + BA ASS MASS. Q• 200 Main Street� y Hyannis MA 02601 � M . 0 �ATfD MAt A`� 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi i. CERTIFIED MAIL# 7011 0470 0001 4525 7314 July 5,2012 First Property Management 1046 Main Street#11 Osterville, MA 02655 RE: BAYBERRY SQUARE CONDOMINIUMS ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at Bayberry Square, 1645 Falmouth Rd/Rte 28, Centerville, MA for Buildings C,D, & E, was last inspected on 4/28/2012, by James L. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of the 1995 TITLE 5(310 CMR 15.00) due to the following: • System is in hydraulic failure You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH z 4hasMcKean, R.S. CHO L Agent of the Board of Health •� Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\1645 Falmouth Rd.Cent.doc if i 4 Town of Barnstable Barnstable �pF THE TQ�� BOARD OF HEALTH erica�1 '9°"ktMASSBLE.�, 200 Main Street, Hyannis MA 02601039. - d DM p�0 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi CERTIFIED MAIL# 7011 0470 0001 4525 7192 June 13,2012 Bayberry Square, Bldg C,D&E 1645 Falmouth Rd/Rte 28 Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located Bayberry Square, 1645 Falmouth Rd/Rte 28, Centerville, MA was last inspected on 4/28/2012, by James L. Sears, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5(3 10 CMR 15.00); due to the following: • System is in hydraulic failure You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health j - I i Q:\SEPTIC\Letters Septic Inspection Failures or Future Eva]\Regulatory Authority.doc tt� Town of Barnstable Barnstable • oF r BOARD OF HEALTH All-""'er"a0ty RA S 'MASS. 200 Main Street, Hyannis MA 02601 9 MASS. O t6g9� M a�00 2007 ArfD AI Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi CERTIFIED MAIL# 7011 0470 0001 4525 77314 July 5, 2012 Bayberry Square, Bldgs C, D& E �� c/o Mary C &Owen F Croughwell, \ P O Box 88 Ul Centerville, MA 02655 ORDER TO COMPLY W H STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located ayberry Square, 1645 Falmouth Rd/Rte 28, Centerville, • MA was last inspected on 4/28/2012, by James L. Sears, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5(310 CMR 15.00); due to the following: 0 System is in hydraulic failure You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\1645 Falmouth Rd.,Cent.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14915 Logged In As: Parcel Detail Monday,July 2 2012 Parcel lookup Parcel Info Parcel ID 209-086-001 I Condo Unit UNIT 1 C Condo BAYBERRY SQUARE I Building BLDG C Complex Location 1645 FALMOUTH ROAD/RTE 28 I Pri Frontage Sec Road Sec Frontage village CENTERVILLE I Fire District C-O-MM Town sewer exists at this address NO I Road Index 0522 Interactive tl. Map Owner Info • Owner CROUGHWELL, MARY C& OWEN F J Co-Owner Streetl PO BOX 88 Street2 City OSTERVILLE I State MA zip 02655 Country - Land Info Acres 0 use OFF CONDO MDL-06I zoning SPLIT Nghbd 0003 Topography I Road Utilities I Location Construction Info Building 1 of 1 _. Year 1983 I Roof I EXt BAS,TOWNHOUSE UNI7t700t- Built Struct Wall Living 708 Roof AC None Area I Cover I Type Style Condo Office ( Int Wall Drywall Bed Rooms Int Bath Model CornCondo I Floor Carpet Rooms 0 Full Grade I Heat Elec Baseboard Total Type Rooms Stories 2 Stories I Heat Electric I Found- Poured Conc. Fuel ation • Gross 708 Area http://issq l2/intranet/propdata/ParcelDetaii.aspx?ID=14915 7/2/2612 °p SHE T°may Town of Barnstable Barnstable BOARD OF HEALTH mica�1 9 B°ySS. 200 Main Street, Hyannis MA 02601 �prEo MAt 15, 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi CERTIFIED MAIL# 7011 0470 0001 4525 7321 July 3,2012 Bank of America,NA 475 Crosspoint Parkway Getzville,NY 14068 • ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 107 Old Craigville Road, Hyannis, MA was last inspected on 12/5/2011;by Michael T. Bisienere, a certified septic inspector for the State of ; C Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines L of the 1995 TITLE 5(310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. %4* - Failure to repair/replace the septic system with the deadline period will result in future enforcement action PER ORDER OF THE BOARD OF HEALTH J .. Thomas McKean, R.S. CHO ! Agent of the Board of Health Ltr 1 ! Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\107 Old Craiville Rd.Hy.2nd ltr.doc � r Town of Barnstable Barnstable �FSNE T Board of Health 1 edee�y ;R, MASS. ` 200 Main Street, Hyannis MA 02601039. 8 D MASS. 0q �OrfD MA.Aim 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi CERTIFIED MAIL #7011 0470 0001 4525 7253 June 25, 2012 Carole A. Morris c/o Bank of America, NA 475 Crosspoint Parkway Getzville, NY 14068 YOU ARE SCHEDULED TO APPEAR BEFORE THE BOARD on Tuesday July 10th at 3 m in the Town Hall Hearin Room 2nd floor, 367 Main Street Hyannis, p g y , MA due to your failure to repair or replace the failed septic system at 107 Old Craigville Road, West Barnstable. The State Environmental Code Title V requires all failed septic systems to be repaired or replaced within two years. The Town of Barnstable Board of Health has more stringent deadlines dependent upon the type of failure identified. In this case, there is backup of sewage into facility or system component due to overloaded or clogged SAS On January 5th 2012 you were ordered to repair or replace the septic system within sixty (60) days from the date you received notification. However, at this time we have no record that the system was repaired or replaced. You will be given the opportunity to testify, present witnesses, documentary evidence, and other official information regarding this case. PER ORDER OF THE BOARD OF HEALTH Wayne Miller, M. D. Chairman Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\BOH Itr.doc ! 7 r � Town of Barnstable Barnstable BOARD OF HEALTH SHE Tp�y* A8-AmeeieaCity� 9 BARN SABLE 200 Main Street, Hyannis MA 02601 m �Arft 39- Aim 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M. Junichi Sawauanagi -CERTIFIED MAIL# 7011 0470 0001 4525 6874 May 24, 2012 Carole A. Morris c/o Bank of America,NA 475 Crosspoint Parkway Getzville,NY 14068 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 107 Old Craigville Road, Hyannis,MA was last inspected on 12/8/2011, by Michael T.Bisienere, a certified septic inspector for the state of Massachussetts. The inspection of the septic system showed that the system "Fails"under the guidelines of the 1995 TITLE 5(3 10 CMR 15.00) DUE TO THE FOLLOWING: • Backup of sewage into facility or system component due to overloaded or clogged SAS. On January 51h 2012 you were ordered to repair or replace the septic system within sixty (60)- days from the date you receive notification. However,the system was not replaced as of this date (May, 2012). You are again ordered to replace the failed system within thirty(30) days. Failure to repair/replace the septic system with the deadline period will result in future enforcement action PER ORDER OF THE B ARD OF HEALTH T omas McKean, R.S. CHO Agent of the Board of Health Second Ltr Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\107 Old Craiville Rd.,Hy,2nd Itr.doc ;_ i Town of Barnstable Barnstable pp SHE Tp� Regulatory Services Department e' • BARNSTABLE. • I.F MASS. C Public Health Division �A 1639. �e 2007 a 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7011 0470 0001 4525 5549 January 5 2012 Carole A. Morris c/o Bank of America,NA 475 Crosspoint Parkway Getzville, MY 14068 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 107 Old Craigville Road,Hyannis, MA, was last inspected on 12/8/2011, by Michael T. Bisienere, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS.. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. ORDER OF T E BOARD OF HEALTH omas c n, R.S. Agent of the Board of Health -1 i Yi Q:\SEPTIC\L.etters Septic Inspection Failures\Town of Barnstable.doc i i i USPS.com®-Track&Confirm https:Htools.usps.com/go/TrackConfirmAction.action J' English Customer Service USPS Mobile Register/Sign In V S+ 4_'01111 Search USPS.com or Track Packages Ouick Tools Ship a Package Send Mail Manage Your Mail Shop Susiness Solutions Track & Confirm You entered:70110470000145255549 Status:Delivered Your item was delivered at 8:58 am on January 06,2012 in GETZVILLE,NY 14068. Additional information for this item is stored in files offline. 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Forms&Publications> - Postal Explorer,Site Index; Careers, CopyrghPO 2012-USPS.All Rights Reserved https://tools.usps.com/go/TrackConfinnAction.action 3/13/2012 7 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments. 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is requires for every Centerville MA 02632 4-30-12 page. Cityfrown State Zip Code Cate 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. Imng Out forms msWhenA General Information onthe computer, ,1H OF rMgS��i4i use only the tab ��`��' S9 1'' 1. Inspector: _ �: •• key to move your p o; •.yG's cursor-do not ,lames D. Sears JA M ES m use.the return key. Name of inspector, ) r �_ Capewide Enterprise, LLC ��•.•o� �o�� Company Name 153 Commercial Street iNSp,E`��0�` Company Address i11��/51I Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The Inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. l am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-30-12 .� spector's Signature Date z ' The system inspector shall submit a copy of this inspection report to the Approving Authorit�p(Board of Health or DEP)within 30 days of completing this inspection. If the-system is a i hared system qf,, has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submWthe 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. L t5irrs•11l1 o Title 5 F :Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required f0C every Centerville w-_ __.-_ _ _.___ __� MA_... .. 02632-_ 4-30=12'—' -- page. Cityrr6wn 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: 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): k t5ins-11i10 Title 5 Oftldal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 e Commonwealth of Massachusetts i itle 5 Official inspection Fortin Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. 6LDG.A Property Address Bayberry Square Owner Owners!dame information is �_ .. .u,.w.___ required for every Centerville MA 02632 4"30=12 page. Cityrrown state Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cunt.): ❑ 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-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts ,p `title 5 official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for every Centerville -- ._ MA 02632- " - 4=30-12' _.: __:w__.._,...-_...-._w.-__ page, cityrrown state Zip code Date of Inspection B. Certification {cunt.} 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 oBackup 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 t5ins•11/10 Title 5 Of dal Inspedon Form:Subsurface Sewage Disposal System•Page 4 o117 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Nance information is _ . _w..r. _._,. .. _M_ _,. __ 4 ..... ._..,_ requir�f for every Centerville MA `m� 02632 ' 4-3012 page. Cityrr wn State Zip Code Date of inspection B. certification (cunt.) Yes No ❑ Z 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. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. {This ,system passes if the well water analysis, performed at a DEP certified laboratory,for fecal colifonn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this forma The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system faits. 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 16,000 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 it 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•11/10 Title 5 Qredal Wspedion Form:Subsurface Sewage Disposal System•Pap 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not,for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owners Name information Is required for every Centerville_ MA 02632 4-30-12 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You(rust indicate"yes"or"non as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant; or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or 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-systerris? The size and location of the Soil Absorption System(SAS)on the site has` been determined based on: Z ❑ 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11/10 Title 5 Official Inspedon Farts:Subndace Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is __ -___.-w __ _.� required for every Centerville MA"--- 02632 4-30 12 page, C4/'r6wn State Zip Code Date of inspection D. System Information Description: The system is a 1000 gallon.precast tank, two D Box's and two 500 gallon chambers. t Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Data Commercial/industrial Flow Conditions: Type of Establishment: Office Design flow(based 440 8'on 310 CMR 15203) Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 3,702 sq.ft. 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: NA t5lnsk•11110 Title 5 Official kvpedlon Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official inspection Forte Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. 6LOG.A Property Address Bayberry Square Owner Owner's Flame information is required for every Centerville - _ MA 02632 4-30-12..._... _ _... _... page. City/rown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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•11/10 We 5 Official Inspecllon Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner owner's Name information is Centerville __._ -�-.-_.. .r,. MA - 02632`_ ____ 4=30=12 _._ � ruired for every _ page. Wrown state Zip Cade ®ate of Inspedion D. System Information (cost.) Approximate age of all components,date installed(if known)and source of information: New leaching installed in 2006 Were sewage colors detected when arriving at the site? a Yes ® No Building Sewer(locate on site plan): Depth below grade: 8'feet Material of construction: E cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage,etc.): PVC piping 4"sch 40 and cast iron Septic Tank(locate on site plan): Depth below grade: 8.6' 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 precast 2° Sludge depth: t5fns•11/10 Title 5 MEW Inspedon Form:Subsurface Sewage D4osa)%%tam•Page 9 of 17 Commonwealth of Mai"chuse#li- ` itle 5 Official Inspection Fore Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is _- __.,.....__ „F - required for every Centerville MA t 02632 4^3d page. Cityfrown state Zip Code Date of inspection D. System Information (cost.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 16" Mow were dimensions determined? TAPE-PIAN PAST REPORT Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Yearly pumping,tank at 8'-6 below grade inandout let Tees Both covers steel at grade no sign of leakage or over loading Grease Trap(locate on site plan): Depth below grade: 1 feet Material of construction; ❑concrete ❑metal ❑fiberglass ❑polyethylene other(explain): Dimensions: Scup,thickness Distance from top of scum to top of outlet tee or baffle Distance-from-bottomW scum to bottom-of outlet tee or baffle- Date of last pumping: Date t5ins•11ND Tme 5 officW tnspecUm Form:Subsurface Sewage Mpo"System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Baybeny Square Owner Owner's Flame information is required for every Centerville - _R__.w_ MA — 02632 __ page. Cfty/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: 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 151ns•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Rage 11 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is Centerville - ;: . .. MA _a. 02632 ,. .... 4_30.12 requires for every ~ page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No 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.): Two D Boxes existing D Box at 7'below grade one line out steel cover at grade clean and solid New Box from 2006 at 9'-T Below grade two lines out, Box is clean and solid w/steel cover at grade, No sign of over loading or solid carry over 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Pop 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name . information is Centerville - ` __„ __ _.:..::._ . _ �w A w ___ 02632' "" 4=30=12" required for every page. c4frown state Zip Code Date of Inspection D. System information (cunt.) Type: ❑ leaching pits number ® leaching chambers number 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions ❑ overflow cesspool number: ❑ innovative/altemative system Typetname of technology: Comments(note condition-of soil,signs-of hydraulic failure, level of ponding,.damp soil, condition of vegetation, etc.): Leaching is Two 500 Gal Precast chambers H2O w/4'stone on ends, sides and in between chambers Chambers are wet no high stain line no sign of over loading or solid carry over chambers are 9' below grade w/steel covers at grade. 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•11110 `fide 5 official Inspection Form:Subsurtace Sewage Disposal System•Page 13 of W Commonwealth of R9assachusetts `title 5 Official inspection Form Subsurface Sewage Disposal System Form-{dot for Voluntary Assessments 1645 Falmouth Rd. BLDC.A Property Address Bayberry Square Owner Owner's Flame information is required for every Centerville - .. r. .. NIA . 02632'-' 4-30-12 w..-,._ -. . page, ckyrr6wn 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•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page U of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. SLDGA Property Address Bayberry Square Owner Owner's Name information is Centerville _ .._ _._.:... . .._,.. __.:. v MA--'-" 02632 required for every page. Cityrnywn 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 f a � tSins•11/10 We 5 Offidai inspection Forth:Subudace Sewage DNx)sW System•Page 15 of 17 °rviap Page 1 of 2 e 'own or'!S Barnstable Geographic Information System Parcel � Cueto vs Map Abutters Map Size zoorn Out in y 4. t i 4 17 S7 0= 20 F`et og ... Set male 1 Aerial-Photos MAP DISCLAIMER - !'nm�rinhf�M1S_�t1flR Town w4 Fi„anet�f�ln AdE AU sinkta remnx httn://www.town.hamgta7ble.ma.u.-,farcimS/�nngeoann/man.asnx?nronertvIF)=2090X-6A OI&... 4/2Qi7ffig r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System:Form-Not for Voluntary Assessments 1645 Falmouth Rd, SLDG.A ,p — Property Address Bayberry Square Owner Owner's Fume information is required for every Centerville - _ .._ _,.. . _.. _.. MA w`A_.. 02632--- 4=30=12'. - page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: Check Slope Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water Bottom of chambers t Vfeet 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: 2006 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) I� Checked with local Board of Health-explain: As-Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used: USGS Observation Well Data USED: Technical Bulletin 02-0001 plate*2 annual ranges of groundwater elevations G.W, Perpast Report Before filing this Inspection Report, please see Report Completeness Checklist on next page. tSins•11110 Me S Official inspection Form.Subsurface Sewage Disposal System-Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official inspection Farm Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. SLDG.A Property Address Bayberry Square Owner Owner's Flame information is wired for every Centerville _. _.. .. __. .a.. MA'-'--- 02632 --_ page. Citylrown 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 1 < tSins•11110 TMe 5 Official Inspection Form:Subsurtace Sewage Disposal Sys•Page 17 or 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface.Sewage.Disposal System.Form-Not for Voluntary Assessments- 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is Centerville MA 02632 4-30-12 required for every - page. Cdyrrown 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 ng out forms A. General Information onkthe computer, \\`\\`\` ��N OF�r /I�����'�i i use only the tab 1 Inspector: � 0 key to move your 1 `o?' •?G cursor-do not jrygg D. Sears =z JA M E S :m use the return — _ key. Name of inspector Capewide Enterprise, LLC % �'•.o o,�Q Company Name G ` 153 Commercial street ��� 151wun u1� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 6(310 CMR 16.000).The system: 0 Passes. 0 Conditionally Passesai{s •.a C3 E Needs Further Evaluation by the Local Approving Authority i 4-30-12 in or s Signature Date ° G F The system inspector shall submit a copy of this inspection report to the Approving Authority(B-bbard of Health or DEP)within 30 days-of completing this-inspection. If the-system is-a-shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies'sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address hover the system will perform in the future under the same or different conditions of use. V II t5ins•11110 Title 5 Mid :Su6surrace Sewage Disposal System•Page 1 of 17 t tx Commonweal o#Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is __..... . �_� _x�•- -..,. __ Centerville required for every entere 02632 4-30-12 page. cityrr6wn Mate Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 0. 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are . indicated below. Comments: P B) System Conditionally Passes: 0 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,exhibitsL substantial infiltration or extitfration or tank-failure-isimminent 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 oldis available. ❑ Y ❑ N ❑ ND(Explain below): t5ms•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Poe 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface.Sewage.Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information isCenterville MA" 02632 4-30-12 _.. v.. ... �. ...�r...__„ required for every page. cityrrawn Mate Zip Code Date of inspection B. Certification (cost.) B) System Conditionally Passes(cant): ❑ 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: i ❑ 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 CiVIR 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 t5ft•11110 TdIs 5 offiaal hspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official inspection Form .19 Subsurface.Sewage.Disposal System Form-Not for Voluntary Assessments: 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner owner's Name information is required for every Centerville MA 02632 4-30 12_ ._.._..- .._ _,. -.. ". . . page. citylYown state Zip Code Daft of Inspection B. Certification (cons.) 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 watersupply. ❑ 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 ❑ E Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins•t to o Trtle 5 OFfidai Inspection Form S+bstidws Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface.Sewage.Disposal System Form-Not for Voluntary Assessmentslug : 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner (Miner's Name information is required for every Centerville NIA` 02632_" 4=30=12 page. Citytrown state Zip Code gate of inspection B. Certification (cons.) 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 suppiy ❑ ❑, the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection ❑ ❑ Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in 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 t5hu•t trio rd9 5 Of hIM Inspection Form:Subamlace Sewage Disposal SyAem•Page 5 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface-Sewage-Disposal.System Form-Not for Voluntary.Assessments- 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is a Centerville MA 02632 4-30-12 required for every -- - _ page. CWTown state Zip Code Date of inspection C. Checklist Check if the following have been done.You must indicate"yes"or uW as to each of the following: Yes No JZ- ❑ Pumping-information was provided,by me.owner,-occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? 0. ❑ Were ail 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):: Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11110 Title 5 Off clal Inspection Form:Sut adore Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts V Title 5 Official inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd, BLDG.B Property Address Bayberry Square Owner Owner's game information is ,T... Centerville _.:__ ,_. .required for eve MA ." 02632 ... - 4-30=12 page. CityR'own state Zip Code Cate of Inspection D. System Information Description: The system is a 1000 gallon septic tank distributiob box and four 500 Gal H2O Chambers. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[i€yes separate inspection required] ❑.Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump. El Yes ® No Last date of occupancy: present Date Commercial/Industrial Flow C6hditions- Type of Establishment: office Design flow(based on 310 CMR 15-103j 330 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): sq. ft. Grease trap present? ❑ Yes No Industrial waste holding tank present? ❑ Yes 0 No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available. NA t5ins•1 U10 Tdle 5 pfidal lnsp�Form:Subwurace Sewage Disposal System•Page 7 of 17 - i Commonwealth of Massachusetts `i='tie 5 official inspection Fora Subsurface.Sewage:Dlsposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is required for every Centerville _. __. .-_� _� y _. MA........ 02632 � � 4-30 1 2,,., page. City/Town State Zip Code gate of Inspection Q. System Information (cant.) Last date of occupancy/use: [late Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system(yes or no)(if yes,attach previous inspection records',if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Q Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): tSms•1 Vt0 Tito 5 OW=W Inspection Farm:Subsurface Sewage Disposal system•Page 8 of 17 Commonwealth of Massachusetts ugTitle 5 O icoal Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary assessments.. 1645 Falmouth Rd. BLDG.B Property Address l Bayberry Square Owner Ownees Name information is required for every Centerville _ _ _.-_.._ ,..__ MA _..._._ 02632 4-30-12 per. Cfty/Town State Zip code Date of InspecUorl D. System Information (cons.) Approximate age of all components,date installed(if known)and source of information: 2009 Were sewage odors detected when arriving at the site? a Yes U. No Building Sewer(locate on site plan): Depth below grade: a'feet Material of construction: ❑cast iron 0 40 PVC 0 other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Piping 4" PVC SCH 46 Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: year Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal Precast 1 Sludge depth: t5ins•MID Title 5 official kispection Form:Subsw laace Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage.Disposal System form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is _ _ �.. _. _ required for everyCenterville MA 02632 _ 4-3a-12 page. citymwn State Zip code Bate of Inspection D. System Information (cunt.) Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1" pn Distance from top of scum to top of outlet tee or baffle O Distance from bottom of scum to bottoms of outlet tee or baffle 1T' How were dimensions determined? TAPE-PIAN PAST REPORT Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Yearly pumping, tank at 2'below grade w/steep covers at grade, Two inlet Tee's outlet Tee, No sign of leakage or over loading Grease Trap(locate on site plan): Depth below grade: feet Material of construction: 0 concrete ❑metal [I fiberglass ❑polyethylene other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance`frombottom of-scurmto bottom of outlettee-or baf e- Date of last pumping: date t5ms•11110 Title 5 offices�spection Forth:Subsurface Sewage,Disposal System•Page 10 of 17 L I Commonwealth of Massachuseft Title 5 official Inspection Forms, Subsurface.Sewage.Disposal System Form-Not for Voluntary Assessments. 1645 Falmouth Rd, BLDG.B Property Address Bayberry Square Owner Owner's Flame information is - - required for every Centerville MA Q2632 4=3 page. CitytTown State Zip Dodo Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 t5ms•11t10 Trite 5 QffidW hupecfion Form:Subsurface Sewage Disposal Sysism-Page 11 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. .. Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is. Centerville __ ....� MA ._ 02632 _ 4-30-12 .... required for every _ ~.�� page. cityrrown State Zip code Cate of Inspection D. System Information (cons.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,any.evidence of solids carryover,any. evidence of leakage into or out of box, etc.): D Boxes is new 2009 Box is clean and solid wlsteel cover at grade No sign of over loading or solid carry over . ._.. } 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.): Soii Absorption System(SAS)(locate on site plan,excavation not required):. If SAS not located, explain why: t5ins•11110 We 5 offidW hWachm Form:Subsurface Sewage Dwposat System•Page 12 of 17 c c Commonwealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments, 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is Centerville _r _____:e..,. MA __.... 02632 4-30-12 required far every _. _ page. cky/Town State Zip cede Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): Leaching is Four 500 Gat H2O chambers w/3'stone ,steel covers at grade chambers are 3'below grade-leaching has 3"water, no high stain line -No sign of overloading or solid carry over."" 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts- Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is Centerville _��_ .�..z�. . �M .. ,,.w. MA __ required for every 02632 4-30 Z page. cityrrown state Zip Code ®ate 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•11110 Title 5 Official won Form:Subsurface Sewage Disposal System•Page 14 of 17 L Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments: 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owners(Name information is required for every Centerville MA 02632 4-30=12 T page. city/Town siate. Zip code Date of Inspection D. System Information (cunt.) 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 t5ms•11/10 Till 5 Offic W kmpactlon Form.Subsurface Sewage Disposal System•Page 15 of 17 I is 2 .. _ i e Wi Bldg, A pa n 1/6 r' ZN 04 ol Ll 40' -PROPOSED TIC pa vb' IVY' d :" �=r� � � -TANK c SEP Vic,, PROPERTY LINEVENT—MANIFOt� ALL CHAMBERS C /DNlFNu u Edge of cavemen# iC rs 'G Parking BASIN `rf Commonweafth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information is _. :., _ __....._ ... required for every Centerville MA ` 02632 4-30-12 page. cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water. 11 feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 7-2-09 If checked,date of design plan reviewed. Date Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑. Accessed USGS database_explain: You must describe how you established the high ground water elevation: Used: USGS Observation Well Data USED:Technical Bulletin 02-0001 plate#2 annual ranges of groundwater elevations G.W,Perpast Report Before filing this inspection Report, please see Report Completeness Checklist on next page. 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage[Disposal System•Page 16 of 17 1 Commonwealth of Massachusetts- Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.B Property Address Bayberry Square Owner Owner's Name information Is required for every Centerville _ _r _ �,__d__�_._._.. _ . t MA -"" ' 02632 4-30=12 - 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 Z. System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ns•11110 Tine 5 official Wnspedion Form:Subsurface sewage Disposal System•Page 17 of 17 do No. * Fee_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBL ALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes p ration for Mispo8AY 6pBtem ConstCurfion Permit C!APficat�on for Permit to nstruct t( ) Repair()o Upgrade( ) Abandon( ) ❑Complete System ElIndividual Components n ess or Lot No. ((CA j Fa/vao ui!q 2� Owner's Name,Address,and Tel.No. S rsA_)e/o r z ri,•� ie�, Ge171'E2 i//G TGc � i�+7�Fz/ S'y/ v3g7b.a.e Caws riral� Ce^ / Assessor's Map/Parcel VA" 13. Installer's Name,Address,and Tel.No.piai�e� Designer's Name,Address,and Tel.No. Mirr k'&+I kt Gu ort/.il !L) 3/cls g C Pit�'✓t/e /1'!4 C,�Fv��l(e Type of Building: Dwelling oms Lot Size 73,,y y 3} sq.ft. Garbage Grinder( ) Other Type of Building Cc n ao No.of Persons , _�e� S o rs( ) Cafeteria( ) Other Fixtures �' n Y/ e Design Flow(min.required) 3 -7 j gpd Design flow provided 'T 9 3 . I gpd Plan Date_ `7—CS -Zoo Izi Number of sheets Revision Date Title l(o q- 3A e,/ c.t S�v4_c_c Size of Septic Tank ZCoanQ wu,,} 1 jpp %&t Type of S.A.S.(4 (4-20 Soo 5n t,. L.C. ;' Srv�4 Description of Soil Nature of Repairs or Alterations(Answer when applicable)_ t4-ZLI l,)pa S4L Z Go.,n,OM" fh� L 2,o n* 3 0 (4 Soo 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 Board of He Date 1- 05 Application Approved by Date ({_V5 Application Disapproved by Date for the following reasons Permit No. ao` — '1 Date Issued V '—Y— -� No/ U o"t - , `` Fee f � t THE'COMMONWEALTH OF MAS3ACHUSETTS Entered in computer: PUBLIC-kl ALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes , 1 r� • ,� cation for 30ispoBal,6pstein Construction'30 ermit Application for Pe i� nstruct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Loca ion duress or Lot No. ((o ff y' Fa/w��;�, 2.Tj Owner's Name,Address,and Tel.No. 5 �4- i r Z 5 ,•,.•..,,, Ce--i Rt/r l/G )-.f t -o'fe✓ S'vy ,?a",1.1 . r-_, r,.•ri I Assessor's Map/Parcel Flo Installer's Name,Address,and Tel.No.Cq/> Designer's Name,Address,and Tel.No. /'GJIjJx '7G.� Cvr(rt<.eF"tr)rr Guoyt�rz /Lr/j /"�`/iy�..r� /Zl� �/�S •t°iGz i"Lr�v r/� /j'i%I C Mtn!-i/�/!(� Type of Building: Dwelling -No-&FBed o� Lot Size 7 3, C 4 -'4 sq.ft. Garbage Grinder( ) Other Type of Buildin No.of Persons S o%y.ers( ) Cafeteria( ) Other Fixtures 2 .33Y, S �l�y/ Design Flow(min.required) 3 -7 `j gpd Design flow provided gPd Plan Date `7- I Number of sheets 3 Revision Date Title Size of Septic Tank I�;vc� �1 Type of S.A.S.(4 0 Sb 0 C Description of Soil ce Nature of Repairs or Alterations(Answer when applicable) Ll-2y 00a SAL Z C<,'"t-o kf F/-wc L TO 14^ ZU r 3 Q [ I J 4 , I'♦'' Z� Cje C) C n L L•C- Date last inspected: ��bcft 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 Board of Health. Signed / �' Date 8' 0 Application Approved by ri O Date P' V Application Disapproved by Date for the following reasons Permit No. 06 C► �I Date Issued 1 _0 � . THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliante a THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by _n���', � (=�'-•ed P I� S-p� ("�� at I Io`I5 has been constructerd,in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. fw_1`��/ dated ?--LI vU ai Installer Co-),-,.. C1, s" 0/,_o Designer 1;✓1 c, sz,�., c,4J o✓Zl. _ be rgoms ri"^h Prr c;,.I a 3 3 Y G r r_P 7 4,1�70--Approved design flowl _2��5- gpd The issuance of rhis per mit shall not be construed as a guarantee that the system will nc}holri�as designed. Date 01 a Inspector f _ y � No. --- aacl-- - -- - --- - ---------•---,-- - - '--- -' -- Fee----- --- = - �yl ad- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Misposal 6psteln Construction i9ermit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at ((o 1-t < fzv j}-G -LZ C,. +4I.. 0 r and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 /(�J/} Approved by l • • I� Town of Barnstable Regulatory Services Thomas F. Geiler,]Director a Public Health Division Thomas McKean,]Director 200 Main Street, Hyannis,MA 02601 Pax: 508-7%-6304 Office: 508-962.4644 Date: Sewage Permit# — -2q L Asseaeor s Map/Parcel 4 Installer& D r Certification Wnr �s F-t.✓ C-G t-e.e cal �r►t el �'i 5'e1 Designer: „n'"i +� N c -Cv A C. - Installer. 4P ----�- rZ- w, Cre 4 s k l cA C<-1 Address: x . Address: C �..,�,�✓,'11,� O'Zri3'� Cn Per I-i w-' slissued a permit to install a ( ) uista er) , lG q� ►'l& f2al Icl 18 on a design drawn by septic system at (ad ess) � �'T C.�►ti 1--��e T� f dated ILlg ( signer I certify that the septic system referenced above was installed substantially according to the desi , which may include minor approved changes such as lateral relocation of the distributio Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic syystem n o�referencedabover�y verticallTe�lo relocation o with f any or changes onettt. greater than 10' lateral relocatPlan isin Or of the septic system) but in accordance with State & Local Itegulations. diheosoils certified as-built by designer to follow. Stripout(if required)was insPec were found satisfactory. � �,�OF 440. O� �G PETER T.. is Slgna ) v M civil_ EE � �ign No.35109lgn (A ix De 1$ ) P U S O T I q;bffioe fmmeWa fIc*tJ=fomdoc TM 70HA q,>N m gWTNgIWTnW-4 F.T.F.C11bRAG IA:FA F;AA7/A7./AT. J Town of Barnstable P# a / Department of Regulatory Services ZMMSUBt$ : Public Health Division Date - sz 200 Main Street,Hyannis MA 02601 ll Date Scheduled Time d� r . �U Fee Pd. Soil Suitability Assessment for Sewage isposal Performed By: Witnessed By: V!% 17/. LOCATION GENERAL INFORMATION Location Address L, Tg Owner's Name Address j L K j fLo,>Cr. 2 Assessor's Map/Parcel: 2 O Ct /p g V Engineer's Name G ,W; d a_ i NEW CONSTRUCTION REPAIR V Telephone# q 'L Land Use 42,44,1"-e,�"a WnWo-j Slopes(%) l G Surface Stones ru Distances from: Open Water Body I CCU ft Possible Wet Area L.Gc�ft Drinking Water Well k ft Drainage Way_7 Z Gti ft Property Line Z-V r3 L9 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands In proximity to holes) 4—V $icQ9 1 � L-f-LCAJ-1-H Parent material(geologic) �'�^ `' h Depth to Bedrock NJ A— Depth to Groundwater. Standing Water in Hole: tl�k IVA 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 soli mottles: In. Depth to Weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Dater Index Well level Adj.factor — Adj.Groundwater level,, PERCOLATION TEST bate Tlma. Observation Hole# r Time at 4" 1 ,1 Depth of Perc L 52— Time at 6" /I L 2 4 i \ Start Pre-soak Time @ ` 11me(V-611) /1 f13 } End Pre-soak Rate MinJlnch 2 Site Suitability Assessment: Site Passed tx Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPnCWERCFORM.DOC r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color . Soil- Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ravel L( 1�- 1� �L �O `z 2 C Z P S z s 1' C1 yo 5 � 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) 1 � a 5 3 sb c, s l a 2 57 6 5 D ,EP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencx.%Gravel) . J DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture . Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consi n Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes. . Within 100 year flood boundary No Yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervi us material 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 tk 1.kc�-5 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required t ' ' ,expertise and experience described in 310 CMR 15.017. Date Signature Q:1S.EPT10PERCFORM.DOC Commonwealth of Massachusetts 4 W Title .5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the S �9 computer, use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 026321 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification 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 ❑ F,ai(s ❑ Needs Further Evaluation by the Local Approving Authority c 4/28/2009 Ins c •is nat a Date -- r�r On The system inspector shall submit a copy of this inspection report to the Ap roving 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. 9 5/cq l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 / r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 1645 Falmouth Rd. BLDG.A Property Address 1 Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which,indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria'not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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•09/08 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 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 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 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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 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•09/08 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 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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. E] ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityrrown 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: .Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection-required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 400.8 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 3,702 sq.ft. 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: NA t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 4/28/2009 Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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-09/08 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 wM s 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every 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: New Leaching installed 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 8' feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through leaching vent. Septic Tank(locate on site plan): Depth below grade: 8.6 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 Sludge depth: 6" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town 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 26" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 10" 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.): Pump septic tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 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 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (corn.) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town 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.): Sandy dry soil.No signs of hydraulic failure.Chambers has 6" of water on bottom at time of inspection.No stain lines observed higher. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map I Abutters I Map.Size ONE Zoom Out. I I I I I I I 1rn 4F 0rR ry F / 15 1 �t 07 (9 G I I. S t t� 1 r y F ty� o zc Fie .......__....................... ..._................__............ .................,.___ .......... Set Scale 1" = 20 I Aerial Photos , __.... _..._ ... '. MAP DISCLAIMER (`—orinhf )nns;-,)onA T—Ain of Rorncfohln hAC All rinhf¢—a—, httn://www.town.barnstable.ma.us/arcims/anngeoann/man.asnx?nronertvTT)=2090R6A01&... 4/29/7009 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of chambers 11' 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: 2006 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical.Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 +j . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1645 Falmouth Rd. BLDG.A Property Address Bayberry Square Owner Owner's Name information is required for Centerville Ma. 02632 4/28/2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 _ C Fob �q Dom. evNo. �v J Fee THE COMMONWEA TH OF MASSACHUSETTS Entered in computer: i PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes applicatton for �Dtgozal &p!5tem cow5truction vermtt Application for a Permit to Construct( ) Repair a/) Upgrade( ) Abandon( ) ❑ Complete SystemJ,Individual Components Location Address or Lot No. ��� Owner's Name,Address,and Tel.No.Al-A PV VOW) Assessor's Map/Parcel Installer's Nnaame,Address,and Tel.No. ^ kesigner's Name,Address and Tel.No.E�o . r OE Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( AA Other Tyte`of Building No. sons Showers( ) Cafeteria( ) Other Fixtures N S f Z • •S Design Flow(min.required) V 7 . 6 5 gpd Desi n flow provided gpd Plan Date Number of sheets nnrr Revision Date ZZ A Title S liC Size of Septic Tank Type of S.A.S. lam, 5�0(91��„r14A � Description of Soil AA Nat re of epairs or Alterations(Answer when applicable) � 1� / ��p . Date last inspected: Iq 5e y r&j crES 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 rtifi ate of Compliance has been issued by this Boa of Heal h. Si e G Q Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. .�d6, Date Issued P4 V tli--� - / lf Fee v No.Aff �_% ,1„ °- Entered in computer: - _ THE CO`MMO WE,�JH OF MASSACHUSETTS ..iv PUBLIC HEALTH DIVISION TOWN,OF BARNSTABLE, MASSACHUSETTS Yes ,. Application for Migpogot bpptem Con.5tructiou Permit Application for a Permit to Construct(") Repair ) Upgrad'e O Abandon`( ) ElComplete System Individual Components Location Address or Lot Nod 6 1 S N W ,t 1 Pp- *A Owner's Name,Address,and Tel.No. KA't�,�v U6"W) �S� Assessor's Map/Parcel 409 l 3 Installer's Name,Address,and Tel.No. esigner's Name,Address and Tel.No f wp"o .L 70-d VVJI) 1 2,11 a 'Type of Building: 3 9 - 94f 7 • Dwelling No.of Bedrooms 'Lot Size .�� sq.ft. Garbage Grinder (M Other Type of Building C- y�. rl� No.9 sons s Showers( ) Cafeteria( ) Other Fixtures F Z�7. t Design Flow(min.required) Z77 . S S gpd Design flow provided � . [� - gpd w Plan Date Z N t96 Number of sheets - Revision Date ZZ /dT l Title UQ S ��i S y� 1�1C -Y ' Size of Septic Tank gg-yg --' /n K/ r.7,A Type of S.A.S. ? Description of Soil Lq » it S4 1AA A4o T 40+ tiNature of epairs or Alterations(Answer when applicable) N �, 'r -G� Date last inspected:�rf_,P_ Agreement: �• The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewageldtsporal 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 4 Compliance has been issued by,this Board of Health. Si e r, , JG /�- Date '"" �/ n Application Approved by / ✓ U �Gr Date r Application Disapproved by: w Date for the following reasons Permit No. Date Issued ----------- R ---- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTI7)�dt hat the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by `-Y\Z at lSJ L4 s has been constructe .n c ordance with the provisions of •tIe 5 and the yfor Disposal System Construction Permit No. dated (A ! IlJ Installer r Designer G`Q. #bedrooms Approved design flow gpd The issuance of this perUin shal not be construed as a guarantee that the syst�dmwin=CO. designed. Date 60 Inspect .�...�, ` ——————————————————————————————————— — ———No. /� Fee THE COMMONWEALTH OF MASSACHUSETTS �P PUBLIC HEALTH DIVISION—BARNSTABLE; MASSACHUSETTS G A (J" 1 Migpo!9o.Y;6pztem Con5truction permit Permission is hereby me +to onst ct ( ) e ) Upgrad ( ) A d ( ) System located i i and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Constru tiion must be,completed within three years of the date of is iermj�t Date /A /0 Approved by l/ Town of Barnstable Regulatory Services Thomas F.Geiler,Director • BAMSUBM . Public Health Division - Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: `I "G� I0) � Desi er• LIM y- I cSG�, Installer: 1�Oil-�C �DNlA) LV\C .gn . �2,,p Address: . �lAty)vrM Address: Y UA M66 �P �c�n ,� �2103� On /-z 1 (�_�_ i dt�: to ` rj j i \4 ---'51 C, was issued a permit to install a (date) (installer) septic system at `z ased on a design drawn by ( ) dated (designer I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. xr I certify that the septic system referenced above was installed with major changes (i.e. r4 greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as built _ designer to follow. oFM,yss90 �o EDWARD L. yc PESCE m o CIVIL ignature) No.32001 9 /STEP��F`�Q NAL (Designer's Signa e) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTD DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH -THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/SepticlDengner Certification Form W ae! .� CD w � .2 w� l TOWN OF BARNSTABLE LJOCATION 110YT lw�e y �` (3LA6 SEWAGE# V ILAGE Ce�if rvd� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. OYt F+h r1cS1®, n9 .7°1 D'-Oly71 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 5btj (size) 10 vl NO.OF BEDROOMS OWNER_ 1fns Sq, GH �e3,s` PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ��� Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) '� Feet Edge of Wetland and Leaching Facility(If any w t ands e within 300 feet of leaching facility) Feet FURNISHED BY N A r ��, �� �5' � �a a �� �3��� �2��_2�3 Town of Barnstable oft r Regulatory Services Thomas F. Geiler,Director Public Health Division * snttxsn$ t Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 E1 Phone: 508-862-4644 Email: health(cDtown.bamstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 May 31,2006 Mr. John Anderson Anderson Hardware 1638 Falmouth Road Centerville,MA 02632- Dear Mr. Anderson: Thank you for your time and cooperation during the hazardous materials inventory and site visit-, at Anderson Hardware on May 31, 2006. This letter contains information from that visit that wilt.: help you become compliant with the Town of Barnstable Code, Chapter 108: Hazardous is Materials. Enclosed are copies of the Chapter 108: Hazardous Materials Code, the Toxic and Hazardous Materials On-Site Inventory form from the site visit and a sample contingency plan for your' facility. Please note the observations and the recommendations or orders identified at your place of business during the hazardous materials inspection: OBSERVATIONS: • MSDS on site RECOMMENDATIONS/ORDERS: • . Please post a contingency plan in accordance to the Town of Barnstable Code: Hazardous Materials § 108-6 (E). • Any waste oil or other hazardous waste shall be removed and disposed of in accordance with the Massachusetts Hazardous Waste Management Act. On Site Inventory Total The Toxic and Hazardous Materials On-Site Inventory from May 31, 2006 shows that you have approximately 1052 gallons of toxic and hazardous materials being used, stored, generated and disposed of at Anderson Hardware, 1638 Falmouth Rd., Centerville,MA(Please see enclosed Toxic and Hazardous Materials On Site Inventory sheet). The Board of Health has determined that the using, storing, generating and disposing of over I I I gallons of hazardous materials per month requires businesses in the Town of Barnstable to obtain an annual Hazardous Materials Permit. This permit has been obtained from the Town of r� Barnstable Town Offices, 200 Main Street, Hyannis,MA 02601. The expiration date will be June 30, 2007. If you have any questions about these findings,the orders and recommendations, or you need further information, guidance or assistance,please do not hesitate to contact the Public Health Division. Sincerely, Ae�fo L'T)A� Alisha L. Parker Hazardous Materials Specialist All orders to correct violations of the Town of Barnstable Code Chapter 108: Hazardous Materials shall be completed upon receipt of this letter. Thomas A. McKean,RS, CHO Director of Public Health Enc. On-Site Inventory(copy) Chapter 108 (copy) Contingency Plan(copy) No. !/ Fee . THE QOM�IONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -{TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for Tigpoga[ A*pgtem Cou.gtruction Permit Application for a Permit to Construct( ) Repair rV Upgrade( ) Abandon( ) ❑ Complete System kIndividual Components Location Address or Lot No.1 ft t ka B&-DG Ow am s Te. / S GEAlG�Cr2V,fl,G1E, � � L {^I�J�S Assessor's Map/parcel �f A� Installer's Name,Address,and Tel.No. (�DC�C �aVt� P i ner's 13 e Address nd Tel.No. u/pA{�`.. P ^a Q,�•.(3oX qq`S OeswiJ P®c�l uhpN 0 4v3 Ck .-� SsCC. _ Y Type of Building: / Dwelling No.of BedroomsD �( Lot Size / V sq.ft. Garbage Grinder Other Type o Building;CAA, i No.of Persons Showers( ) Cafeteria( ) Other Fixtures `�' rD. X 9Y�11 Sf e Design Flow Ljmin.required) �gq / gpd Design flow provided �• Z gpd Plan Date y-� Number of sheets Revision Date 2Z jKAY? Title A DI S Y / Size of Septic Tank L Type of S.A.S. — L /� Description of Soil H - Nature of Repairs or lteratio s(Answer when applicable) Date last inspected: IqS RAG rre3jr Agreement: 5Healt The undersigned agrees to ensure tt ion d n ce of the afore described on-site sewage disposal system in accordance with the provisions of Titl; of t m Code a d_not,to place the system in operation until a Certificate of Compliance has been issued by is Board of /v�rTn�A �91VI A Si o Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued _ V ' . No. (% D --- Fee z-_ i Entered n computer: THE "OM :ONINEALTW OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION; T.QWN OF BARNSTABLE, MASSACHUSETTS ZippYication for �Difsponl gppotem Cow5truct%on Permit Application fora Permit to Construct O Repair j Upgrade O Abandon O ❑Complete System Individual Components Location Address or Lot No.V FAL'vt/vv' 4 RA-ALt6 F Ow am ress Te.E_ti� 'u. SAL Asso�ss Assessor's Map/Parcel J G� Q LL i 9(,Ar, F Installer's Name,Address,and Tel.No. �t t �'^ aV�N �` ner's e dress d Te1.No. Q : `AV P,o.aCyA 9qS OeM�;r Pool%N-tP. t'�'L&3�+ S'�Gls = �/' -r- SSA. LAYAA114 do S 413 u 4pe of Building. 0 Dwelling No.of Bedrooms — Lot Size sq.ft. Garbage Grinder l Other Type o Building COkOO . No.of Persons Showers( ) Cafeteria( ) Other Fixtures t%O15 Z5 S r X /5G� 5� ygq.�/ Gp� cry ,y Design Flow in.required) 1/1F •q gpd Design flow provided �V � gpd Plan Date �S A)iA A 06 Number of sheets /� I Revision Date 2, d4A ��. Title Sc cCi SysT� 1A 4D EMY Size of Septic Tank, x I- Type of S.A.S. J 500 L 6ACir. 614AM&9-s' AAA vqF:7'1 , Description of Soil 1111_ LIS" e,6 T 4� jF . S Nature of Repairs or teratio s(Answer when applicable) /ryy r' 1;` .5TS l�/'i� 6o i �. S. 4 ` ' Date last,inspected: RG T „. Agreem'ent: , . . The undersigned agrees to ensur�o constr• ctio�,aed�kn et'nalnce of the afore,described on-site sewage disposal system in 'accordan'ce with the provisions of�65 o jhAnvir9nm fzI Code'add n t o place th system in operation until a Certificate of Compliance has been issued b ithis Board of Healt / »/VO �pw�n d ,.. 7 Sigaa i 1 0 Date Application Approved by ,f Date � 0 ' Application Disapproved by: 11Y V Date for the following reasons ,, • //^^ — Permit No. r(/ —-————--'DateIssued-—— THE COMMONWEALTH OF MASSACHUSETTS -, BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT FY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( ) Abandoned( )byc 1 t ""'\ at � 4 r^ L wq' , I een c n ruct�' sordance with the,grovisions of Title 5 and the for Disposal System Co truction;Permit No. C/ Of""�dated 6 A ) p Installer of tit-10 AaV�o, Designer #bedr(;611 \C Approved design flow 1}A and The issuance of this ermitl all not b/ construed as a guarantee that the s stern ill f nctia��"i�i losi nod. Date 'y p �) 1 g y � \\�_ '"� !0 Inspector _tisP►. —— ————————————————————————--———————— Q - 1-- d----- ———No. — - -- Fee / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS tq �0 ' �Digpo!gaY *p!5tem C�, ttgtruction Permit Permission is hereby Monstruct ( ) pai Up e Abandgn ) ,System located at t �= IUC 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 --""y f-proved by PESCE ENGINEERING AND ASSOCIATES 451 Raymond Road Pr el MA 02360 (508j 743.9206 Fax(508)743-0211 CNA& Town of Barnstable Regulatory Services o� Thomas F.Geiler,Director ............. • MAIM `e Public Health Division 1619. °i Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: U L Desi er• G 7• Installer: % G, � c� n Address: . 0 Address: ` �� . (�O>e. On 1�D6 ��Q �� Pr�,v��g 10C.was issued a permit to install a (date) (installer) septic system at 3 on a design drawn by (address) WU � �� _ dated (designer) I certify that-.the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as- t y designer to follow. ��.�N OF MgSsq per' EDWARD L. yGu, PESCE all s Signature) 0 CIVIL N No.32001 7 A90 9FG/sTEP``��`�``Q SSIONA1.ENG\ Ir's Signa' (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Dengner Certification Form , a c.a ,i ��, c ,_< < , . � ,,,_. n.; �r ;� ��.! �� "'� .4 `g � L� © �^rry J•+ �,; .. i' `� `� �l � r '� N � � �� r _ i. � �„ _ TOWN OF BARNSTABLE LOCATION q\%M WA4, 9-Zy, R QCs 1°�B^ SEWAGE# 20% '2 72 V A,LAGE 6e Ok4-yA� ASSESSOR'S MAP&PARCEL ZO'R '?r INSTALLERS NAME&PHONE NO. P N p . �e $�q Qy?y a SEPTIC TANK CAPACITY 1000 LEACHING FACILITY.(type) (3) nO C&cw•w< (size)_O GOA'Vo n NO.OF BEDROOMS OWNER 6. PERMIT DATE: COMPLIANCE DATE: 77 10 4 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 00 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 lands x' within 300 feet of leaching facility) Feet FURNISHED BY Ra C,4.,ev 'ZCQ �, -2 7 � r ��� �. �13x r r� Q\+� r° �` �1 � ��"' �: '�t-� ��� -� #,._� . ... Pat Date: TOWN OF BARNSTABLE Palh�peckd TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: }'J �� dddLi&L"_ZZ BUSINESS LOCATION: &dif lkhzt�Ctl"li, ,�C�1 �I�af��� INVENTORY MAILING ADDRESS: Ii " TOTAL AMOUNT: TELEPHONE NUMBER: 77/ — pzgge CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: v" MSDS ON SITE? TYPE OF BUSINESS: Otoj INFORMATION/RECOMMENDATIONS: ) Z,21)j Fire District: Waste Transportation- AM Last shipment of hazardous.waste: Name of Hauler: _ Destination: Waste Product: - Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or.hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum o� Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils 5 Pesticides ? NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) ct Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED ZQ Any other products with "poison" labels 10 Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) 05 Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS r Town of Barnstable-Health Department Page 1 HAZARDOUS MATERIALS INVENTORY SITE VISITS DBA: ANDERSON HARDWARE Fax: i Corp Name: Mailing Address ,:7.. Location: ::1638 FALMOUTH RD.,CENTERVILLE Street: 1638 FALMOUTH RD. _. _.... _.. ......... mappar: " City: Hyannis Contact: :JOHN ANDERSON State: Ma Telephone: 771-8616 Zip: 02601 Emergency: Person Interviewed: _. .......... Business Contact Letter Date: 5/1/2006 ......_..... Category: ;Retail Store Inventory Site Visit Date: 5/31/2006 Type: 'Retail Follow Up/Inspection Date: . ....... .. . ........ .............. ❑d public water ❑ indoor floor drains ❑ outdoor surface drains license required ❑ private water ❑ indoor holding tank mdc ❑ outdoor holding tank mdc 0 currently licensed ❑d town sewage 0 indoor catch basin/drywell ❑ outdoor catch basin/drywell expir - - -- ❑ on-site sewage ❑ indoor on-site syste ❑ outdoor onsite system date: 6/30!2907 .._ .._..._........_.._.......................... REMARKS: 2/12/97-HOUSEHOLD CLEANERS-4 CASES compliance: BLEACH-7 UNITS; DRAIN CLEANERS-1 CASES; LAMP OIL-8 Satisfactory UNT. 5/31/2006-alp-MSDS on site in a binder and labeled,no waste disposal.Clean and organized.Paid for haz mat permit 06-07. a V Page 2 Town of Barnstable-Health Department HAZARDOUS MATERIALS INVENTORY Chemicals: ❑ Zero Toxic Waste Materials ❑ gty's>25 Ibs dry or 50 gals liquid but less than 111 gals ❑d gty's 111 gals or more of measure motor oil 8 gallons automatic transmission fluid 4 gallons antifreeze(for gasoline or coolant systems) 21 gallons _.._.._.._._...__...____...._.........._....__._.._._-_.._....._._...... ____.._.1..__..._-......_ _ _._.._.._._.....__.__._..___........._.._......._.._..__.._....._.. Windshield Wash 13 gallons __ .__..___.__...__..._.__..._____.__.______... ._......_.. Se ...__......_......_...._._..___.._. alant ( 8 gallons diesel fuel,kerosene,#2 heating oil - - i 2 gallons Misc.Combustible 201 gallons _ - Misc.Flammable 80 gallons Misc.Corrosive 19 gallons misc.petroleum products:grease,lubricants 14 gallons _.__..-__._-. --------- --- _.._ _ _._...._._....____-._..__._......_....._._..____......_ .._............__._. paint,varnishes,stains,dyes 375 gallons ........__.........__._______.__ new lacquer thinner [ 28 gallons ______........._........................................_....__._....._.__..__._._.....__...___..__..___ ._______[..._ _ __..... __-----.. v_.._...._.._..._................_................. car wash detergents 1 gallons car waxes and polishes 1 gallons other cleaning solvents 25 gallons Toxic € 10 gallons __............_...____-._____._._.__.___..._.................._._.___...___..._..._..._......._.._._.._............._..._..._.......___....._. .........._...__......_....._........._._........._............._....._---._._______..__ caulk/grout 3 gallons , fertilizers ( 206 gallons laundry soil&stain removers(including beach) i 28 gallons Fungicide 3 gallons _.._ pesticides 2 gallons ......... ......... Waste Transporter: Fire District: COMM ......... ......... ........... . .......... Last HW Shipment Date: Waste Hauler Licensed: No 16 H Al D W F J OIL WASTE OIL OIL FILTERS ANTIFREEZE . WASTE Kill N I ANITFREEZE GASOLINE WASTE GAS DIESEL FUEL W/W FLUID w ATF KEV-Os(-',I f- 111 //// I1 HYDRAULIC/ MISC. MISC. MISC. MISC. BRAKE FLUID COMMBUSTIBLE FLAMMABLE CORROSIVEV PETROLEUM (GEAR OIL/GREASE/ ,�1►1�, w����1�7NII ��'N �l� IR+, ��''l LUBRICANTS) x I. 1rn. �Nl f 'q hFN t�f�,1111 cva- oo o Ig X��1a tYIKy� P�RIN� - CAR WASH CAR WASH PAINTS/ WAX DETERGENTS THINNERS � ���rru.il�►ti�. � �S LNo 0?5 i 28 z� � EALANT CLEANING BATTERIES/ POISION/TOXIC CAULK/GROU I SOLVENTS BATTERY N N III ACID (103 CO3 �5 foks ,vt W1,*-h C AC'd FERTALIZER WASTE SOLVENT pl,wewcfcle MSDS �S MANIFESTS 2g /Y x $ aDx3fo q PESCE 1ENG'INEERING AND ASSOCIATES 451 Raymond Road / Plymouth, MA 02360 (' Phone 508-743-9206 FAX 508-743-0211 epesce@adelphai.net March 24, 2006 Mr. Don Desmarais, R.S. Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 SUBJECT: Revised Plans, 1645 Falmouth Road, Building F, Bayberry Square Condominiums, Centerville, MA Dear Don, Please find attached 2 copies of revised plans for the proposed septic system repair for 1645 Falmouth Road, Building F. The revisions involve the following items: • The test pit locations have been added to the plan • The existing water line is now shown. • The North arrow has been adjusted correctly on the site plan Thank you, for your help with this project, and as always, please call if you have any questions Sincerely, ` w i spa ram- Edward L. Pesce, P.E. ` CD Attachments DATE: " FEE: t{� 1639•�� REC. BY Town of Barnstable SCHED. D`^ ATE-- Board of Health 200 Main Sheet,Hyannis MA 02001 Office: 508-862-4644 Susan G.Rask,PLS. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION (6 q.5 FAL M li %� &I/ 06 A CE"V 66 ►Y tll Property Address:j p{ �` Assessor's Map and Parcel Number: Dl7 _ Size of Lot: C- tl Wetlands Within 300 Ft. Yes Business Name:.Rky No 1X_ ,,��,pp,�,�S,�ubbdivision Name: APPLICANT'S NAME:e>� f'1ZUriEry Phone Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON o 1� wmb L Name: �ALiN a�1 TA& Cf Name: � er Address: 3g p1wA(Ad D Address: ` k ���,y l� [�,,,�_„ pLyMOIl�ir�.l rV IYJI�IJ INb� D23� Phone: Phone: - 5q3- a2oro O�pG,�, VARIANCE FROM ULATION(t,ist tteg)� ' N FORYARIAN (May attach if more space needed) 6 , b 1,FEw � - iv NATURE OF WORK House Addition D ????? House Renovation D Repair of Failed Septic System hecklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate completed sets. _ Four(4)copies of the completed variance request form _ Four(4)copies of engineered plan submitted(e.g.septic system plans) _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) C:\Documents and Settings\decollik\Local Settings\Temporary Internet Fi1es\0LK3\VARIREQ.D0C I Jun 14 06 05: 44p shorey mfg co 15087605716 p.2 06/14/2006 12:52 5082553176 EAST CAPE _ PAGE 01 east cape engineering, duct 44 Route 28 P.Q.Box 1625 Orleans Mass.0260 vtr+o cut vcviNc Glut_ENGiNEE RiNIi t L•hD p�lot w•rp.c.[lOU4CGc irrr N�a.h.vc er.�.=nn.nenr.,L � Q.,Z�-7s�0 p�eneu�•t...vv rPkVCT 5 V.tAL' hex 505-255.3176 D r�VCT YI�T(i:f¢4Yr June 14,.2006 Dennis Eajoie Shorey Manuafacturing Co.,Inc. 351 White's Path So.Yarmouth,MA 02664 RE: Ivry Well Review— 1645 Route 28 Dear Dennis: East Cape Engineering,Inc.completed a review of the prEiposed installation of H- 20 septic leaching dry wells for the proposed system repair for Biulding A located at 1645 Route 28. Based on our review of the plans,the dry wells as specffied'on the design plan are adequate to carry the surface and soil loads at the proposed buried depth. If you have any questions,feel free to give rile a call. �W of MARK A �. . Sincerely, v • t,RcKEN7.lE c. GISTe9- Mark A.McKenzie;P. . �'rS�oNAt Treasurer-East Crape Engine G. MAM:j to voC.b+ns 06417 Shorcy r% xv � APESCE ENGINEERING AND ASSOCIATES O 451 Raymond Road PIy mouth 'MA 02360 Phone 508-743-9206 FAX 508-743-0211 eyesceft-adelphai.net March 24, 2006 Mr. Don Desmarais, R.S. Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 SUBJECT: Revised Plans, 1645 Falmouth Road, Building A, Bayberry Square Condominiums, Centerville, MA Dear Don, Please find attached 2 copies of revised plans for the proposed septic system repair for 1645 Falmouth Road, Building A. The revisions involve the following items: • The North arrow has been adjusted correctly on the site plan Thank you, for your help with this project, and as always, please call if you have any questions i k u +=S 4 i'ti Sincerely, DO - - V - ry Edward L. Pesce, P.E. Attachments Town of Barnstable MAM a�trASLL. Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Sumner Kaufman,MSPH Paul Canniff,D.M.D. March 6, 2006 Mr. Edward Pesce, P.E., R.L.S. 451 Raymond Road Plymouth, MA 02360 RED „1645gFalout Road, Cetitrller.7".AssesorasMap 2v09, pr�el8 '. Dear Mr. Pesce, e granted a conditional variance, on behalf of your client, Kathleen (_I endora, to construct a septic system at 1645 Falmouth Road, Centerville. The granted is as follows: 310 CMR 15.221 M: The top of the distribution box and leaching chambers will be located more than 36" below grade. The variance is granted with the following conditions: (1) The applicant shall submit written documentation from a structural engineer certifying that the specially constructed distribution box and leaching chambers will withstand the weight of seven to eight feet of soil to be placed on top of the leaching chambers as proposed. -(2) The engineer shall revised his plans showing both northerly directional arrows so that they actually point toward the north. j (3) The applicant shall obtain approval from the MA Department of Environmental Protection. The existing septic tank and piping are at lower elevations thereby restricting the engineer's ability ,to design the distribution box and leaching chambers at elevations any higher than what is proposed: Sinc y, V\Myn Miller, .D. Chair an PesceVendola2006 Town of Barnstable Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Sumner Kaufman,MSPH Paul Canniff,D.M.D. March 6, 2006 Mr. Edward Pesce, P.E., R.L.S. 451 Raymond Road Plymouth, MA 02360 'RED 1645`Falrnoufh Road Cent ivrlle� Assessor'sMa 2,09arce1086 o.>, R Dear Mr. Pesce, You are granted a conditional variance, on behalf of your client, Kathleen Vendora, to construct a septic system at 1645 Falmouth Road, Centerville. The variance granted is as follows: 310 CMR 15.221 (7): The top of the distribution box and leaching chambers will be located more than 36" below grade. The variance is granted with the following conditions: (1) The applicant shall submit written documentation from a structural engineer certifying that the specially constructed distribution box and leaching chambers will withstand the weight of seven to eight feet of soil to be placed on top of the leaching chambers as proposed. (2) The engineer shall revised his plans showing both northerly directional arrows so that they actually point toward the north. (3) The applicant shall obtain approval from the MA Department of Environmental Protection. The existing septic tank and piping are at lower elevations thereby restricting the engineer's ability to design the distribution box and leaching chambers at elevations any higher than what is proposed. Sinc y, V\Vayn#Miller, 9.D. Chair an PesceVendola2006 1 First Property Management 1046 Main Street, Suite 11 Osterville, MA 02655 508-420-0299 February 6, 2006 Thomas McKean. R.S., C.H.O. Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 Subject: Request for Variance, 1645 Falmouth Road, Building A, Bayberry Square Condominiums, Centerville, MA Dear Mr. McKean, Please be advised that as the property,manager with authority to act on behalf of the owners of Bayberry Square Condominiums, I have authorized Mr. Edward L. Pesce, P.E. to act on our behalf for all matters pertaining to the Request for a Variance for the septic system repair at 1645 Falmouth Road, Building A in Centerville. Th Yo ! 1 Andrew J. Witter,President First Property Management Agent for Bayberry Sq. Condominium Trust IN UN 17 2F •- �• C carnrnan EL • 4 31-7 I U1 I I ! �� i>� �r-'a�',�:� a ;-J :fig'' ..:...... .... .... � • !f6 .'' ;,y:: r!,.� ..wv. %, : ,:5'.,:f%;�,ri<`:Y':�<.?F..yi#.:. .,'•���+�"'iFy'fi^".SiUKkF:8�f�9):�f ''�yf„hn.���:' .I •;� %,rf,:J,... � �,•;'yt::. %Y�sSt. E<x:f.`l: <':�fg..'' ;t • `y ¢'�'v3p ;3',,g;r% /,?�%;�'J,:.r. ��%': !i>. 4i �uE „�Q��a6¢':y� a<;%� I J ! 'J,w:� :r, i:"� E $`5%i;YZ/. 'i�.ft 4:3><'$��•..', /�;tf/23:r:i::..6;i::�}fi!�. , < .......... e0jA1A f 3/�T�� CCornmon czrec� RfCHAAD A. SAMR z„S f: ,,... gat;:�hg/;:;«;$1?'.•<a e•r.; i%• ___................................... . •vY.5tt6(RLM�S.'�, - ��Ct1F7[Li.1TL"'M'�A".t1T7�� - . f� ��!•L Y�� sf.!.��G CC�f �z F .2� A MR., nwr 'Y b : Y• .'t. v ::i�'.'L.Gy aR H:l':e: :�<�� V:'¢)"5:;•:::: "'."JY74"ibS.IYG/ I •�C G�Lam';__,�.• COIL-a�lC� /. 4 5.3 ,`�/ T �" ^r��.2 0.4 1' i - `' Qo 7y r : it 3 r CGa!Eco ��..: co o J \ COMMON /.1 REA 4-• i 25 1AII G..� • r— — y3 sF NO .., ; :.F W � :..� }�:� y:..•y/,. yr. �: 's<• A. y;%'s. i Y.%A``"''r" :Sry,KK':frJS.6:: '�•3yf +. ''i'K' F'.:#: '�,�` /C• 1+ '•.e�';:?.t •. f,/Q (y,�.. .!x;::;�.: �',���+'.�.�'���� �% cE.3 a �r3''4 '.,<�S:f <b<2�£v.:'9y"v Y iyr :�x.�4; � '•:;%fi'1'• �s9;1•ti!'7 ��: �6 q.QY�.. ...��3 ';'! .'• �i(.• {:.9»+�}.fc'/�� 3' '/5...'u,. •i3.:n L::'d ,s : : Is. ` +,7r UA//T �' E C � . • J . I Imo. u ' � � i �• ,� � �< (� �� , . p � ) � � � 15=� ". Y4�:,, .Y, �, ;� �,: ��K�s ::.'shy: ;, / bYr' . . ,. :. . .. ::# ,.$` �C (` B. q� Y '` S 'vLN: �3�,� 9-2 ; :��::..::.��:. :�;�:s li+ D - \ �. ?8�!o�� f o r' `J 2 to- W o 1 i O t 3 •Z N r Z CP.. 0 z Icy a j - , s COMPLETE •N COMPLETE THIS SECTION ■ Complete items 1,2,and 3.Also complete A. Sig item 4 if Restricted Delivery is desired. X —77 ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we Can return the Card to you. B. Received by(Printed Name C. Date of Delivery ■.Attach this card to the back of the mailpiece, 0 or on the front if space permits. D. Is delivery address different from'item i? ❑Yes 1. Article Addressed to: If YES,enter delive �a�~d,�re sbelow: ❑No ON , rFEBIAI �,R POYANT i O 102006 HYANNI S, MA 02601 3., Service Type fi " ❑Certified Mail ❑ reseMail eN ., ❑Registered ❑"Retum Rece`a cipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes, 4r, 8 9>fl 0: f _�s PS Form 381 , miry_ 2004Ir��S D is Return Receipt 102595-02-W1540e UNITED STATES POSTAL SERVICE First-Class Mail I Postage&Fees Paid USPS Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4 in this box • pESCE ENGINEERING 'i &ASSOCIATES 451 Raymond Road Plymouth,MA 02360 a a.5 III,,,fill), SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2;and 3..Also complete A. Sign a re ` item 4.if Restricted'Delivery.is"de'i lred. X Agent ■ Print name and address on.the reverse ❑Addressee so that we-can"return the-Card to:-you. , ai<Received by Print a) C. at of Deli ery ■ Attach this card to the back of the'mailpiece, �C n " a or on the'front if space permits. D: Is delivery address different from item 1 ❑Y 1. Article Addressed to: If YES,enter delivery address below: ❑No MASS SOCIETY FOR PREVENTION 1577 FALMOUTH RD/RTE 28 3. Service Type i ❑Certified Mail 13'Express Mail CENTERVILLE, MA 02632 ❑Registered. ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑,Yes 2: ArticleNumE 700.4 1350j 0000 0327 3481 ' (t ransfer f " -- PS Form 3811,February 2004 Domestic'Return Receipt 102sss=o2-M-ts40 "UNITED STATES POSTAL SEAR CE"``? First-Class Mail Postage&Fees Paid USPS ' Permit No.G-10 • 'Sender: Please p t your dame, addressarrd ZTP4iirthis'tioz "' I I PESCE ENGINEERING &ASSOCIATES- 451 Raymond Road Plymouth,MA 02360 I I I I l�lltlti�llll'�tl�ll1��111111111111111ttll{tl1111111 till 11111' - -- - SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signatu X e ❑Agent item 4 if Restricted Delivery is desired. -■-Print your name and address on the reverse ❑Addressee 1.so that we'can return the card to you. B. Received by(Printed Name) Q ate of De ivery ■ Attach this card to the back of the mailpiece, -10 o0 or on the front if space permits. D: Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No 1 BRIAN T DACEY TR CENTERVILLE PLAZA TRUST P O BOX 95 3. Service Type CENTERVILLE, MA 02632 ❑Certified Mail ❑'Express Mail ❑Registered ❑Retum Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Ezra Fee) . ❑,.Yes 2. (T�I�fa=, :.7004 1350°.0000�.03`27 5498= I S �PS Form 3811,February M4 Domestic Return Receipt 102595`02-M-tb4o I •tip::. �. UNITED STATES POSTAL-Sf VCE°'''i r`,� First-Class Mail le . i o Al Postage&Fees Paid '. USPS Permit No.G-10 crJ • Sender: Please printyour ame, address,-an tZTP+44ri. is-dk",--- PESCE ENGINEERING &ASSOCIATES K 451 Raymond Road Plymouth, MA 02360 4 �C1��+' ��l�t11111t�Dll�it��llill4l`�ititt�i`lt/�'It�l!-{i�lIIIII{�1t11 5 SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sign item 4 if Restricted Delivery is desired. - ❑Agent ■ Print your name and address on the reverse X ''a ❑Addressee so'that we can return the card to you. B. eceived by(Printed Name) C of D ivery ■.Attach this card to the back of the mailpiece, B. or on the front if space permits. D. Is delivery address different from item 1? Y s 1. Article Addressed to: If YES,enter delivery address below: ❑No JAMES S GARRETT, TR PB&C SERIES, LLC ONE ROBERTS RD 3. Service Type PLYMOUTH, MA 02360 rued Mail ❑Express Mail Registered 11 Return Receipt for Merchandise —- ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2' (r,a�1 7004 2890 0000 3909 497 11—W . PS Form 3811,February 2004 Domestic Return Receipt 02595-02-W 540 I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 0 • Sender: Please print your name, address, and ZIP+4 in this box ' I I PESCE ENGINEENNG 3 ASSOCIATES 451 Raymond Road Plymouth, MA 02360 I I I i COMPLETE • ■ Complete items 1,2,and 3.Also complete A. Signature_ item 4 if Restricted Delivery is desired. -❑Agent X • Print your name and address on the reverse ❑Addressee so'that we can return the card to you. eceived by(Printed Name) C.-Date of Delivery ■.Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No - OLDE CENTER HOMES INC j C/O JOS,EPH& GIN FREEMAN 33.HANCOCK RD t 3. Service Type FRANKLIN, MA 02038 Certified all(1�113 0 ss Mail cS?� ❑Re istered R Recei t or erchandise 9P �� - -- ❑Insured Mail C.O. 4, Restricted DeliAA( x �ra Fee)V r `❑Yes 2. Artii � am700A f 2890: 000,3 21,00- 3012 PS Form 3811,February 2004 Domestic Return Receipt 102595-62-W540 UNITED STATES:r wow, F &4c z?a, t3� m sum ail Postage& id FA U OW • Sender: Please print your name, address, and ZIP+4 in this box • PESCE ENGINEERING 8 ASSOCIA TES 451 Raymond Road Plymouth, MA 02360 I I I I I I I i SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. . ❑Agent ■ Print your name and address on the reverse ?Rk�Ct��� ❑Addressee so that we'can return the card to you. B. Received by(Printed Name) C. D e of D livery ■ Attach this card to the back of the mailpiece, S'—�U b or on the'front if space permits. 1. Article Addressed to: D: Is delivery address different from Rem 1? ❑Yes _ — - If YES,enter delivery address below: ❑No DEBORAH CASSELL t PO BOX 283 � EAST SANDWICH 02537 3.*Service Type ACertified Mail ❑'Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 7.004 28.99 . =13 209,9 PS Form 3811,February 2004' Domestic Return Receipt 102e9 2-M-154o UNITED STATES POSTAL SERVICE ,,., First-Class Mail Postage&Fees Paid e USPS Permit No.G-10 • Sender: Please print your�name, address, and ZIP+4 in this box • I I I I pESCE ENGINEERING &ASSOCIATES I I 451 Raymond Road i Plymouth, MA 02360 I � I I a 2 III%$„1111ttlltt(1ll11ltt till 1111111111111114111111 till 111111 INE tp� Town of Barnstable BARNSTABLZ * Regulatory Services y MAss. i639. �e Thomas F. Geiler,Director TFD MA'S A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 26, 2005 First Property Management#11 1046 Main Street Osterville, MA 02655 Re; Bayberry Condominiums NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 1645 Route 28, Centerville,MA was inspected on . June 24, 2005 by James D. Sears a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: SYSTEM C Leaching facility consists of two pre cast pits with steel covers at grade. Both pits are full, and are not leaching. Distribution Box and cover under black top.. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE ALT DEPARTMENT 1 t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONME NTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION r` 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 w TITLE 5 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A a. CERTIFICATION Property Address: 1645 ROUTE 28 i _ 7 CENTERVILLE,MA 02632 — { Owner's Name: BAYBERRY CONDOS ,r 151 Owner's Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Date of Inspection JUNE 24,2005 ell - c.a r Name of Inspector:(please print) JAMES D.SEARS ---• MA Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 i CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority T Fails Inspector's Signature: Date: 7'�S- 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 tot he buyer,if applicable,and the approving authority. Notes and Comments SYSTEM C—REPORT THREE OF FOUR ****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 1 c Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: NNE 24,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y.N,ND)in the for the following statements. If"not determined" please explain. _ 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Y Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CNIR 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of 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 *x This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000, 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 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 leaching is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone lI 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 is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6115i?000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping infonnation 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 0 proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)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 CT.v!R 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: .TUNE 24,2005 FLOW CONDITIONS RESIDENTIAL N/A Number of Bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: OFFICE CONDOMINIUMS Design flow(based on 310 CMR 15.203): N/A Basis of design flow(seats/persons/sgft,etc.): N/A Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: Last date of occupancy/use: PRESENT OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 1997,1998, 1999,2000—BARNSTABLE PLANT Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1984 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: NNE 24,2005 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction lute: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): Depth below grade: 20" Material of construction: //concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: N/A Sludge depth: 1" Distance from top of sludge to the bottom of outlet tee or baffle: N/A Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: TAPE AND ASBUILT Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.ONE INLET TEE,2' STEEL INLET COVER AT GRADE. NOTE: OUTLET COVER UNDER BLACK TOP. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX AND COVER UNDER BLACK TOP. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of purnp chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type J leaching pits,number: 2 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS TWO PRE CAST PITS WITH STEEL COVERS AT GRADE. BOTH PITS ARE FULL,NOT LEACHING—NEED TO REPLACE LEACHING CESSPOOLS: N/A (cesspool must be pumped as part of inspectionX locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) I Title 5 Inspection Fonn 6/15/2000 9 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 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. #P O �. Ys TM c F 0 Title 5 Inspection Form 6/15/2000 10 I, Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 _ CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: DUNE 24,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 13+ 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: Observation 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: NOTE: 13+' TO GROUNDWATER. GROUND WATER DEPTH TAKEN OFF REPORT ON FILE AT BOARD OF HEALTH. Title 5 Inspection Form 6/15/2000 11 r r {r. ;}. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION t 350 MAIN STREET & . WEST YARMOUTH,MA 508-775-2800 , P 7,5 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1645 ROUTE 28 - CENTERVILLE,MA 02632 ( y Owner's Name: BAYBERRY CONDOS cW Owner's Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Date of Inspection JUNE 24,2005 v Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco c�a Mailing Address: 350 Main Street -- M West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ;4 Fails 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 tot he buyer,if applicable,and the approving authority. Notes and Comments SYSTEM B—REPORT TWO OF FOUR(SYSTEM IS FOR THREE BUILDINGS) ****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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 D. System Failure Criteria applicable to all systems: N/A 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 leaching is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet-but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone IT 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 is failed. The owner or operator of any large system considered a significant threat under Section E or failed guider Section D shall upgrade the system in accordance with 310 CUR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAYt 18,2001 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 backup? ✓ 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)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(3xb)] Title 5 Inspection Form 6/15/2000 5 r Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: C O MM E RC IALAN D U S T RIAL Type of establislunent: OFFICE CONDOMINIUMS Design flow(based on 310 CMR 15.203): 842 Basis of design flow(seats/persons/sgft,etc.): 842 Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: Last date of occupancy/use: PRESENT OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 1997, 1998, 1999,2000—BARNSTABLE PLANT Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: _ gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1984 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/1512000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): Depth below grade: 8' Material of construction: concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,500—2,000 GALLON Sludge depth: • 1" Distance from top of sludge to the bottom of outlet tee or baffle: N/A Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: TAPE AND ASBUILT 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 AT WORKING LEVEL. THREE INLET TEES,ONE OUTLET TEE.BOTH COVERS T STEEL AT GRADE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: e concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Forni 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Continents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS 9'BELOW GRADE,20"X20"INSIDE WALL TO WALL. ONE LINE IN,TWO LIENS OUT.2'STEEL COVER AT GRADE. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 2 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) TWO PRE CAST PITS,9'BELOW GRADE.BOTH PITS HAVE 30"WATER.BOTH PITS HAVE 2'STEEL COVERS AT GRADE. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: _ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: _ Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 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. sYsT 1 3 0 F C a Title 5 Inspection Form 0/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 13+ feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: 13+'TO GROUND WATER, GROUND WATER DEPTH TAKEN OFF REPORT ON FILE AT BOARD OF HEALTH. Title 5 Inspection Form 6/I5/2000 11 kf ° r F ` +A�SxtONf r"g E"zy a� � 'wfm t �r f b;ya;'f. t t .i u. ' •e � r S r Y v V 5 5�M I C O a r 10 CO) G Fool c S �STM mo o do s Ys rM Gmas ABUTTER'S MAP 209 PARCEL 086 BAYBERRY SQUARE CONDO PARCEL- MULTIPLE UNITS /OWNERS 1617 FALMOUTH ROAD/RTE 28 Map 209 Parcel 085 GARRETT, JAMES S TR%PB&C SERIES, LLC ONE ROBERTS RD PLYMOUTH, MA 02360 126 OLD POST ROAD Map 209 Parcel 091 ROBERTS, GUYLAINE E 126 OLD POST RD CENTERVILLE, MA 02632 1577 FALMOUTH ROAD/RTE 28 Map 209 Parcel 083 MASS SOCIETY FOR PREVENTION 1577 FALMOUTH RD/RTE 28 CENTERVILLE, MA 02632 116 OLD POST ROAD 28 Map 209 Parcel 087-02 LYNCH, ROBERT E JR 92 KENDALL AVE FRAMINGHAM, MA 01701 ' a 1663 FALMOUTH ROAD/RTE 28IRTE 28 Map 209 Parcel 87-001 DACEY, BRIAN T TR CENTERVILLE PLAZA TRUST POBOX95 CENTERVILLE, MA 02632 ACROSS THE STREET 28 1620 FALMOUTH ROADIRTE 28 Map 209 Parcel 013&003 POYANT, MARCEL R POBOXK HYANNIS, MA 02601 r i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION Q � y V 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 7 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION g c Property Address: 1645 ROUTE 28 ` �— CENTERVILLE,MA 02632 r`- D Owner's Name: BAYBERRY CONDOMINIUMS Owner's Address: 1645 ROUTE 28 � CENTERVILLE,MA 02632 Date of Inspection JUNE 24,2005 cn Name of Inspector:(please print) JAMES D.SEARS c,� co Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: —0J 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 tot he buyer,if applicable,and the approving authority. Notes and Comments SYSTEM D—REPORT FOUR OF FOUR ****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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOMUZUMS Date of Inspection: TUNE 24,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ./ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOMINIUMS Date of Inspection: JUNE 24,2005 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance . This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOMINIUMS Date of Inspection: JUNE 24,2005 D. System Failure Criteria applicable to all systems: N/A 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 — ,7— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pit is less than 6"below invert or available volume is less than%day flow 7— 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CUR 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is-located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 Title 5 Inspection Form 6/15/2000 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOMINIUMS Date of Inspection: DUNE 24,2005 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 scuni ✓ 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)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(3Xb)] Title 5 Inspection Form 6/15/2000 5 , Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOMINIUMS Date of Inspection: JUKE 24.2005 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: COMMERCIALANDUS TRIAL Type of establishment: OFFICE CONDOMINIUMS Design flow(based on 310 CUR 15.203): N/A Basis of design flow(seats/persons/sgft,etc.): N/A Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: N/A Last date of occupancy/use: PRESENT OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 1997,1998,2000 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) hmovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1982 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 611512000 6 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOMINIUMS Date of Inspection: JUNE 24,2005 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 20" Material of construction: concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: F, Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT,TAPE&PAST REPORT 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 AT WORKING LEVEL.INLET TEE,OUTLET BAFFLE.BOTH COVERS 18"STEEL AT GRADE. NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete _ metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE, MA 02632 Owner: BAYBERRY CONDOMEgUMS Date of Inspection: JUNE 24,2005 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,). PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 r . Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOMINIUMS Date of Inspection: JUNE 24,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ONE PRE CAST PIT.24"WATER IN PIT.NO HIGH STAIN LINE.NO SIGN OF OVERLOADING IN PIT. PIT T BELOW GRADE. 18"STEEL COVER AT GRADE. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: _ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (,locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOMINIUMS Date of Inspection: JUNE 24,2005 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. 70.0 % O 0 Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOMINIUMS Date of Inspection: NNE 24,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 13+ 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: Observation 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- GROUND WATER DEPTH TAKEN OFF REPORT ON FILE AT THE BOARD OF HEALTH. Title 5 Inspection Form 6/15/2000 11 ,�` ,.r �'� a �t� t^r`z �-` z�,��ry �' u ,� t ,•ti� ,9�k�Y� 't�''Y'�i, sr. ,, f X �r F b a M t 4 r * s e air° + i0 � T da�5 r/14 a'�� �'. ".� - , ( .y,z a, C I s YS�M c � r F 10 CO) G r S ySTF M o do s YS 71s, (DomesticU.S. Postal Service CERTIFIED MAIL RECEIPT • Ln QFFI -.. Lt7 Postage $ • ta7 Pt7 .- Certified Fee Postmapk Return Receipt Fee P� He rn (Endorsement Required) G C3 C3 Restricted Delivery Fee C3 (Endorsement Required) 4og2� C3 Total Postage&Fees $ ° ru C SrC. Johnson & Co. ®9 o!1645 B Falmouth Rd. 12 Centerville, Ma. 02632 PS Form :,° January 2001 I Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A signature upon delivery ■ A record of delivery kept by the Postal Service for two years , Important Reminders. ■ Certified Mail may ONLY be combined with First-Class Mail or Priority Mail ■ Certified Mail is not available for,any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return, Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt'is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". e If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix iabel with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,January 2001(Reverse) 102595-01-M-1049 I Barnstable Assessing Search Results Page 1 of 2 i R 1.7 3 � $ b Y f Home: Departments:Assessors Division: Property Assessment Search Results 1645 FALMOUTH ®AD/RTE 28 Owner: Property Sketch Legend WHITE,ALLEN J US[560]= Map/Parcel/Parcel Extension I 209 /086/604 ' Mailing Address WHITE,ALLEN J ��� ,`S ®�--° -1-b CJ3 PO BOX979 ` b(��j �. vT—A ��>t HYANNIS, MA.02601 � C � MP 2004 Assessed Values: ta'L J Appraised Value Assessed Value Building Value: $67,200 $67,200 Extra Features: $0 $0 Outbuildings: $0 $0 Land Value: $0 $0 Interactive Property Map: ap requires Plug in: Totals:$67,200 $67,200 1 have visited the maps before Show Me The Map ° April 2001 photos available ii Sales History: Owner: Sale Date Book/Page: Sale Price: WHITE,ALLEN J 10/15/1990 7341/227 $78,000 SCHILLING, SUSAN TRS 2/15/1984 4023/100 $55,000 NOWAK, STANLEY P ETALS 7/15/1982 3517/1 $0 2004 Tax Information: Tax Rates: (per$1,000 of valuation) Town Tax $444.19 Town Fire District Rates Other Rates 6.61 Barnstable 2.01 Land Bank 3%of Town Tax C.O.M.M. FD Tax $73.92 C.O.M.M. 1.10 Cotuit 1.52 Land Bank Tax $ 13.33 Hyannis 2.03 West Barnstable 1.36 http://www.town.barnstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/... 9/21/2004 I Barnstable Assessing Search Results Page 2 of 2 °�. 1) Total: $531.44 Due to rounding differences these values may vary Land and Building Information Land Building Lot Size(Acres) 0 Year Built 1983 Appraised Value $0 Living Area 560 Assessed Value $0 Replacement Cost$90,698 Depreciation 14 Building Value 67,200 Construction Details Style Condo Office Interior Floors Carpet Model Commercial Interior Walls Drywall Grade Custom Heat Fuel Electric Stories 1 Story Heat Type Elec Baseboard Exterior Walls Wood Shingle AC Type None Roof Structure Gable/Hip Bedrooms Zero Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms Zero Bathrms Total Rooms Extra Building Features Code.Description Units/SQ ft Appraised Value Assessed Value Property Sketch Legend BAS First Floor, Living Area FST Utility Area (Finished Interior) UAT Attic Area (Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area (Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.barnstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/... 9/21/2004 r D« c ALLEN J. WHITE N 405 SOUTH STREET -P.O. BOX 979 HYANNIS, MA 02601-0979 0 N 1 � O Cn x3 TEL. (508) 775-1146 Z q FAX (508) 778-1883 w w CU rn May 4, 2004 Town of Barnstable Public Health Division Thomas McKean,Director 200 Main Street Hyannis,MA 02601 Dear Mr. McKean: Please be advised that we are not the owners of the property, 1645B Falmouth Road, Centerville,Ma. ` This property has been transferred to C. Johnson & Co. their office is 1645B Falmouth Road, Centerville,Ma. Please acknowledge receipt of this letter. Sincer l � Allen J. hite,Ph.D. / AJW: d G BROWNtech Document Management Systems Page 1 of 1 01 t; Barnstable County Registry of Deeds John F. Meade All Records by Property Adr Property Addr: 1645E FALMOUTH ROAD Search Date: 02-02-2003 through 05-04-2004 Town: Barnstable Document types: Deed document group Database searched: All Land records from 02-02-2003 through 05-04-2004 This may not be a complete listing of activity for the address you are searching.The Registry only began indexing street address information in 1994 and we index the address provided to us by the party recording the document. We have no way of verifying that the address given to us is correct or complete. We provide address information as a search aid only and it should not be relied upon as an accurate reflection of all activity for a given property. PROPERTY ADDRESS LIST z 17374-281 MIMRM7 Recorded: 07-31-2003 @ 1:43:24pm Inst #: 88949 Chg: Y Vfy: N Grp: 1 Type: Deed Doc$: 600,000.00 Desc: SEE INSTRUMENT Town: BARNSTABLE Addr: 1645 FALMOUTH ROAD Gtor: BAYBERRY ASSOCIATES REALTY TRUST(BY TR&0) Gtor: BAYBERRY INVESTORS TRUST (BY TR&O) Gtor: WHITE, ALLEN J (AS ID AS TR&O) Gtee: BAYBERRY SQUARE REALTY TRUST (BY TR) Gtee: JOHNSON,VAN B (AS TR) No (more) matches found HOW TO USE THIS PAGE To see summaries of the next sequential docuuments, click on Next>. To see the previous panel displayed, click on <Previous. To view an abstract, click on the document icon with the "A". To view an image, click on the document icon with the "W, To view an abstract of a referenced document, click it's hyperlink. Most images you will view and/or print will not have marginal reference notations on the image. If you are interested in marginal reference information for a particular instrument/document, check and optionally print the abstract for it. There is no fee for printing abstracts. To print the abstract, right click on the abstract side (not the left side) and, for Internet Explorer, select "Print". http://199.232.150.242/ALIS[WW400R.HTM 5/6/2004 I ZNE t°w� Town of Barnstable Regulatory Services * * * * * BARNSTABLE, * Thomas F. Geiler,Director MASS. g - 1639• ,0 Public Health Division rFD MA't A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 C. Johnson& Co. Date: September 22, 2004 1645 B Falmouth Road Centerville, Ma. 02632 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 1645 Falmouth Road, Centerville was inspected on, 12/27/99 by James D. Sears a Massachusetts licensed septic inspector. ,. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS: Our records show that the system has been in a failed state for more than two years. You are ordered to hire a professional engineer or registered sanitarian to prepare:a plan of proposed replacement septic system component(s). This plan is to be submitted to:the Town of:.. Barnstable Public Health Division Office (Regulatory Services, 200 Main Street, Hyannis),within (90) days receipt of this letter. The plan will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title V. You are a lso o rdered t o u pgrade o r r eplace t he s eptic s ystem w ithin s ix months (180) days o f y our receipt of this letter. Any person aggrieved by any order issued by the local approval authority may appeal to any c ourt o f competent jurisdiction as provided for by the laws of the Commonwealth. You have the option of requesting an adjudicatory hearing pursuant to 310 CMR 15.422 Failure to comply with this order will automatically result in a public hearing scheduled before the Board of Health. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health CC: Board of Health 1/failed—septic_letters j U.S. Postal Service PERTIFIED MAIL RECEIPT A�mestic Mail Only;No Insurance Coverage Provided) N o � p Postage $ LIT Certified Fee r � 0 p� Postmark Return Receipt Fee M (Endorsement Required) a Restricted Delivery Fee C:3 (Endorsement Required) O p Total Postage&Fees LISPS .� f� Sent To a FI ^st !7Nq s^z h�gnca PiY,_e� __-------------------- Street, ---------------------------------- Apt.No.;or PO Box No. O �oy� a3----------------------------------------------------------- r3 City,State,ZIP+4 PS Form :00 May 2000 See Reverse for Instructions Certified Mail Provides: o A mailing receipt ` o A unique identifier for your mailpiece f o A signature upon delivery o A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class,Mail or Priority Mail. o Certified Mail is not available for any class of international mail. N o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery:To obtain g6turn Receipt service,please complete and attach a Return Receipt(PS Form 3911)to the article and add applicable postage to cover the fee.Endorse mailpiece'Return Receipt Requested".To receive a fee waiver for -a duplicate return receipt,a USPS postmark on your Certified Mail receipt is .required. �' o For an additio.h lh fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for.postmarking. If�a postmark on the Certified Mail receipt is not needed,detach'and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,May 2000(Reverse) 102595-99-M-2087 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. J .gent ■ Print your name and address on the reverse X ►Zr � ❑Addressee so that we can return the card to you. B. Received by(Printed Nam(a) C.mate f Del' ■ Attach this card to the back of the mailpiece, / �(� d or on the front if space permits. c ��r A o I D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: o First Property Management 411. w 3. Service Type - I046 Main Street ❑Certified Mail ❑ Express Mail Ostery lle, MA 02655 ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service label) PS Form 3811,August not` ' ` Domestic Return Receipt ' 102595-02-M-1540 �_ i UNITED STATES POSTAL SER -........,First,qlass Mail Postage&Fees Paid LISPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE 200 MAMT STREET HYANNIS, MASSACHUSETTS. 02601 THE T� Town of Barnstable BARNSTABLE, * Regulatory Services 9 MASS. g g Y �p 1639. Thomas F. Geiler,Director rF0 MA'S A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 26, 2005 First Property Management#11 1046 Main Street Osterville,MA 02655 Re; Bayberry Condominiums NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 1645 Route 28, Centerville,MA was inspected on June 24, 2005 by James D. Sears a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: SYSTEM A One pre cast pit is 8' 4"below grade. Pit is full of water up into risor with 2' steel cover at grade. Distribution Box is full over outlet. i You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. B OH H DEPARTMENT COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION 350 MAIN STREET v WEST YARMOUTH,MA 508-775-2800 KM TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1645 ROUTE 28 , CENTERVILLE,MA 02632 Owner's Name: BAYBERRY CONDOS Owner's Address: 1645 ROUTE 28 + CENTERVILLE,MA 02632 ., Date of Inspection JUNE 24,2005 Name of Inspector:(please print) JAMES D.SEARS s c Company Name: A&B Canco r Wr Mailing Address: 350 Main Street < c-> West Yarmouth,MA 02673 --, Telephone Number: 508-775-2800 I air CERTIFICATION STATEMENT c.a I certify that I have personally inspected the sewage disposal system at this address and that we inforc ation reported below is true,accurate and complete as of the time of the inspection. The inspectior was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority _T Fails n Inspector's Signature: LDate: 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 tot he buyer..if applicable,and the approving authority. .Notes and Comments SYSTEM A—REPORT ONE OF FOUR ****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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health;will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1645 ROUTE 28 _ CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: DUNE 24,2005 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CNM 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has.a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance *" This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 hispection Form 6/15.2000 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: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 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 leaching is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CUR 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 Title 5 Inspection Form 6/15/2000 4 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: .TUNE 24,2005 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)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 CUR 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: DUNE 24,2005 FLOW CONDITIONS RESIDENTIAL-N/A Number of Bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: OFFICE CONDOMINIUMS Design flow(based on 310 CMR 15.203): 345 Basis of design flow(seats/persons/sgft,etc.): 345 Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: Last date of occupancy/use: PRESENT OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 1997, I998,1999,AND 2000—BARNSTABLE PLANT Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM -1( Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1985 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15f2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): Depth below grade: 6' Material of construction: concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: F, Distance from top of sludge to the bottom of outlet tee or baffle: N/A Scum thickness: F, Distance from top of scum to top of outlet tee or baffle: ' 5" Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: TAPE AND ASBUILT 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 AT WORKING LEVEL.ONE INLET TEE,ONE OUTLET TEE. BOTH COVERS 2'STEEL AT GRADE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylenes other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alami present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarni and float switches,etc.): DISTRIBUTION BOX: ✓6'+ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Continents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS 82"BELOW GRADE.BOX IS 20"X20"INSIDE WALL TO WALL SQUARE. ONE LIEN IN,ONE LINE OUT. 2'STEEL COVER AT GRADE.D-BOX IS FULL OVER OUTLET. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: RJNF 24,2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type •/ leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ONE 4'PRE CAST PIT,PIT IS 8'4"BELOW GRADE. PIT IS FULL WATER UP INTO RISOR WITH 2' STEEL COVER AT GRADE. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionX locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: _ Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) , � • ,,.S�h 3Y i� _� .. Y . Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: JUNE 24,2005 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. 13Aj F rel 0 s ysrIn ,9 ° RTJ Title 5 Inspection Form 6/15/2000 10 Page 11 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: DUNE 24,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 13+ 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: Observation 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: 13'+'TO GROUND WATER. GROUND WATER DEPTH TAKEN OFF REPORT ON FILE AT THE BOARD OF HEALTH. .IVnr F C s YS�M c 0 0 EA � r F G pad� A 1001 c S 4 Om ° 0 s l T�► 1,- Postal CERTIFIED MAIL RECEIPT (Do4nestic Mail Only; . Insurance Coverage Provided) Ln .7 ►A y L7 Postage $Ln .� y � Certified Fee ark Return Receipt Fee q e ft1 (Endorsement Required) • n b co Q Restricted Delivery Fee Cj (Endorsement Required) .S C3 Total Postage&Fees 4 2 09Zo (u d s Bayside Building o P.O. Box 95 _T Centerville, Ma 02632 IPS Form 3800,January 2001 I Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece i ■ A signature upon delivery ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail or Priority Mail.'` ■ Certified Mail is not available for'any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and"add applicable postage to cover the fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for a duplicate return,receipt,a USPS postmark on your Certified Mail receipYis required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the,clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,Please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,January 2001 (Reverse) 102595-01-M-1049 Barnstable Assessing Search Results Page 1 of 2 9� N Home: Departments:Assessors Division: Property Assessment Search Results 1645 FALMOUTH ROAD/RTE 28 Owner: BAYSIDE BUILDING CO INC Property Sketch Legend AS,,;TC14i HtIUSE t1AI1Tjg02 Map/Parcel/Parcel Extension i 209 /086/C04 Mailing Address BAYSIDE BUILDING CO INC P O BOX 95 CENTERVILLE, MA.02632 2004 Assessed Values: Appraised Value Assessed Value Building Value: $78,300 $78,300 Extra Features: $0 $0 Outbuildings: $0 $0 Land Value: $0 $0 Interactive Property Map: ap requires Plug in: Totals:$78,300 $78,300 1 have visited the maps before g Show Me The Map ;' April 2001 photos available Sales History: Owner: Sale Date Book/Page: Sale Price: BAYSIDE BUILDING CO INC 2/15/1991 7435/197 $ 100 DACEY, BRIAN T TR 8/15/1982 3539/250 $25,000 2004 Tax Information: Tax Rates: (per$1,000 of valuation) Town Tax $517.56 Town Fire District Rates Other Rates 6.61 Barnstable 2.01 Land Bank 3%of Town Tax C.O.M.M. FD Tax $86.13 C.O.M.M. 1.10 Cotuit 1.52 Land Bank Tax $ 15.53 Hyannis 2.03 West Barnstable 1.36 Total: $619.22 Due to rounding differences these values may vary http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/... 9/21/2004 Barnstable Assessing Search Results Page 2 of 2 Land and Building Information Land Building Lot Size(Acres) 0 Year Built 1983 Appraised Value $0 Living Area 602 Assessed Value $0 Replacement Cost$97,500 Depreciation 14 Building Value 78,300 Construction Details Style Condo Office Interior Floors Carpet Model Commercial Interior Walls Drywall Grade Custom Heat Fuel Electric Stories 2 Stories Heat Type Elec Baseboard Exterior Walls Wood Shingle AC Type None Roof Structure Gable/Hip Bedrooms Zero Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms Zero Bathrms Total Rooms Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value Property Sketch Legend BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area (Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area (Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/... 9/21/2004 oFINE A Town of Barnstable o Regulatory Services fARNSTABLE, * Thomas F. Geiler, Director MASS. �A 1639. Public Health Division rFD MA't A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Bayside Building Co. Inc. Date: September 22, 2004 P.O. Box 95 Centerville, Ma. 02632 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 1645 Falmouth Road, Centerville was inspected on, 12/27/99 by James D. Sears a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Backup.of sewage into facility or system component due to overloaded or clogged SAS. Our records show that the system has been in a failed state for more than two years. You are ordered to hire a professional engineer or registered sanitarian to prepare a plan of proposed replacement septic system component(s). This plan is to be submitted to.the Town of Barnstable Public Health Division Office (Regulatory Services, 200 Main Street, Hyannis), within (90) days receipt of this letter. The plan will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title V. You are a lso o rdered t o u pgrade o r r eplace t he s eptic s ystem w ithin s ix months (180) days o f y our receipt of this letter. An person aggrieved b an order issued b the local approval authority may appeal to an c ourt o f Y P g� Y Y Y pp Y Y pp Y competent jurisdiction as provided for by the laws of the Commonwealth. You have the option of requesting an adjudicatory hearing pursuant to 310 CMR 15.422 Failure to comply with this order will automatically result in a public hearing scheduled before the Board of Health. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health CC: Board of Health 1:ffailed_septic_lettus 1U.S. Postal (DomesticCERTIFIED MAIL RECEIPT Only; Ci ewi7 ti 9 d Ln Postage $ Ln Certified Fee _a - Postmark Return Receipt Fee Here" (Endorsement Required) I t 7 C3 Restricted Delivery Fee C3 (Endorsement Required) O Total Postage&Fees $ 4 c�W �Q9Zr Kathleen S. Vendola Tr. 38 Rainbow Drive Centerville, Ma. 02632 Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A signature upon delivery ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. ■ Certified Mail is not available for any class of international mail. . .. e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt;is required. - ■ For an additional fee, delivery.may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the, endorsement"Restricted Delivery". e If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry.i PS Farm 3800,January 2001(Reverse) 102595-01-M-1049, 1, astable Assessing Search Results Page 1 of 2 Home: Departments:Assessors Division: Property Assessment Search Results 1645 FALMOUTH ROAD/RTE 28 Owner: Property Sketch Legend VENDOLA, KATHLEEN S TR Map/Parcel/Parcel Extension 209 /086/A01 Mailing Address VENDOLA, KATHLEEN S TR VEO TRUST 38 RAINBOW DR CENTERVILLE, MA.02632 2004 Assessed Values: Appraised Value Assessed Value Building Value: $ 142,000 $ 142,000 Extra Features: $0 $0 Outbuildings: $0 $0 Land Value: $0 $0 Interactive Property Map: Ma requires Plu in: 41 Totals:$ 142,000 $ 142,000 1 have visited the maps before n Show Me The Map p + � April 2001 photos available ... Sales History: Owner: Sale Date Book/Page: Sale Price: WHITE,ALLEN J TRS 5/15/1993 8575/162 $ 1 SCHILLING,THEODORE A TRS 4/15/1989 6710/282 $432,000 BERKSHIRE COUNTY SAVINGS BN 4/15/1989 6706/209 $407,000 DAIGLE, PETER M&GRACE M 12/15/1987 4827/225 $ 141,000 DAIGLE, PETER M&GRACE M 12/15/1985 4827/225 $ 141,000 NOWAK, STANLEY P 7/15/1982 3517/1 $0 VENDOLA, KATHLEEN S TR 3/4/1998 11262/131 $ 101,000 2004 Tax Information: Tax Rates: (per$1,000 of valuation) Town Tax $938.62 Town Fire District Rates Other Rates 6.61 Barnstable 2.01 Land Bank 3%of Town Tax C.O.M.M. FD Tax $ 156.20 C.O.M.M. 1.10 http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/... 9/21/2004 It: B ,stable Assessing Search Results Page 2 of 2 Cotuit 1.52 Land Bank Tax $28.16 Hyannis 2.03 West Barnstable 1.36 Total: $ 1,122.98 Due to rounding differences these values may vary Land and Building Information Land Building Lot Size(Acres) 0 Year Built 1983 Appraised Value $0 Living Area 1014 Assessed Value $0 Replacement Cost$ 164,228 Depreciation 14 Building Value 142,000 Construction Details Style Condo Office Interior Floors Carpet Model Commercial Interior Walls Drywall Grade Custom Heat Fuel Electric Stories 1 Story Heat Type Elec Baseboard Exterior Walls Wood Shingle AC Type None Roof Structure Gable/Hip Bedrooms Zero Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms Zero Bathrms Total Rooms Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value Property Sketch Legend BAS First Floor, Living Area FST Utility Area (Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/tob02/Depts/Administrative Services/Finance/Assessing/... 9/21/2004 I °FINE Teti Town of Barnstable ,i Regulatory Services BARNSTABLE, * Thomas F. Geiler,Director 9 MA88. �pr�p��as Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Kathleen S. Vendola Tr. Date: September 22, 2004 38 Rainbow Drive Centerville, Ma. 02632 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 1645 Falmouth Road, Centerville was inspected on, 12/27/99 by James D. Sears a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS: Our records show that the system has been in a failed state for more than two years. You are ordered to hire a professional engineer or registered sanitarian to prepare a plan of proposed replacement septic system component(s). This plan is to be submitted to the Town of Barnstable Public Health Division Office (Regulatory Services, 200 Main Street, Hyannis),within (90) days receipt of this letter. The plan will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title V. You are a lso o rdered t o u pgrade o r r eplace t he s eptic s ystem w ithin s ix months (180) days o f y our receipt of this letter. Any person aggrieved by any order issued by the local approval authority may appeal to any c ourt o f competent jurisdiction as provided for by the laws of the Commonwealth. You have the option of requesting an adjudicatory hearing pursuant to 310 CMR 15.422 Failure to comply with this order will automatically result in a public hearing scheduled before the Board of Health. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health CC: Board of Health 1/failed septic_letters Postal (DomesticCERTIFIED MAIL RECEIPT Only; m ca O Postage $ 1 JjHere u7 Certified FeeCO Return Receipt Fee "t't't (Endorsement Required) p Restricted Delivery Fee 0 (Endorsement Required) O Total Postage&Fees $ 4 Y � t` -3 Sent To a i Allen J. White E3 Street,Apt.No.;or PO Box P.O.Box 979 p City,State,ZIP+4 Hyannis,Ma 02601 �' �� �.___ _ __a - - PS Form :00000 See Reverse for Instructions Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece o A signature upon delivery y o A record of delivery kept by the Postal Service for two years Important Reminders. o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece to Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,May 2000(Reverse) 102595-99-M-20K i COMPLETE THIS SECTION ON ■ Complete items 1,2,and 3.Also complete A. Signat a r7 item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by rin d e) C.'ate of Delivery ■ Attach this card to the back of the mailpiece, ^ �`6 or on the front if space permits. D. Is deliv address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No ol Allen J. White P.O. Box 979 I 3. Service Type I Hyannis,Ma 02601 ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. I 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7 000 10( ) O'Z)1 3 1�3 59 0 00'63 (Transfer from service labeq PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540, I � I � U ITED STATES POSTAL SERVICE First-Class Mail r Postage&Fees Paid USPS Permit No.G-10 I I ' Sender: Please print your name, address, and ZIP+4 in this box• i I I Public Health Division Town Of Barnstable 200 Main Street Hyannis,Massachusetts 02601 i i i i i I i fEilf�t�f.� � P "w L �:� oFt rqy Town of Barnstable y ° Regulatory Services g Y BARNSTABLE,.* Thomas F. Geiler,Director MASS. Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Allen J.White Date: 4/29/04 P.O. Box 979 Hyannis, Ma 02601 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 1645 B Falmouth Rd., Centerville was inspected on, 1/10/00 by James D. Sears, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Backup of sewage into facility or system due to an overloaded or clogged SAS or cesspool: .Our records show that the system has been in a failed state for more than two years. You are ordered to hire a professional engineer or registered sanitarian to.prepare.a plan- of proposed replacement septic system component(s). This plan is to be submitted 'to theTown of'. Barnstable Public Health Division Office (Regulatory Services, 200 Main Street,Hyannis), within (90) days receipt of this letter. The plan will bring the septic system into compliance with 310 CMR 15.00,The State Environmental Code, Title V. You are also ordered to upgrade or replace the septic system within six months (180) days of your receipt of this letter. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. You have the option of requesting an adjudicatory hearing pursuant to 310 CMR 15.422 Failure to comply with this order will automatically result in a public hearing scheduled before the Board of Health. �PJRJQRDEPIOF BOARD OF HEALTH Thomas A. cKean,R.S., C.H.O. Agent of the Board of Health CC: Board of Health J:/OeLsepticjetters M 1 Septic inspection Information :...............:::::.::: :::::::::::: 1rlo/z000 ..............in ::::::: ::: i. ..[[.��..rr.....-. :.;:.... 209 `3?a ..: 086B04 > < 0 :vi:{7NiJ1%Hi4: Centerville James D. Sears #` F !s3 2/27/1999 .................. .:.... ........................ ........................ : r 01/ 9/2004 10:34 5087789628 AB CANCO PAGE 01 cry)Z �. EECE-IVE DFR AR 0 8 2004 350 MAIN STREET TOV��; T WEST YARMOUTH,MA HEAA LTHH DEPEPT: 508-775-2800 • TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOA UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP �ARCEL MAP o Property.Address: PARCEL 1tir Owner N As ame: Ttsl AJ FS Owner's Address; _�_4 1!V `_,4 4 C f'�'� Date of Inspection Name of Inspector('please print) Company Name! A&B Canco Mailing Address;, 350 Main Street West Yarmouth.MA 02673 Telephone Number; 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems, I am a DTP approved system inspector pursuant to Section I5.340 of Tittle 5 (310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluat' by the Local Approving Authority Fail 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 tot he 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 l 01/,29/2004 10:34 5087789628 AB CANCO PAGE 02 Page 2 of It OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 have not found any inforination which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15,304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionwlly Passes: One or more system components as described in the"Conditional Pass'section need to be replaced or repaired. The system,upon completion oF'the replacement or repair,as approved by the Board of Health,will pass, Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): brokcn pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/.2000 2 01/;29/2004 10:34 5087789628 AB CANCO PAGE 03 Page 3 of I I OFFICIAL TNSIPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 51 SUR AC'.E SEVtiAGE DiSFOSAL LSSPECTION rOi IX FART A CERTIFICATION(CONTINUED) Property Address: Owner: Date of lnspection: C. Further Evaluation is Required by the Board of Health: �A _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, afety,or the environment. I. 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 salt marsh 2. System will fail unle!is 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 l of 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 eoliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. Title 5 Inspection Form 6/15/2000 3 01/,29/2004 10:34 5087789628 AB CANCO PAGE 04 w. Page 4 of 1 I OFFICIAL INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: N, You must indicate"yes"or"no"to each of the following for all uispections: Yes No �Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool w,' 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 !T Liquid depth in c is less than 6"below invert or available volume is less than 112 day flow v Required pumping more than 4 times in the last year aOl 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 AIA 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 m,ith no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds lindicates that the well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this font[.) /VP (Yes/No)The system Fails. 1 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: A/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes."or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface water supply the system is It:,cared in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I I ofa public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yL-s"in Section D above the large system is 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 CM R 15,304. The iystern owner should contact the appropriate regional office of the Department. Page 5 of 1 l Title 5 Inspection Form 6i l5/,22000 4 01/29/2004 10:34 5087789628 AB CANCO PAGE 05 OFFICIAL INSPECTION F ORNI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if!Le 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) it Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? y Were all system components.including the-SAS,located on site? ii 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 y- Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance oFsubsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)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 CMlk 15.302(3)(b)) T::ic 5 Inspeuci;,-T-*m 6/15.^ 5 01/29/2004 10:34 5087789628 AB CANCO PAGE 06 Page 6 of I I OFFICIAL INS:PECT'ION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS, RESIDENTIAL Number of Bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CbIR 15.203(for example; 110 gpd x#of bedrooms: Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use(yes or no): _ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: COMMERCIALRNDU�SST 2IAL Type of establishment: %.4 /V 5j,1& r 0 - j/off E Design flow(based on 310 CMR 15.203): A-1.7 Basis of design flow(scats/persons/sgft,etc.): AI4 Grease trap present(yes or no): /­14) Industrial waste holding tank present(yes or no): N� Non-sanitary waste discharged to the Title 5 system(yes or no): A.,4' Water meter readings,if available: �(J Last date of occupancy/use: ' 7 OTHER(describe): GENERAL INFORMATION Pumping Records ✓ Source of information: f'f /V Was system pumped as part of the inspection(yes or no): A., If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPT OF SYSTEM 1/Septic tank,distribution box,soil absorption 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 systet-n owner) Tight tank Attach copy of the DEP approval Other(describe): _ Apnrocimate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): VO Tirle.5 Inspection Form o/l.�%2000 6 I 01/29/2004 10: 34 5087789628 AB CANCO PAGE 07 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFr9,CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan): Depth below grade: Materials of construction:: Cast iron �40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): �. Depth below grade; ! Material of construction; Jel'�concrete metal fiberglass polyethylene _ other(explain) If rank is mewl list age; Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of Cettitleate) _ Dimensions; 1 c� Cf ✓�L i0�Z �'/f S/ Sludge depth; ` /e Distance from top of sludge to the bottom of outlet tee or baffle: Scuts thickness: 19 Distance from top of scum to top of outlet tee or battle: Distance from bottom of scum to bottom of outlet tee or baffle. How were dimensions determined; A 1 3 &"L% o- S_- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Al '7"!� �t e3 T k�a,P�re.� ,� v tLx �c.. r T (' o u r/2 a toe r/n rr ti' dil 7/7 T'o,/,2 A,' ti T '3 .C{/� -,:L, ,F f' 76! A., S',6 A Q ,r— C) U F d tea•dam� GREASE TRAP(located on site plan) A1, Depth below grade; Material of construction:..� concrete metal fiberglass ..... polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to tors of outlet tee or baffle: Distance from bottom of;c;;n to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15l2000 7 01/29/2004 10:34 5087789628 AB CANCO PAGE 08 Page 8 of I 1 OFFICIAL INSPIECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT or HOLDING TANK: Al (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: 1 Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) _ Alann level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Al/9 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert; Comments(note if box is level.and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): PUMP CHAMBER: , ,14 (locate on site plan) Pumps in working order(yes or no): Alarins in Working order(yes or no): Comments(note condition of pump chamber.,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15%2000 8 01/29/2004 10:34 5087789628 AB CANCO PAGE 09 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C INFORMATION(continued) Property Address: Owner: Date of Inspection: s SOIL ABSORPTION SYSTEM(SAS): to (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- in nOVative/alterna live system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vege(ation,etc.) Aft ,ras l i T r Tt CESSPOOLS: ��fl (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.); PRIVY: o4,•,4 (locate on site plan) Materials of Construction: Dimensions: ^` Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc,) Title 5 Inspection Form 6/l5i 2000 9 01/29/2004 10:34 5087789628 AB CANCO PAGE 10 Page 9 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINJ PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference laddmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buildini.. f� a C! � tb44 •Z z i' / r F Title 5 Inspection Form 6/15/1000 10 01/29/2004 10:34 5087789628 AB CANCO PAGE 11 Page 1 I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to roundwate:r T 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: L, Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Nealtb-explain: Checked with local excavators,installers-(attach documentation Accessed USGS databaqe-explain: You must describe how you established the high ground water elevation: 23rj7di4 9 ;v o � N 6,. Title 5 Inspection Form j/2000 11 McKean, Thomas From: McKean, Thomas Sent: Friday, January 16, 2004 3:27 PM To: Giangregorio, Robin Subject: SP# 12-2004 The application for"expansion of use" triggers a septic system inspection. The applicant is required to hire a DEP certified septic system inspector to conduct an inspection and to complete the required 11 page inspection report. 1 APPLICATION FOR SITE PLAN REVIEW ' Z� LOCATION lily %-,Non-a aela,'ey Business Name: Wa Tamales Apparel &T N/A Subdivision Plan Assessor's Map# 2()g Parcel# 013 ANR Plan WA Property Address: 1644 Falmouth Road Site Plan Cite p n in Ban table mwared for Centerville, M C2632 Marcel R. Foyant by Til beits Ilg'r Crap. dated OWNER OF PROPERTY Mn-di 26, 1974 Scale V = 20' APPLICANT Name: R. �Yt Name: Kinberly Nye arzi Norrl� Delariey Address: 2R2 BamtahlP Rat Address: 1644 Faith Road P.O. Box K. 91armis. IA 02601 Ge►terville, M� 02632 Telephone: U-775-6029 Telephone 503-771-9009 Fax Fax ARCHITECT/DEVELOPER/CONTRACTOR/ENGINEER AGENT/ATTORNEY Name: N/A Name: J&n W. Kerffley, Fsq. Address: Address: 15% Falr=th Road, Suite 12 Telephone: ra,rwri 7IA M4 02632 Telephone T.i .771-qTp Fax Fax 505-775-6029 STORAGE TANKS(HAZ MAT/FUEL OR ZONING DISTRICT CLASSIFICATION 10S p �' E �is c Overlay(s) NMExistingProposedSq.Ft. 4-60 Ac. Number Number ire Distri t Oy Size Size � 1 2 . 20(��o tcksl .) Above Ground Above G and Side 30 Rear 20 Underground Undergro d Contents Contents i er o Buildin s 3 Proposed N/A Demolition N/A UTILITIES TOTAL FLOOR AREA BY USE Sewer-QPublic ElPrivate Size 1000 gal Existing Water- Public (59•�• Proposed(Sq.a> © ❑Private Basement Electric-®Aerial 0 Underground--- ----- ---Residential Gas-M Natural ❑Propane" Restaurant Grease Trap-❑Size N/A gal Retail 1012.50 1012.50 Sewage Daily Flow * NSA gpd Office Medical Office PARKING SPACES CURB CUTS Commercial (specify) Required Existing 2 Wholesale(specify)( p ') Provided 201 Proposed 0 Institutional(specify) On-Site To Close 0 Industrial(specify) Off-Site Totals 2 All Other Uses On Site Handicapped Gross Floor Area *GP or WP areas restrict wastewater discharge to 330 RE I V E gallons per acre per day into on-site system. Estirmted - Dd stiz g site, .m dimes proposed• JAIL 5 2003 Q:SiteP1an:SPRPG3—02/20/2002 TOWN OF BA NSTF BLS l?aJILDING DIV. Old%ing's Highway Regional Historic District File#_ IA Approved? ❑Yes ®No Hyannis Main Street Waterfront Historic District File#_ N/A Approved? ❑Yes ❑X No Listed in National and/or State Register of Historic Places? ❑Yes No Previous Site Plan Review File# N/A Approved? ❑Yes No Previous Zoning Board of Appeals File# N/A Approved? ❑Yes H No Is the site located in a Flood Area(Section 3-5.1). ❑Yes XO No In Area of Critical Environmental Concern? ❑Yes ]No Is the Project within 100' of Wetland Resource Area? ❑Yes ®No Site sketch—informal presentation ❑Yes No Site Plan prepared,wet stamped and signed by a Registered PE and/or PLS. [Z ❑Yes ®No Parking and Traffic Circulation Plan ❑Yes 0 No Landscape Plan and Lighting Plan ❑Yes ®No Drainage Plan with calculations and Utility Plan ❑Yes ®No Building Plans, (all floor plans, elevations and cross sections) - Ddstirg site XD Yes []No See Sketch Plan Attired Note that all signage must be approved by Code Enforcement Officer at the Building Department Lot area in sq. ft. 4.60 Axes Total Building(s)footprint sq. ft. Maximum Lot Coverage as%of Lot % D sting Site - No Ouges Proposed GROUND WATER PROTECTION OVERLAY DISTRICT REQUIREMENTS: DISTRICT: AP Lot Coverage (%) Required Proposed Ch"I�e Site Clearing (%) Required I\b Chap Proposed No Owe PRINCIPAL BUILDING _ACCESSORY BUILDING(S) ❑Yes ]No Number of floors 1 Height: ft. Number of floors Height: ft. FLOOR AREA: FLOOR AREA: Basement sq. ft. Second sq. ft. Basement sq. ft. Second sq. ft. First sq. ft. Attic sq. ft. First sq. ft. Attic sq. ft Other(Specify) Subject Unit sq. ft. Contains 1012.50 sq. ft. Please provide a brief narrative description of your proposed project: Ddstir>Q tan� salon seeks to make interior alterations onl to existir-2 floor plan to add ore- addttlonal tar'am booth. The booth will be 7 x 7 , totaLLirig 49 square feet. Tarmi% salon is I tEd in ar► existirig irg p no OU site bons. I assert that I have completed(or caused to be completed)this page and the Site Plan Review Application and that,to the best of my knowledge,the information submitted here is true. Jaru 15, 2004 M�e aril .ratur� a� ��art y rrm Icy, by their Date aft rra,Y, rr u�T PRINTED NAME OF APPLICANT Q:SiteP1an:SPRPG4 02/20/2002 f G.. 1 � 9 i e 1 _ 1 i � F i 6 kV 1 rLU tA Vw '^ �. f- i I i .c. ---� ...r---._ ._ _� � �� r— ._ �—. . -� t 1 1 E ``__ i c� � iI '� !: Y �• f� _�� t: �` I �---�� w�' ! tq �--.... ......_._--�__ �� y�;� _ i� J � g 1�^ Y Ye � II - h� xt Sgtik3^vi ,. i i+lq g l 6 , f •t1 r� : b �r � I ` � �� � � I gam , r � ,' � 1 �� Yo I V! 'a� '' �•_.'• � I , Y � _;� ,� 1. •� � � :,y / -�• � { fl 1 I• +++ I I r 1 1 y I I : q„ A ,I ,' •.` .q ft'�' r f d. � I tl G� �.�� C �, � ogo� g�g �:L2, � `? , = r, �il' �•, 6, d� ----I� ���E{ggR 3" Iny.i i�F�i�l I � 11 :yi � - , � .�, q gip;\ i��� Cy '1 �•c +� Sl�6�p'; A AE� b llllj � :=. , 'h+t.a, I�9 P r ,•,,n a �Ft it YI� rF VMSS`'s'P' ti' � r .5'+`,+i" ,e,.y q,..;� d' HI"1"75 ,n '•f` c& ' ��r� +'4�� ...b���• 3 n r�,ar�'��` � +�"'�(� ,,5' �. ,vi' l�'�,�.,c,�i,�_*s ��.,^��+ :; ��".%�r��'m'4ts�k`Y�`kx`�.tkY�� �,�t'�r•F �l+ek.,�r'i. ,ys3�y".vw��•�a'ir,_'i4�`_`,>S�s.a,.�'�v'��f� , COMMONWEALTH OF MASSACHUSET P,XECU7'IVE OFFICE OF ENVIRONMIJI /y�> ' DEPARTMI NT OF ENVIRONM+NT., �H••�',•may 350 MAIN sTREL- WEST YARMOU am SOR-77$-2800 Cco"' r TITLE,5 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTAf SIJBSOIZFACE SEWAGE DISPOSAL SYSTEM bVtcrv► PART A CERTIFICATION I Property Address: 1645 ROUVF 28 f C'I:N-I-[iRV1LLf', MA 02632 Owner's None: 13AY131.1ZRY CONDOS---- 0mler•s Address: 1645 1ZOU"IT?28 _— ------------ --Ct:Nll'.IZVII,Lf?, MA U2G32 — �, I)alcol,Inspection MAY 18,2001 -- ---_-----.----- I Naive of Inspec(or:(please prinO JAML'S D.SE.AIZS Company Name: A&I3 Casco -- Mailing Address: 350 Main Street West Yarmouth,MA 02-673 'I'clephone Number: 509-775-2800 -- -- — CERTIFICATION STATEMENT I certify Ihat I have personally inspected the sewage disposal system at this address and that fie information reportecl below is tnre. accurate and conrplc(c as of the lime of the inspection. The inspection was performed based on my 0aining and experience ill the proper function an(1 maintenance of on site sewage(Iispos,rl syslcrrls. 1 am a f)EP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM 15.000). -I-hc system: X Passes _ Conditionally Passes Ncecls Further Evaluation by the Local Approving Au(horily Fails Inspector's Signature: --- — Date: The system inspector shall submi( a copy fealt) or DEP) within :ZO(lays of comp of this inspection report to the Approving Authority (Board of fleting (his inspection. If the system is a shared system or has a cics'gn flow of 10,000 gpd or greater, the inspector and the system owner shall submit file report to (lie rtppropriate regional office of file DER 'The original should be sent to the system owner and copies sent lot Ile buyer, if applicable, and the approving authority. Notes mid Comments SYSTEM A -- REPORT ONE OF FOUR ****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 or different conditions of,use. system will perform in the future under file sarnc Title 5 filspcClion Fors ( I.5/2 00 1 s�r 3 Page 2 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X , _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18 2001 C. Further Evaluation is Required by the Board of Health: N/A _ Conditions exist wluch 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(i)(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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of 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 x 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: Tide 5 Inspection Form 6/1 5/2000 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes" or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in leaching is less than 6"below invert or available volume is less than%day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm, provided that no other failure criteria are triggered. A copy,of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CNIR 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed sunder Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 1 1 Title 5 Inspection Form 6/I5/2000 4 h' OFFICIAL INSPECTION FORM SPO AL SYSTEM INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE PART B CHECKLIST Property Address: CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 Check if the following have been done. You must indicate"yes" or"no" as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of constriction,dimensions,depth of liquid,depth of sludge and depth of scum X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CM 1 5.302(3xb)] Title 5 Inspection Form 6/15/2000 5 1:1�{ir JI �I e Page 6 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: Number of current residents: __- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: OFFICE CONDOMINIUMS Design flow(based on 310 CMR 15.203): 345 Basis of design flow(seats/persons/sgft,etc.): 345 Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: Last date of occupancy/use: PRESENT OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 1997, 1998, 1999,AND 2000—BARNSTABLE PLANT Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) hmovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1985 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 / OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: _ Continents(on condition.of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 6' Material of construction: X concrete metal fiberglass polyethylene _ other(explairt) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of' certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 1" Distance from top of sludge to the bottom of outlet tee or baffle: N/A Scum thickness: I,, Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: TAPE AND ASBUILT Conunents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL. ONE INLET TEE,ONE OUTLET TEE. BOTH COVERS 2' STEEL AT GRADE. GREASE TRAP(located on site plan) N/A Depth below grade: Material ofconstruction: _ concrete _ metal fiberglass _ polvethylene 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: Commnents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 /* Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS 82"BELOW GRADE.BOX IS 20"X20"INSIDE WALL TO WALL SQUARE. ONE LIEN IN,ONE LINE OUT. 2' STEEL COVER AT GRADE. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) :. Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits, number: 1 leaching chambers,number: leaching galleries, number leaching trenches, number,length leaching fields, number, dimensions: overflow cesspool;number: innovative/alternative system Type/name of technology: Continents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ONE 4'PRE CAST PIT,PIT IS 8'4"BELOW GRADE. PIT HAS 18"WATER WITH 2' STEEL COVER AT GRADE. CESSPOOLS: N/A (cesspool must be pumped as part of inspection Xlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 IZODUJJ 28 CI N I'1:.RVIL,l,E,MA 02632 Owner: 13AY1.31-RIZY CONDOS Date of Inspection: MAY 18,2001 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to al least two permanent relerence landmarks or benchmarks. Locate all wells within 100 lest. Locate where public water supply enters the building. 0 0 Ll O_ o I� Tod Y Title 5 Inspection Form 6/15/2000 10 d: ' lsk'rf. i e`Y 1 � / Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28 CENTERVILLE,MA 02632 Owner: BAYBERRY CONDOS Date of Inspection: MAY 18,2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 13+ 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: Observation 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: 13'+' TO GROUND WATER. GROUND WATER DEPTH TAKEN OFF REPORT ON FILE AT THE BOARD OF HEALTH. Title 5 Inspection Form 6/15/2000 11 f CE13TERVMU-OSTERVILLE-MARST013S MILLS FIRE DISTRICT 1875 ROUTE 28 CEUTERVILLE,MA 02632 (508) 790-2380lFAXa(508) 790-2385 O!L/HAZARDOUS MATERIAL RELEASE FORM F.A.# r LOCATION: ADDRESS OF RELEASE:- I AA? An..to 98 lfnrmov Anrlwraxnn AarAwnral rn.,t or.ri 7 7 u irfA n9/.'�') DATE OF RELEASE. PRODUCT RELEASED ESTIMATED QUANTITY: CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY:- PrnrYnr nntifi�atinnax n-1,.. rt<. rti.,l i.< .,..a _-A n..i 1 1 NOTIFICATIONS: FIRE DEPARTMENT: °iES(d NO( DATE: i IA rnn TIME: t I A9 I NATIONAL RESPONSE CENTER YES( 1 Nam) DATE:-TIME: DEPT.OF ENd IRONMENT AL PROTECTION YES( ) N ) DATE:-TIME: OIL SPILL COORDINATOR: YES( ) NO( ) DATE: TIME: TOWN BOARD OF HEALTH: YES ) NO( ) DATE. �wTIME:*>>i z TOWN HARBORMASTER: YES( ) NO(n) DATE: TIME OTHER AGENCIES: COMMENTS tWh41A enndvirting Jq rnntinw fire nrempntion €m iryAV of t_ht- chnnnina rnn- y T nhrprnnd what :inn .�_enred to h. mndarate ranii1 of n nwtrnlPimm nrodnrt to thn rear of 1642 Route ?$... rnntwr,-i l i a T aiiwp ri l rt-d wozkmt-n in hui l di ng who gtated tha mill wnc n;Anpmt whpy they arrivoil in morning_ . The g„411 vs,n nyinil-w co-wered wit'M sau Tt w,aa Plan lnented nr, tha nst+ nit Arinpwnn- Tan fnrthar mrtinn rnnld hang beer. t�Trc.n T..r thia' Damn rtanont Mna,rnp. ra-na nr lrotl to nni-i fy tht: Trim RpnI th Dpn_t y for evaluation. REPORTED BY DATE: 1L1c(nn WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C-O-MM FORM #58 I..f Septic Inspection Information E ta.E t.............................. ]ate 1/10/20 Se:tc lr s eic€No> tis ss trs 209 pv f3usess: lBayberry Square tturker 1645 A dre O e 8 lltag Centerville rrsper James D..Sears li s ct #atet> 513tettk 5tiMu F Pe:::::::::::::::::: 2/27/1999 ........................ 0. ii ei�tf? System A Rich Cannpn left message 10/6/04 that a leaking hopper caused the septic to fail.He spoke with someone at town hall and septic was OK'd Tom M said to consider the septic system passed. #eiE j it RePa t:Date` l+tvt iiEa#ivt tl to 9/22/2004 £n :Ii:stalTer< .................... ... 0 Lplfidlt `: c4t 3/22/2005 TOWN OF BARNSTABLE OMPLIANCE: CLASS: 1.Marine,Gas Statio7Repair satisfactory 2•Printers BOARD OF HEALTH 3.Auto Body Shops j unsatisfactory- 4.Manufacturers COMPANY .,1 �l G (see"Orders") 5.Retail Stores �D 6.Fuel Suppliers ADDRESS � Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline Jet Fuel (A) *`I Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil(C) IV transmission/hydraulic Synthetic Organics: degreasers YVi�sc llaneo kfF DISPOSAURECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply O Town Sewer Public XOn-site OPrivate 3. Indoor Floor Drains YES NO O Holding tank:MDC_ O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES I/ NO OfffifERS. O Holding tank:MDC O Catch basin/Dry well , O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product 1. 2. o�� Person(s) Interviewed inspector Date t+ .� -� :— COMMON WEAI:I'1I OF MASSACHUSJsTTS , I�XECUTIVE OFFICE OF ENVIRONMENTAL A°I'Fi/�JRS l - DEPARTMENT OF ENVIRONMEN'CAL.YRO1x,?ECTION i ONE WINTER STRF.,F,T, BOSTON MA 02108 (617) 292-5500-, _= t IV fD D 70� ARNSTAg� T T Y COXE 350 MAIN STREET ';T ecretary WEST YARMOUTH, MA ` ARGEO PAUL CELLUCCI > I)A�VTI)x . STRUHS Governor - 508-775-2800 ¢j/ 1 Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION _ MAP 209 PAR 086 SYSTEM B PROPERTY ADDRESS: 1645 ROUTE 28, CENTERVILLE ADDRESS OF OWNER: DATE OF INSPECTION: DECEMBER 14, 1999 BAYBERRY CONDOS NAME OF INSPECTOR : JAMES D. SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (506)775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY X FAILS �+ INSPECTORS SIGNATURE: DATE: The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS: REPORT 2 OF 4 NOTE: SYSTEM IS FOR THREE BUILDINGS SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. revised 9/2/98 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 INSPECTION SUMMARY: Check A,B, C, orD: A] SYSTEM PASSES: N/A I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The System,upon completion of the replacement or repair,as approved by the Board of Health will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 D]SYSTEM FAILS: YES You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to Determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in pit is less than 6"below invert or available volume is less than%day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site Has been determined based on: X Existing information.Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)11 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 ROUTE 28,CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 FLOW CONDITIONS RESIDENTIAL: N/A Design flow: g.p.d./bedroom for S.A.S. Number of bedrooms(design) Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (yes or no): If yes,separate inspection required Laundry system inspected(yes or no): Seasonal use(yes or no) Water meter readings,if available(last two(2)year usage(gpd): Sump Pump(yes or no): Last date of occupancy: COMMERCIAIJINDUSTRIAL: YES Type of establishment: OFFICE CONDOS Design flow: 842 Gpd(Based on 16.203) Basis of design flow Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no) NO Non-sanitary waste discharged to the Title 5 system:(yes or no) NO Water meter readings,if available: N/A Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1997,1998,1999 BAARNSTABLE PLANT System pumped as part of inspection:(yes or no) If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system r Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known)and source of information: 1984 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: YES (Locate on site plan) Depth below grade: 8' Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) i Dimensions: 1,500-2,000 GALLON 11'LONG Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: N/A How dimensions were determined TAPE&AS BUILT Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TANK AT WORKING LEVEL,THREE INLET TEES,ONE OUTLET TEE BOTH COVERS T STEEL AT GRADE GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised 9/2/98 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: YES (locate on site plan) Depth of liquid level above outlet invert: OVER Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) D BOX IS 9'BELOW GRADE,20"X 20"INSIDE ONE IN,TWO OUT 2'STEEL COVER AT GRADE PUMP CHAMBER: N/A (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 2 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) TWO PRE CAST PITS,9'BELOW GRADE ONE IT FULL,OTHER%FULL,LESS THAN%DAY AVAILABLE VOLUME PITS NOT LEACHING CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 9 i F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) s ysT� 3 0 F C revised 9/2/98 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater 13+ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) NOTE: GROUND TAKEN OFF REPORT ON FILE BARNSTABLE HEALTH DEPT. revised 9/2/98 11 f '=; �iOM.MC)NWIsAI,'I)I OI? M/1SSAC;1]IJSI�'I"I'S01 ENV]1�XisCU'['IVI�, O�'I ICF; OIL I .ONMi�,N'I'Ai., /\T� �)1 1'11RTMI,N'I' OI I�NVLItONM.I;N'I'/11, ,t ONE WINTER ;TREE 1', BOSTON NIA 02108 (617) 292.5.10- JAN 6 200pF1( Y ( OXI; 350 MAIN STREET To,WjpOF@q�� rnrnry WEST YARMOUTI 1, MA HFAIIHDEpT� AR,r:EO I'Alll, C:GL,L11C(;I I)AVFI%It STRU S Gom nor 50£1-775-2800 Iy �,,� (•�I ntnll.^-.^.inert" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �Q 0V 0 1 J'' PART A �L �� CERTIFICATION MAP 209 PAR 086 SYSTEM C PROPERTY ADDRESS: 1645 ROUTE 26, CENTERVILLE ADDRESS OF OWNER: DATE OF INSPECTION: DECEMBER 14, 1999 BAYBERRY CONDOS NAME OF INSPECTOR : JAMES D. SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: _A& B Canco__ MAILING ADDRESS: 350 Main Street,We Yarmouth,MA 02673 — TELEPHONE NUMBER: 50f3 775-2a00 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY X FAILS INSPECTORS SIGNATURE: _ DATE: The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department of Environmental Protection. The original should be sent to the systern owner and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS-. REPORT 3 OF 4 SITE OVER ALL PASSES,INSPECTION OF SYS T EM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.TI IERE IS NO GUARANTEE ON TILE LIFE OF THE SYSTEM. revised 9/2/98 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 INSPECTION SUMMARY: Check A, B, C, orD_ A] SYSTEM PASSES: N/A I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The System,upon completion of the replacement or repair,as approved by the Board of Health will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NIA Conditions exist which require further evaluation by.the Board of Flealth in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 D] SYSTEM FAILS: YES You must indicate either"Yes'or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to Determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in pit.is less than 6"below invert or available volume is less than%day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 4 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site Has been determined based on: X Existing information.Ex. Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)115.302(3)(b)J X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. revised 9/2/98 5 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 FLOW CONDITIONS RESIDENTIAL: N/A Design flow: g.p.d./bedroom for S,A.S. Number of bedrooms(design) Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (yes or no): If yes,separate inspection required Laundry system inspected(yes or no): Seasonal use(yes or no) Water meter readings,if available(last two(2)year usage(gpd): Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: YEA Type of establishment: OFFICE CONDOS Design flow: Gpd(Based on 15.203) Basis of design flow Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no) NO Non-sanitary waste discharged to the Title 5 system:(yes or no) NO Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1997,1998 1999 BARNSTABLE PLANE System pumped as part of inspection:(yes or no) If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution boxisoil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 1984 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: YES (Locate on site plan) Depth below grade: 20" Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: N/A Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: 01' Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How dimensions were determined TAPE&AS BUILT Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) MAIN TANK AT WORKING LEVEL,ONE INLET TEE 2'STEEL INLET COVER AT GRADE.OUTLET COVER UNDER BLACKTOP GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised 9/2/98 7 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: YES (locate on site plan) Depth of liquid level above outlet invert: N/A Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) D BOX COVER UNDER BLACKTOP PUMP CHAMBER: N/A (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,if possible,excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 2 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding;damp soil,condition of vegetation,etc.) TWO PRE CAST PITS,BOTH HAVE 2'STEEL COVERS AT GRADE ONE PIT FULL,ONE%FULL BUT HAS SIGNS OF BEING FULL CESSPOOLS: NIA (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(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.) PRIVY: NIA (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.) revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28, CEN 1-ERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECE_MBER 14, 1999 SKE1 CH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes irrto house) O S Y5 C O A T� revised 9/2/98 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater 13+ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: GROUND WATER TAKEN OFF REPORT ON FILE BARNSTABLE HEALTH DEPT. revised 9/2/98 11 L _ COMMON WEA.1,7.7I OF MASSACHUSE'I TS fl EXE( UTIVE OFFICE OP ME ENVIRONNTAL Ffm DEPA:RTME.NT O.F ENV1.R0NME.NTAL PR TE CTIO ONE WINTER STREET, BOSTON MA 02,108 (617) 292 ri�>0.0 1/ELA�f A r i Foe JA N 6 20 '� 0 T.a I Y CORE 350 MAIN STREET p�yFATH LSDWF Secretory ARGEO PAUL CELLUCCI WEST YARMOUTH, MA )) .i. STRUIIS Governor 508-775-2800 Commissioner 20 � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 209 PAR 086 SYSTEM A PROPERTY ADDRESS: 1645 ROUTE 28, CENTERVILLE ADDRESS OF OWNER: DATE OF INSPECTION: DECEMBER 14, 1999 BAYBERRY CONDOS NAME OF INSPECTOR : JAMES D.SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY. X FAILS j' INSPECTORS SIGNATURE: DATE: � 2- /c The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS: REPORT 1 OF 4 SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. revised 9/2/98 1 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 INSPECTION SUMMARY: Check A,B, C, orD: A] SYSTEM PASSES: N/A I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The System,upon completion of the replacement or repair,as approved by the Board of Health will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 2 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 D]SYSTEM FAILS: YES You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to Determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in pit is less than 6"below invert or available volume is less than%day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. NIA Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 4 L r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1645 ROUTE 28,CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site Has been determined based on: X Existing information.Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 ROUTE 28,CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 FLOW CONDITIONS RESIDENTIAL: N/A Design flow: g.p.d./bedroom for S.A.S. Number of bedrooms(design) Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (yes or no): If yes,separate inspection required Laundry system inspected(yes or no): Seasonal use(yes or no) Water meter readings,if available(last two(2)year usage(gpd): Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: YES Type of establishment: OFFICE CONDOS Design flow: 345 Gpd(Based on 15.203) Basis of design flow 345 Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no) NO Non-sanitary waste discharged to the Title 5 system:(yes or no) NO Water meter readings,if available: N/A Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1997,1998,1999 BARNSTABLE PLANT System pumped as part of inspection:(yes or no) NO If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: 1985 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: YES (Locate on site plan) Depth below grade: 6' Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: N/A How dimensions were determined TAPE&AS BUILT Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TANK AT WORKING LEVEL,ONE INLET TEE,ONE OUTLET TEE BOTH COVERS 2'STEEL AT GRADE GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised 9/2/98 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: YES (locate on site plan) Depth of liquid level above outlet invert: OVER Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) D BOX IS 82"BELOW GRADE,20"X 20"INSIDE ONE IN,ONE OUT 2'STEEL COVER AT GRADE PUMP CHAMBER: N/A (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 4'PIT Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ONE 4'PIT,8'-4"BELOW GRADE PIT IS FULL,NOT LEACHING 2'STEEL COVER AT GRADE CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) 0 revised 9/2/98 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBE 14, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater 13+ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions X Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: 13+FEET TO GROUNDWATER TAKEN OFF REPORT ON FILE BARNSTABLE HEALTH DEPT. revised 9/2/98 11 i A CERTIFIED SEPTIC SYSTEM REPORT r�: J .: REcEivFO JAN 3 1997 . a LOCATION BUILDINGS B',C,D, AND E . BAYBERRY SQUARE 1645 ROUTE 28-;/;;v, CENTERVILLE, MA 02632 PREPARED FOR MR. A. WITTER FIRST PROPERTY MANAGEMENT 832 MAIN STREET OSTERVILLE, MA 02655 BUYER NONE AT THIS TIME PREPARED BY HILLIARD HILLER P .O. BOX 250 CENTERVILLE, MA 02632 508-778-1472 YIS �w k n +S a-1 Al- Q Commonweam of Massachusetts Executive Office of Environmental Affairs Department of • Environmental Protection VANISM F.Weld Trudy Core Gewn+or swrw-y MBee peal Calluoel David B. Snuhs tL 3oesabr COf1A�'O"" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION tY,C'�.Qie y 5Ql/�2,E �iGQGS i3�G,D E /t� sropertyAddresc �G�� /QY�' �? 8 GT,s,�� G%GLf Address of Owner. )&"of Inspection: (If different) �a '`��l'v 5, dame of Inspector. �5i�1;�L�iGGrC � �a7�SS company Name.Address and Telephone Number. �G' 'X o7.5"G CERTIFICATION STATEMENT r certify that I have personally inspected the sewage disposal system at this address and that the information repored below is true. accurate sad complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and m.int,g"an of on-sits sewage disposal systems. The system: ��asaes Conditionally Passes _ Needs.Further Evaluation By the Local Approving Authority _ Fails. Inspector's Sigaaturw ?/2,, Date: A'/* The System Iaspeesar shall submit a copy,of this inspection report to the Approving Authority within thirty(30)days of compl.aung 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 -port to the appropriate r*gioaal office of the Department of Environmental Protection. Tba wi&W should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Cb..l ,C,or D: Al ISYSSTTEM PASSES: / I lam not fimnd any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15303. Any fai m trnw%a not evaluated are indicated below. Bl SYSTEM CONDTITONALLY PASSES: One or more system component&need to be replaced or repaired. The system,upon completion of the replacement or repair,peaces LWiarce yes,ea or not determined(Y, N, or ND 1. Dem-ibe beau of deter —lion in all instances. If"not determined", explain why am) _ The septic tank is metal. crackea. ar cnusily unsound, snow subatant•.a.l inf tration or exAltrat:on. or tank failure is i...mment. The system wiL pass spec-.on if the exstuig septic tans s replaced with a preforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Wlrtesr Street • Boston,Massachusetts 02108 • FAX(617) 556-1049 • Telephone(617) 292-550o P. tfd on a e, wd Pipe, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Data of Inspection: B1 SYBTSM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health.in.order to deternure if the system is failing to protect the public.health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY•AND THE ENVIRONMENT: Cmapool 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. S) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DE7XRhKINE9 THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENI` The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has'a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and in less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) O` IECR (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 46/9Y/'�/'/'y later. �— late of Itspeotiot: )1 SYS=FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 C�Tt 15.303. The basis for this dstmminatioa is identified below. The Board of Health should be contacted to determine what will be necessary to oarrec: the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Diw-harge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or oasspool. Static liquid level in the distribution box above outlet invert due to an cverioaded or dogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1,1 day flow. Raquind pumping more than. 4 times in the last year NOT due to clogged or obstricted pipetsi. Number of times pumped Any portion of the Soil Absorption System. cesspool or pray is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a sur:ace water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds. ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The fo&rwing criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10.000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the systam is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface dri,nkcng water supply the system is located in a nitrogen sensitive area(Interim Wellhead Prote t,=Area (IWPA) or a mapped Zone 11 of a public water supply well) Tha owner or apaator of any such system shall bring the system and facility Lnto full mmpiiance with the groundwater treatment program ngaismsats of 314 CUR 5.00 and 6.00. Please consult the local regional office of the Department for.further information. (revised 11103/95) 3 SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART B CHECKLIST Pra"ty Addi4mc .e%' OG e'e Owner. /�Sj lerx d�� Date of Iaspgwdoo: Zbeck if the following have been done: .I,--Pumping information Was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates wring that period. Large volumes of water bave not been introduced into the system recently or as par, of this inspection. _L�s built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. 4-'Me system does not receive non-sanitary or industrial waste flow. _6CThe site was inspected for signs of breakout. vAll system components, Y�c.�uding the Soil Absorption Syste n. have been located on the site. The septic tank manholes were uncovered opened. and the interior of the septic tank was iaspec-ed for condition of baffles or tees, material of construcion, dimensions, depth of liquid, depth of sludge,depth of scum. [�The uric and location of the Soil Absorption System on the site has been determined based on casting information or appruzimtted by non-intrusive methods. .Z The fadlity owner(and occupants- if different from owner, were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 13 Property Addeesc 3pwner. Date of Inspection: FLOW CONDITIONS RBOIDENTIAL• Design flow gallons Number of bedrooms: Number of orient residents:_ Garbage grinder(yes or no):_ Lsun&y connected to system(yes or no):_ Sessonsl aes(yes or no):_ Water meter madings, if available: Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of astabli�hmeat: OrF/G.�' u��G'C'-S — Design dow:12211oas day Grasse trap present: (yes or no)_Ae Industrial Waste Holding Tank present: (yes or no)A Nan sanitary waste discharged to the Title 5 system: (yes or-.no)- Water nww.rsadings, if available: Last date of oospaney:,,fZLaC"-rL/ OTEW (Desersbe) Last date of occapancy: GENERAL INFORMATION PUMPING RECORDS and source of information: system pumped as part of inspection: (yes or noi_ If yes,-hums pumped: gallons &awn for pumping- TYPE OF SYSTEM (/septic tankAUstrsbutioa bo/scil absorption system sb*cesspool O.e4ow cesspool Ptry shred system(yes or no) (if yes,attach previous inspection records. if any) odw(explain) APPROXIMATE AGE of all components. date installed(if known) and source of information: Swage adore di teased when arriving at the site: (yes or no i (revised 11/03/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION (continued) Property Address: 2,F- Owner. Date of Iaspsction: ia��.q/yam SEPnC TANK !/ (losts on site plan) Depth Wow pa&: watarw d Basin:,(�oonaete_metal_FRP_othertesplain) Dimensions: Uf" OL'Ba 8htdge depth: O Dist+ Qom top of sludge to bottom of outlet tee or baffle:_,)I So=this mess: O Dim=Qvm top of ectm to top of outlet tee or baffle: � Distance from bottom of scum to bottom of outlet tee or baffle:_ Cammsnts: (recommendation for pumping, condition of inlet and outlet tees or bat?les, depth of liquid level u: relation to outlet invert, st:uatual integrity, evidence of leakage, etc.). TAe-f 6"t-? GREASE TRAP:_ (beats on sits plan) Depth bek w Qadr Material of c+*utraction: —concrete_metal_FRP _othenezplain, Dimensions: Beam thir�eee: Dit==from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: comments: (reoommaidation for pumping,condition of inlet and outlet tees or baiMes, depth of liquid level in relation to outlet invert. structural intagrity, esidmas of IaLkage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PrspeelpAddtass: h'T.� Oemei: 9e- F/.25r' /�.� e' 7 Date of Inspeodan: Ja J' �c1G TIGHT OR HOLDING TANK_ (toasts an rite plan) Depth below Vida: Matwial of oonstroction:—concrete_metal_MP_other(explain) Dimaasioas: Caprtity: astllons Design flow gallons/day Alarm level' Comments: (condition of Wet tee, condition of alarm and float switches. etc.) DISTRIBUTION BOX:. (loeate an site plan) Depth of liquid level above outlet invert- d Comments: 4 (note if level ad distribution is equal,evidence of solids carryover, evidence of leakage into or out of box, etc.) �OlI iv�7 4 /9G= _. / iG U T S ekc,,' X e--,a /r PUMP CHAMML (locate an sib plan) pumps is worlaag;asden(yes or no) . Comuasmrs: . (acts oom Wi m of pump chamber,condition of pumps and appurtenances. etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION•(continued) PPopeety Address: /�ys /QT/G.�� c=,�.tiT/'/�1�C-� i . r. /p Owner. �/X; ;/— i Date of Inspection: som A880RrriON SYSTEM (SAS): (locate as ails PLY it pomade;excavation not required,but may be Oppraaimated by non-intrusive methods) If not determind to be Present,explain: Type: leeching Pits, number. leeehing chambers, number._ Leehing galleries, number: Lee}tiag trenches, number,length: Lechiag fields, number,dimensions: Omflow cesspool, number: Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation.etc.) /0/ c�>yys /G%o L I�'/S'`' 00 tv/ls G� t, An S B /S CRUPOOL9: (locate an site Plan) Nobsr and lcm2fi:,gursuoa: . Depth-top of to inlet invert: Depth of solids layer. Depth of seam layer. Dimenocas of caespooL NatajaL Of Construction;- Indic—of pound rater: bd1ow(ceespooI must be pumped as psrtt of inspection) 4=msn•&-(note onoditiva of soil. signs of hydraulic failure, level of pan ding, condition of vegetation. etc.) PRIVY:_ N=ft on sirs plan) Ysteriah of mns negina Depth of sstida- Dimensions: Ummw=(note eondhion.of soil.signs of hydraulic faaure, level of Poading, condition of vegetation, etc.) (revised 11/03/") S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Pvopw7 Addrasc /G`l5 �Tly o7 d' Data°f Ta �d/�Sj SKME OF UVAGE DISPOSAL SYSTEM: ioeiuds ties to at least two permanent references landmarks or benchmarks locate an wmu s within 100' 6 G I !J i o 0 P DEPTH 70 GMUNDWATER Depth to Fmodwaear: 7 7- feet MLbw of datarmiz a or apprac=tion: 9 5 l/ (raised 11/03/95) g TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH O 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANYVA� .. 7�ii.�G - (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS Class: 157_� 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground IN OUT IN OUT IN OUT #&gallons 777 Test Fuels: Gasoline,Jet Fuel(A) Diesel, Kerosene, #2 (B) Heavy Oils: V new motor oil(JC) �<5 oa v V .L&,<d- transmission/hydraulic HytheticPrganicsaar� as rs Avl Misce neous: Prnli owed 4 s ,sod S ei- c� sLo DISPOSALIRE(:LAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply A ' ` O Town Sewer Public 1 0 On-site OPrivate 3. Indoor Floor Drains YES NO O Holding tank:MDC_ !✓ O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product .",7 YES NO 2. e n ) Interviewed Inspector Date I TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Statio ,Rep r BOARD OF HEALTH > satisfactory 2.Printers 3.Auto Body Shops / ` n unsatisfactory- 4.Manufacturers COMPANY ` 9a-�1-� (see"Orders") 5.Retail Stores .� 6.Fuel Suppliers ADDRESS `12-P I=") Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) •f- 0, transmission/hydraulic Synthetic Organics: degreasers M l ce ne 4r w ,, _ kA671 VZA �v '7W ►'h s��-c�v4 c c ci et.CJ 3 DISPOSAURECLAMATION REMARKS: 1. Sanitary Sewage 2.W ter Supply �`OL/�.�Oe� Town Sewer Public )On-site OPrivate 3. Indoor Floor Drains YES N0--.X O Holding tank: MDC O Catch basin/Dry well O On-site system nn 4. Outdoor Surface drains:YES x NO ORDERS: O Holding tank: MDC Catch basin/Dry well O On-site'system 5.Waste Transporter Name of Hauler Destination Waste Product 1 YES INO 2. AM <y5A) Interviewed Inspector Date v Date: �J TDXAb AND HAZARDOUS MAT T LS REGI TRATION FORM NAMEOFBUSINESS: 7L_o_�- %etfQ. BUSINESS LOCATION: MAILINGADDRESS: Mail To: TELEPHONE NUMBER: _ � Board of Health � Town of Barnstable CONTACT PERSON: &�dJ P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: r _ Hyannis, MA 02601 TYPE OF BUSINESS: Does your firm y of the toxic or hazardous materials listed below, either for sale or for you own use? YESstore NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity qlpk _._.qG�'" ze(for gasoline or coolant systems) rain cleaners ntifrVEW USED Cesspool cleaners _12utomatic transmission fluid Disinfectants ,E ine and radiator flushes C oad Salt (Halite) ydraulic fluid (including brake fluid) Refrigerants ,otoorr°ils - Pesticides li NEW USED (insecticides, herbicides, rodenticides) li Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda s Car wash detergents Jewelry cleaners T ar waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN F BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair fi OARD OF HEALTH, )R' satisfactory 2.Printers 3.Auto Body Shops ^ �q O unsatisfactory- 4.Manufacturers COMPAJly j� C ! ®�✓ _� (see"Orders") 5.RetailFuel ut1 ers ADDRESS 1-63f- Tfvtof eJ Class: 7.Miscellaneous f QUANTITIES AND STORAGE (IN= indoors; OUT-outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground IN OUT IN OUTf IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers is�ell� u � U W-4 jAn _ \ e -,0 DISPOSAURECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply O Town Sewer (Public 3KOn-site OPrivate 3. Indoor Floor Drains YES.,>� NO O Holding tank: MDC C& W O Catch basin/Dry well O On-site system ' 4. Outdoor Surface drains:YES X NO ORDERS: O Holding tank:MDC Catch basin/Dry well O On-site system 5. Waste Transporter ' ' of Destination Waste Product 1. YES INO 2. Person (s) Interviewed Inspector Date I t CA � CERTIFIED SEPTIC SYSTEM REPORT LOCATION BUILDING A BAYBERRY SQUARE 1645 ROUTE 28 %�6L1f4oUfk edl'ff a$ CENTERVILLE , MA 02632 PREPARED FOR MR. A. WITTER . FIRST PROPERTY MANAGEMENT 832 MAIN STREET OSTERVILLE, MA 02655 BUYER NONE AT THIS TIME PREPARED' BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 LA v--. 19= l 5 y7 IK �w k X 43 Pt J ^ G N p Commonwealth of mossochusens Executive Office of Environmental Affairs Department of Environmental Protection MIIWte F.Wald Trudy Case Oenmer GD"� David B. Stru An"Paw CMluocl lts U.Omssnt �;pt„n�ener SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: �`yS �Q�`C G lcx re,�G%GLF_ Address of Owner- (If different) 5/— Name of Imp-Mr. /�• �//GL-i�=�Z C7Si�1',�L';G�.0 .�f� �?�SS Company Name.Addreaa and Telephone Number. IT.- Z 'X o7 5 G CERTIFICATION STATEMENT I aa=tify that I hew•pu=nally inspected the sewage disooaal system at this address and that the infor ation reported below is true. .c=mte and complete as of the time of inspection. The inspecion was performed bases on my training and experence ir-the proper function and of on-ass sewage disposal systems. The system: _1*1passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Author.:,: _ Fails Inspsatot's Sigaatw,e: Date: //�%i r, to the A rov Author_ty with=thirty(30) days of compiaLmg this The System Inspector shall submit a copy,of the Mapes on repo FP �€ inspsaaoy, If the system is a shared system or has a design now of 10.000 gpd or greater, the inspector and the&ystent owner&hall submit the report to the appropriate regional office of the Department of Environmental Protection. The original shwld he sent to the system owner and copies sent to the buyer, if applicable and the approving authority. VISSPEt,'TION SUMMARY: Chsc&B,C,or D: Al SYSTEK PASSES: not found any information which indicates that the system violates any of the failure =-.sera as defined is 310 CUR 15503. Any 6%jure ernara not evaluated are indicated below. Bl SYBTSM CONDITIONALLY PASSES: One or sae m system components need w be replaced or repaued. 'Pie system,upon compieti.on of the repiaeement or repair,posses impsmon- Indieat•yes,*mar not determined(Y, N, or ND!. Desc-be hasu of deter ixiatren in all instances. If"not deter =ed-. explain why am The septic tank is metal. e-acted. stnicuraily ttrsottnd. snows suhstaatai :sii:rat:on er ez�ltrnttor_ or task failure is imminent. 7he system wl_ '.ass ;:spec:cn _ :he exst::.5 sept: arts :s replaced wit= a yonferatag septic tank as approved by the Boar.&.of??salt:. (revised 11/03/95) 1 One WWw Street • Boston, Masaacnusetts 02108 • FAX(617) 556-1049 • T•lephon•(6t7) 292-SS00 w • � v..msa on ascvcwa vion SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prop"Addreew ,�y� /'Tf' a r �'•�rG/Gc€ Omer Date of Inspection: Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass ins pecion if(with approval of the Board of Health): broken pipe(s)are replaced. obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broicen or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced oboxru ion is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health =order to deter-une if the rnmem is failing to protect the public health safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DBTERMINEc THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE Pt:BLIC HEALTH AND SAFETY AND THE ENVIRONMENrl'-. Casapooi or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER IF APPROPRIATE) DEPERMIKES THAT THE SYSTEM IS FLNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT- _ The system has a septic tank and sou absorption systet: and is with= 100 feet to a surface water suppiv or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well.. The system has a septic tank and sou absorption system and is withi: 50 feet of a prvate water supply well. The system has a septic tank and sou absorption system and is less than 100 feet but 50 feet or more from a private water supply well.uaiesa a well water analysis 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 Ism than 5 ppm. 3) OTISER (revised 11/03/95) I ' SUBSL FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Prop"Address: /6V3 ,t r a�, c�,v,'���:�U.� Owner. �j' �/25i /�.Poro�/,�TY Date of Inspeadaw a/ � D] SYSTEK FAILS: I has determined that the system violates one or more of the following failure c-ter a as defined in 310 C3LR 15.303. The basis for this dstarmiaation ct is identified beioW. The Board of Health should be contacted to determine what Will be necaasar.v to correct she Backup of sewage into facility or system component due to as overloaded or clogged SAS or cesspool. Discharge or pondi:g of eslluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or casepool. 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 1,2 day fSow. Required pumping more tzar. 4 times in the last year NOT due to clod or obstructed pipeca.. Number of times pumped Any portion of the Soil Absorption. System. cesspool or pnvy is below;he high groundwater elevation. Any portion of a cesspoo.or privy is within 100 feet of a surface water supply or t-ibutary to a surface Water supply. Any portion of a ceaspooi or privy is within a Zone I of a public Well. Any portion of a cesspool or prvy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater th r.50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well wear analysis for ooliiorm bacteria.volatile organic compounds. ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following crisera apply to large systems in addition to the criteria above: The systam sexes a fa'1;ty with a design flow of 10.000 gpd or greater(Large Sostem and the system is a significant threat to public heakh and s afM and the environment because one or more of the following conditions exist: tbs systam is within 400 feet of a surface drinking water suppiv the+ syscam is within 200 feet of a t-:butary to a surface drai ing water suPPiv _ tkw nscam is located in a nitrogen sensitive area (Inure=wellhead Prctecion Area (IWPA) or a mapped Zone II of a pabli: war supply wall) The ownw or opsrazar of any such swum shall bring the system and facility into .full mmp1ance with the groundwater treatment program rsgnir®mu of314 CUR 5.00 and 6.00. Please consult the iocai regional oMce of the Department for further information. (revised 11/03/9'S) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Pteperty AAdrerc ��y /'/•'/ SC�t//�j_'�£' �GOCY /G yS /'Tx Date of nInspel000n: ii>2T�' /�/Q��6.�'ItC.vT Cheek if the following have been done: L—?=q ag information was requested of the owner. occupant. and Board of Fealth. D.p4 vNone of the system components have been pumped for at least two weeks and the system has been receiving normal now rates during that period. Large volumes of water have not been =troduced into the system recently or as part of this inspection. built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for aigas of sewage back-up. i/T`he rpstem does not receive non-samtass or irdust—:al waste flow The site was inspected for signs of brealc"t. All system,components.lrcluding the Soil Absorption System. have been located on the site. The septic tank manholes were uncovere, opener. and the inte.—:or of the septic tactic was inspected for condition of baffles or tess, material of construction., dimensions, depth of liquid. depth of&judge, depth of scum. _L—Ths size and location of the Soil Ah wrption System on the site has been determined based on existing information or appro=mated by non-intrusive methods. fadkty owner(and ocenpants, if different from owner! were prrvided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION A� Property Addms: /&-/5— ,TW- ;?c Owner. 9> r//Is i ��'i v�"E%�7� f�i/s',�/�G.f .st.E-� 7- Date of Inspection: /a1�/Ajc FLOW CONDITIONS RESIDENTIAL. Desip dow:---fallons Number of bedroomu: Number of current residents:_ Garbage Ruda(yea or no):__ Lacey oom oned to system(yes or no):_ Seasonal=8(yes or no):_ Water meter readings, if available: Last date of ownpancy: C0M]fl=AL/INDUSTRIAI.: Design flow: 9 day Grease tap present: (yea or no)-A::v Industrial Wesel Holding Task present: (yea or no) NonaanZaryweste discharged to the Title 5 system: (yes or-no)-&r Water maw. if available: Last date of oxopaacy: /) e ?Ly OTIHM.(Des=lm) Last date of ooeapancy: GENTIL-% .INFORMATION PUMPING RECORDS and source of information: �G Oyu=pumped as paz of inspection: (ya or no i � If ygL volume pumped: gallons Reason for pumping- TYPE OF Sperm Sept tankMistrsbution box/soil absorption system cesspool Oserflow aeaspool Privy Shared system(yes or no) (if yes, attach previous inspection records. if anv) Other,(aorplain) APPROXNATE AGE of all compouez- date tustailed (Lf kno—n) and source of informatwn: C'��% !2f $Ian/,5 Bewale odors detected when arr vtng.at the site: (yes or no j _ (revised 11/03/95) S II ( 4 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORMATION (oontinued) Pvapvfty Addzw& Date of pmcteon. BBPM TANK: !/ (Ionia oa site plan) Depth below p+as: 46, Nsaetiai of oeaeUmction: d,,Coa T rte_metal_FRP _others explain) G' R?,l Dimeaoaa :_9' swes dqnL. /a Distanrn ham tap of sludge to bottom of outlet tee or bafIIe: � Scam thwkness: O Distance hoes top of scum to top of outlet tee or baffle Dista=hom bottom of scum to bar= of outlet tee or bafne: ,7 Catemtats: (raommecdation for pumping, condition of inlet and outlet tees or bat'nes, depth of liquid level L. reiat:on to outlet invert, strutural integrity, evidence of leakage, etc.) Ti`�C�K .Q.sia T�.ES- LGrI--At o f�4-�e GRUSE TRAP-_ (loots m Bite plan) Depth below p+sde: Material of aoastructmu: _concete_metal _FRP _othenezpla::., Des: 11eam thic�eas: Distance hom tap of scum to top of outlet tee or baffle: Dissaace horn bottom of srlm to bottom of outlet tee or baffle: Commmta: (rmmmmdation for pumping,condition of inlet and outlet tees or baiMes, depth of'':q-,Ud level in relation to outlet invert. structural integrity, wideao of leakage. am.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEMM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) �9 PropertyAddmm /G y5, Owner. Date of Inspeedon. TIOST OR BOLDING TANK_ Oncost on ate plan) Depth below VW@: Material of aossawtion: _aonerete _metal_ _other(eaplain) Dhomosions: Cap@Cn 011oas Design llow: osllonsiday Alarm level: Comments: (condition of inlet tee.condition of alone and float switches. etc. DISTR BLTRON BOX. (loose on she plan) Depth d ligmd level above outlet Inver.:' _ Comments: �. (you if level and distrsbution is equal evidence of sciids carryover, evidence of leakage into or out of box. etc.) PUIdP CBAMBEP— (lame an aids plan) pmep,in working a:der.(yes or no) Gammons: (yeu condition of pomp chamber, condition of pumps and eppusssnances. etc.; (revised 11/03/95) r N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORh ATION•(oontinued) Prop.rtyAddr..a: /'�.1/��G-L oat.at Iaap.etlao: BOIL ASSORPTION SYSTEM (SAS):_ Uoata as M"plan,if Roma%L:4mcww&=n not required.but may be approximated by non intrusive methods) If not detaemiaed to be present,=plain; Typs: g pits, number. "Phi,g chandmv, number._ lrehinQ galleries, number. laachiag trenches, number,length: laachimg fialds, number, dimensions: awr>3ow oaespool, number: Comments:(note condition of soil. signs of hydraulic failure. level of ponding, condition of vegetatiometc.) ,LZ:�' CZSSP00L9:_ (locate an sits plan) Number and configuration: Dspth•top a(Ugvid to inlet invert: Depth of solids layer. Depth of seam layer. Dimaodoas of caaspooL us"Aals o(OMMMexios Iadieatiom d groundwater blow(eeaapool must be pumped as par. of inspectio- Cammamts (mite condition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.) IiRIVY•_ (loots on we plan) materials d mmen-action: Depth of ads: I}imen:ioas: Cammmts:lints cols ition of soil.sips of hydraulic failure, level of ponding, condition of vegetation. etc.) (revised 11/03/") 9 } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �A SYSTEM INFORMATIO,gN (oontinued) Pl"m ty A Date of n/.r�5 SKVCH OF 88WAGE DISPOSAL SY9MM: i,— d ties to at kaet two permanent references landm.riw or benehmarlw lwas an wens within 100' C,. DEPTH TO GROUNDWATER Depth to pmadman f t fief aetbad of dstatmiasai� cr.pptffimatiot:: �A✓,�//ji/�,G'L.E G-/S 5/tG'La-� i h'� 5iT/� /�/.{c�%iL T�1/_� oil'%i%cam/(' r,e-a zf 4 r i&,C mil AS 4.2 2" eke. T xxx e� GS ks y 5 (revised 11/03/95) 9 i V CERTIFIED SEPTIC SYSTEM REPORT JAN 3 19 �a �T O LOCATION i " ";ov BUILDINGS B,C,D, AND E . BAYBERRY SQUARE 1645 ROUTE CENTERVILLE, MA 02632 PREPARED FOR MR. A. WITTER FIRST PROPERTY MANAGEMENT 832 MAIN STREET OSTERVILLE, MA 02655 BUYER NONE AT THIS TIME PREPARED BY HILLIARD HILLER P .O. BOX 250 CENTERVILLE, MA 02632 508-778-1472 o, 9 c l ID y �w k � 45 N Q f e;�c i Commonweafm of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WW=F.WNd Trudy Co:e Gomm Paul Ce lueei David�'Stru are SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION y SCZv,¢/�� GLCGS /3�c,O a E te Adams ys Owner - law /QT�' � P � Grt���'U/GLF_ Address of Owne . / la of Inspection: /off f 0�9/`7G (I1 different) fame of bwpector. H. /1/1L/yiZ �5i�l:�G�iGGrC ' f� ac?CZSS :ompany Name,Address and Telephone Number. ✓s- Z--X "7 52:; ;ERTIFICATION STATEM IN'T that I have personally inspeced the sewage disposal system at this address and that the information reported below is true. accurate End complete as of the tune of inspection. The inspection was performed based on my training and experiencein the proper function and naintenoney of=.site sewage disposal systems. The system: _ �)�asaes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails. Inspector's Signatw-w 21A�k Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of complaLing this inspection. If the ryaam is a shared system or has a design flow of 10,000 gpd or greater,the inspect-or and the system owner shall submit the _part to the appmpriate regional office of the Department of Environmental Praterion. The original shoald be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Chsc>�B,C,or D: All SYSTEK PASSES: �I have not found any information which indicates that ttie system violates any of the failure =-teris as defined in 310 CUR 15303. Any future c mtaria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more systam components need to be replaced or repaired. The system.upon completion of the replacement or repair,posses Iadiears yea,ao or not determined(Y, N. or ND) Desc^be basis of deter=--tioa in all instances. If'not dewraiaed-, explain why mt) _ The septic tank is metal. Cracked. str.rcuraily 4 sound. snows substantial u•Sitran.on or mfiltrat:on. or tank failure is imminent. The system wtll sass ::spec::on •f the ea:stung septic tank is replaced with a;onformrng septic tank as approved by the Board of health. (revised 11/03/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617) 556-1049 • Telephone(617) 292-MM w • �v.wW.a on a.cxWe aaa, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) Pmpertr Adsirerec owner' '7" Date of Inspection: Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water 1-1 observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four Linea 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 replaces obetru cuon is removed Cl 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 protec the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINER THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DEPERffiNES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRON3M%Q"I`: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and sou absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free 4vm pollution from that faclity and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTEM (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) roperty Address: /G t/5- /R T,, a2 caner. ate of InspeaUm ] SYSTEM FAILS: I have determined that the eyneni violates one or more of the following failure criteria as defined in 310 CILR 15.303. The basis for this daermination is identified below. The Board of Health should be contacted to determine what will be necessary to oorrec: the huhire. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of eilluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or oasspool. 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 1,'2 day flow. Required pumping more than 4 times in the last year NOT due to clogs or obstructed pipets:. Number of times pumped Any portion of the Soil Absorption System. cesspool or pray is below the high groundwater elevation. Any portion of a cesspool or privy is within. 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a oesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable..attach copy of well water analysis for aoUbrm bacteria volatile organic compounds. ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10.000 gpd or greater(Large System) and the system is a significant threat to public hWth and safety and the environment because one or more of the following conditiors exist: the eystam is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drnrrg water supply the system is located in a nitrogen sensitive area (Interim wellhead Protection Area (IWPA)or a mapped Zone 11 of a public wiser supply well) The owner or opawurr of any such system shall bring the system and fac lily into full compliance with the groundwater treatment program tsgnirsmcts of 314 CM$ 5.00 and 6.00. Please consult the local regional office of the Department for.further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Party Address Owner Date of Inspeetion: 'Cheek if the following have been done: iC Pumping information was requested of the owner. oc:apant. and Board of Health. 1/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the svatem recently or as par, of this inspection. A.built plans have been obtained and examined. Note if they are not available with N/A. _The f whit?or dwelling was inspected for signs of sewage back-up. The system does as receive non-sanitary or industrial waste flow_ -,.—The site was inspected for signs of breakout. L-All system components, 4L'uding the Sou Absorption System. have been located on the site. f!The septic tank manholes were uncovered opene_ and the interior of the septic tank was inspected for condition of bales or teas, material of constru=ion, dimensions, depth of liquid. depth of sludge,depth of scum. !=Tbs aim and location of the Sail Absorption System on the site has been determined based on costing information or approximated by non intrusive methods. _Z71he facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 6,Gi D &AC, lwner. )ate of Inspection: 1.21 ma c FLOW CONDITIONS AZBMEENTLAI. now._____jpLllonj Humber of bsdm=s: Number of current residents:_ Garbage Mader(yes or no):_ Laaadrj aonnected to system(_yes or no):_ Seasonal an(yes or no):_ Water meter readings, if available: Last date of oaatpancr COMMERCIAL/INDUS'TRIAI.: Design flow.8 pllons/day Graeae trap prasmt:.(Yes or ao) ' Industrial Waste Holding Tank present: (yes or no)A Ncn.nnitary wasta discharged to the Title 5 system: (yes or-no) Water mew.nadings, if available: Last date of oxapaacy: I�R , fLy OT$XR.(Dssarbe) Last date of occupancy-. GENERAL INFORMATION PUMPING RECORDS and source of information: /11 Y, XPu- 0- hA�/�l1Fir System pumped as part of inspection: (yes or noi_ If yes,volume pumped: ¢allons Seneca for pumping: TYPE OF SYBPEM �Septie tankAismibut;^n bda/soil absorption system stir&Cesspool Oea4ow ceerpool prily Slimed system(yes or no) (if yes,attach previous inspection records, if any) Other(a:plain) APPROXIMATE AGE of all componenu. date installed(if ltnowW and source of information: Sweep odor detected when arrrnng at the site: ryes or no i (revised 11/0 M) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION (continued) Property Addrew&- Owner Inspection: / err miff v� �,���,�T Dace of Ina S PnC TANX </ (locate on cha plan) Depth bah..PS&.—L—V Material of coastavetion:.4zmnnete_metal_FRP_vtheri explain) Dimeaocas: ilk DlCB,-' Owes depth: O Distance fmm tap of sludge to bottom of outlet tee or baffle: ,;)2 scam th�: O Distance from top of smrm to top of outlet tee or haffle: Distance from bottom of scum to bottom of outlet tee or baffle:,7i:: Comments: (r.commandation for pumping, condition of inlet and outlet tees or ba.Lnes, depth of sauid level in relation to outlet invert, rtrucural integrity, a.ideaa of leakage, eu.). 7Ay1Y K V GPJASE TRAP:_ (locate an sits plan) Depth below grads:_ Material of ooastruction: —concrete_meal_FRP _otherlexplam, Dimensions: S=thie�aas: Drat=from top of scum to top of outlet tee or baffle: Distance from bottom of smrm to borom of outlet tee or baffle: Commaats: (temmmendation for pumping, condition of inlet and outlet tees or baffles, depth of Liquid level in relation to outlet invert. strurttrai integrity, arwou a of leakage, etc.) (revised 11/03/95) 8 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PmpertyAddrase: Date of Inspeadon: TIGHT OR HOLDING TANK:_ (loot+an sib plan) Depth below Volim Material of ooastivc Lion:_ca=ete_metal_FRP _other(explain) Dbo msions: Capmity rallons )dip flow ¢allons/day Alarm level: Commaats: (ooaditica of inlet tee, condition of elarm and float switches. etc.) DISTRIBUTION BOX: (louts an site plea) Depth of liquid level above outlet invert- b - Comments: (note if level snd distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) ��vll %Vt7 1:iGA1 ':� L.e�G/�G fiL'iL L�✓J 7-/,41 E 11--.e'1 v >Z AAC 2 Z>i 4,er 7hf /s /�/r��•> 7- [✓/4s PUMP CHAKBZIL (lows as sib plan) p=ps is wmkmg aniar.(yes or no) Commsau: ` (mon mmditian oaf pump chamber,condition of pumps and appurtenances. etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Addrwc fG ys lfT/L Owner. 7y //'Si � '�/'TY .� C .i Date of Ieq»etioa: BOIL ABSORPTION SYSTEM (SAS): cf— (bats on sire Piano if posanble;excavation not required,but may be appr=X ated by non-intrusive methods) If not dstrmiaad to be Present,explain: Type: lssehiag pits, aumber.� �SE E Oi/�'�/'!�/•i v v /�yS C 5 1nc� m numb chabers, er._ 1-14ing galleries, number. Lsehiag tttmches, number,length: Machin-fields, number, dimensions: owrflaw cowpool,number: Camaunts:(note condition of soil, signs of hydraulic failure, level of pending, condition of vegetatioa.etc.)_ 19i-_y f'.2 CESSPOOLS: floats on site plea) Number and oaafigaretion: DepthAoa of liquid to inlet invert: Death of solids layer. Death of w=n layer. Dimsm dons of caaspool; YatariaL of aoamt oetion: Iadiestioa of ground water: inflow(oeaspool must be pumped as par,of inspection) Cammsats:(note condition,of sail signs of hydraulic failure, level of pending, condition of ve getation, etc.) (bats an site plan) ltateriaL of wommucdcn Depth of solids• Dimensions: Commsmn:(noes condition_of soil signs of hydraulic Whim, level of pending, condition of vegetation, etc.) (revised 11/03/95) e r Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Pmp7"draw /Gy/S �i� a a G��T 2G�rGLf SEITM OF SEWAGE DISPOSAL SYSTEM: ioeit�ds ties to at Last two permanent references landmarks or benchmarks ]Deaf+all walls within 100' G t Q i yG T s DZFM 70 MOUNDWATER Depth to RO=dwmw 7 7- feet s+sthod of dstwmim ti or apprtaimation: L 9S (revised 11/03/95) 9 CERTIFIED SEPTIC SYSTEM REPORT a ,pass � LOCATION4' 3 Ig9J BUILDING G BAYBERRY SQUARE S`F 1645 ROUTE 28 CENTERVILLE MA 02632 PREPARED FOR MR. A. WITTER FIRST PROPERTY MANAGEMENT 832 MAIN STREET OSTERVILLE, MA 02655 BUYER NONE AT THIS TIME PREPARED' BY HILLIARD HILLER P .O. BOX 250 CENTERVILLE, MA 02632 508-778-1472 1 5 97 y n -�S 4-, 4-1 � p Commonweattr! of Mossoc`lusetts Executive Office of Ervironmentcl Affairs Department of Environmental Protection M Trudy Cosa ahn F.W" savwary Gomm Argae Patti Guuxi David 8 s LL Gomm r SLTBSUWACE SEWAGE DISPOSAL SYSTEM INSPECTION FOILM PART A CERTIFICATION q1qY,a,e.2,oey sQvr°�� (1LQG G ,� r//t'sT P�(c�E-,CTY �i �.Gr�GC��t�•> 7 Addeeec 16yJ Address of Owner. Data of Ianwitiow (If different) S�— l�bi,�'tiL'iGG.0 Naa><e of Iaspaator. /-/• Compaay Name,Address and Telephone Number. ,-'X o7 5G CERTIFICATION STATEME.`T I cartifp that I have personally inspected the sewage disposal system at this address and that the mioration reported below is-tie. ac r+te and complete am of the time of iaspeeaon. The inspecior.was perforaed bases on my:raining and experiences:he proper function and ma;++•�^•^•+of=-site sewage disposal systems. The system: ,--,"Passes conditionally_ Conditionally Passes _ Needs Further Evaluation By the Local Approving Author.:;• _ Fails � / M/�/ Inspector's SlpatuL.0 ,(y� Date: /� The$ystaat inspector shall submit a copy of this inspection report to the Approving Authority withi:thi.r.y (30) days of compia;.iag this iaspec=n. If the system is a shared system or has a desipr.So-of 10.000 gpd or greater, the inspector and the system owner shall sahmit the _pact to tbs sppopriata regional office of the Department of Environmental Protection. Tia original ahoeld be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. D18PZ=GN SUbOdARY. Cbsclr&B,C,or D: Al SYgMd PASSES: I haw not hosed any information which maicates that the system violates any of the failure shells as defined in 310 CUR 15303. Azq bilim a mwm not evatnated are indicated below. Bl SYBTSM CONDITIONALLY PASSES: One or=wa symam components need to be repiacea or repaired. 1 he system.upon mmpietion of the replacement or repair,Passes Indirase jas as or not dmerminsd(Y, N, or ND!. Describe hasu of deterzo—stion in all instances. Lf'not deter=aed'. e:pla= why mt) _ The septic tacit in metal. crackea. rt:ar r&Uv inscuna. shows suonantal exAltrst:or or tank failu a is immiaent. The system wt_ ,ass ::apes:cn --'-.he ex sting septic ass is a?hcea W::: a;onfcraung se;t.c tarkasikpproved by the Boars of I?ealt:.. (revised 11/03/95) 1 Otte YNtttae Street • Boston, Massaenuserts 02108 a FAX(617) 556-1049 • Telephone(617)292-55M w • � PnMeO On 4seycwa vaor. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Add:aar Owner. �v Date of Inspection: B]SYY9=CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution bos is due to broken or obewtu~.ed pipes) or due to a broken, settled or uneven distribution baz. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution b=is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets): The system will pass inspection if(with approval of the Board of Health): broken pipew are replaced obstruction is removed CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions gist which require further evaluation by;he Board of heal;: in order to determine if the ryste=is failing to protect the public hasith safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINE✓ THAT THE SYSTEM IS NOT FUNCTIONING IN A KANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY•AND THE ENVIRONMEV1%.. 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 mast:. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER IF APPROPRIATE) WERM3NES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEAPI: The system has a septic tank and soil absorption system and is within 100 feet to a surface water ruppiy or tributary to a aurfaee water cuppiy. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply weL. The system has a septic tank and soil absorption system and is within 50 feet of a prvate water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply Weil.uusless a well water analysis for coliform bacteria and voiatile organic coatpounds indicates that the wall is free 4om pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: /G y 5 Owner. r? .af�/'lsl� /�.vT Date of Inspsadm / DI SY9=FAIIA: I bate determined that the system violates one or more of the following failure criteria as defined in 310 CIM 15.303. The basis for this deuemination is identified below. The Board of health should be contacted to determine what will be neeassary to mrsx the Backup of sewage into facility or rystem component due to an overloaded or clogged SAS or cesspool. Diaeharge or pondi g 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 1.2 day flow. Required pumping more than 4 times in the last year NOT due to ciog^ec or obstructed pipes:. Number of times pumped Any portion of the Sou Absortion System. cesspool or pray is beic-the big::^ groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a casspool or privy is within a Zane I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than.50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attacs copy of well water analysis for CoUbrm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following cetera appiv to large systems in addition to the criteria above: 7U system serves a facility with a design^. flow of 10.000 gpd or greater(Large System) and the system is a significant test to public bsal+h and safety and the environment because one or more of the following condit:ars east: tbs nstam is within 400 feet of a surface drinking water supply tba system is within 200 feet of a tributary to a surface drnicag water suppiv the system is located in a nitrogen sensitive area (Interrw wellhead Pmtecion Area (TWPA) or a mapped Zone II of a pabli: water supply well) Tba owner or operator of any such system shall bring the system and facility Into full cimpUance with the graunawater treatment program rupurmmsnts of 314 CUR 5.00 and 6.00. Please consult the local regional office of the department for further iaformauon. (revised 11/m/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Pnoperty Addrrs Owner. Date of Iaepeadon: 'Cbeck if the following have been done: ��Punq=g information was requested of the owner. oc:.spant. and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receivizu3 normal flow rates during that period. Large volumes of water have not been introduced into the svetem recently or as par, of this inspectioa. vAs built plans have been obtained and examined. Note is they are not available with N%A. _The facility or dwelling was inspected for aigrs of sewage back-up. The system does not receive non-sanitarc or industrial waste flow The site was inspected for signs of breakout. "All system components, excluding the Soil?,bscrpticr. System, have been located on the site. The septic tank manholes were uncovered. opened. and the interior of the septic tank was inspeced for condition of baffies or tees, material of Construction, dimansions, depth of liquid. depth of sludge. depth of scum. The size and location of the Soil Absorption System on the site has beer,drte- , ed based on casting information or appr�mated by non intrusive methods. ✓The facility owner(and occupants. if different from owner, were provided with information on the prover maintenance of Sub Surface Disposal System. (revises 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: r Owner. 1v Date of Inspeotion: FLOW CONDITIONS RESIDEN4'IAI� Design flow:______pllons Number of bsd:ooms: Number of earseat residents:_ Garbage grinder(yes or no):_ Laundry onnected to system(yes or no):_ Seasonal use(yes or no):_ Water meter readings,if available: Last date of occupancy: COMMERCIAL/INDUSTRIAL• Type of establishment: oFr'/G, Design flow:-allons/day Grasse trap present: (yes or no)- Industrial Waste Holding Tank present: (yes or no)_ Non.sanitaty waste discharged to the Title 5 system: (yes or no)-&o Water meter.readings, if available: Last date of occupancy: � ' L/ OTHER:(Describe) Last date of owspancy: GENERAL INFORMATION PUMPING RECORDS and source of information: fFx System pumped as part of inspection: (yea or no)_ If yes,volume pumped: ¢allons Resson for pumping: TYPE OF SYSTEM 860c soil absorption system Sin&cesspool Overflow Cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(Crplain) APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 5 �L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Date d IaspmUon: marl C TANK (Iotats an site plan) Depth below V%&: 1117' Mssetw of 0=0b.ttetion: vooncate_metal_TW_vtheriexplain) Dimmooas: 8hedp deptJL Distam from top of sludge to bottom of outlet tee or baMc Dunce&a=top of scrim to top of outlet tee or baffle: Distm=from bottom of seism to bottom of outlet tee or baSle: �G Commmts: (temmmendatica for pumping, condition of inlet and outlet tees or baines. depth of:ieuid level X. relatsot:to outlet invert, structural integrity, evidence of lea)W, etc.) 1V1,e X- o9 anus$TRAP (locate oa aia plan) Depth below V%de: Material of ocmff=%etioa: _eoaalete_metal_FR? _otherexpia.Lri: Dimmsims• Ileum thie>mesr: DW=cm ftom top of scum to top of outlet tee or bathe: Distance from bottom of sa:m to bottom of outlet tee or baMe: Cammmu: (reeomn mdatiaa for pumping, condition of inlet and outlet tees or balMes. depth of'liquid !eve; in relator. to outlet invert. structural intagriry, svideace of lmakw, am.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 15L.4(r G. Data of lnqmdm 71GET OR HOLDING TANK:_ (bear.an site plan) Depth bmiow pmde: Matenal of aamatroGioa: _ecrnesete_mrtal_MP —other(-plain) Dimanxions: Capaeity: aa<llons Demp flow: a alonslday Alarm]eel Comments (ooadition of inlet tac,condition of alara and float switches. etc.) DISTRMVTION BOx:-L,- (loaara as we plea) T6. Depth of becdd level above outlet invert: (mote if lewd ad di m*udon is equal. evidence of solids carryover. evidence of leakage into or out of box. etc.1 PUMP CRAMS B:_ (base an albs plan) pumps in working a:dam(Yea or no) . Ca®mmts: (nm a®dit9oa of pomp chamber,condition of pumps and ap Mums"'• etc-, (revised 11/03/95) ' i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION•(oontinued) Propert,Adcinum Date of Impsetiow 7 SOIL AR901UMON SYSTEM (SAS): Ooeeta an site plate if po sal ;Qcavation not required, but may be approximated by non-intrusive methods) If am daternbod to be pramnt, ss:plain: Typs: pats, number. hubini dhambars, mtmber._ Lohtag plleries, number 1re4ki-g trenches, number,length: heehiag fields, number,dimensions: overflow oeespool, number: Comments:(nm oondition of soil. signs of hydraulic failure. level of ponding, condition of vegetatiometc.) CS88POOLS: (font.an as plan) Number and oomifiguratitm: Depth-top of liquid to islet invert: Depth of&"&layer Depth of==layer Dime000as of awspool- Yaceials of aadamadoa: Iadieatioa of gru mdwatei inflow(cewpool must be pumped as par- of inspec:ioni Commes=(note aomdition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.) MV7 _ (loots an we plan) lfilauL of 000102vnioa: Dimensions: Depth of s"w Ca®m�me(note an dWan of soil. signs of hydraulic failure, level of ponding, condition of vegetation. etc.) (revised 11A13/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addrew Owner. ase 88g7CH OF SEWAGE DISPOSAL SYSTEM: ieeLtde tir to at Last two permanent references laadmarice or benchmarks bests an vans wkhin 100, - �T� - - ------ � II ``tt1 U O v� DZFM 70 GROUNDWATER Depth to Qamdwta,✓7_�feet sestbod of denemiageoom or appracimation: &i l-_-_5 AqG,Z Tlfe S/T� 711X e i 45 7G7' (revised 11/03/95) 9 i COM.MON WEAL'111 OF MASSACH.USE 1'1'S EXECUTIVE, OFFICE OF ENVIRONMENTAL AFF�TRS',' DEPARTMENT OF ENVIRONMENTAL PROTECTION h_ ONE WINTER.STREET, BOSTON MA 02108 (617) 292-5500 RIi 'aU JA N ,� JXF 350 MAIN STREET 9�µty0F Secretary ARGEO PAUL C?]..LUCCI WEST YARMOUTH, MA yFAL'�DEFIN AAV D c„ tills Governor 508-775-2800 y . cc O ftln fSSiOnel' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 209 PAR 086 SYSTEM D PROPERTY ADDRESS: 1645 ROUTE 28, CENTERVILLE ADDRESS OF OWNER: DATE OF INSPECTION: DECEMBER 14, 1999 BAYBERRY CONDOS NAME OF INSPECTOR : JAMES D.SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: DATE: The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS: REPORT 4 OF 4 SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME . OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. revised 9/2/98 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1645 ROUTE 28,CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 INSPECTION SUMMARY: Check A,9, C, orD: A] SYSTEM PASSES: YES I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The System,upon completion of the replacement or repair,as approved by the Board of Health will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed t s r revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1645 ROUTE 28,CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 D]SYSTEM FAILS: N/A You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to Determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded 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 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1645 ROUTE 28, 1999 Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the Board of Health. X None of the system components have been pumped for at least two weeks and the system Has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site Has been determined based on: X Existing information.Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 ROUTE 28,CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 FLOW CONDITIONS RESIDENTIAL: N/A Design flow: g.p.d./bedroom for S.A.S. Number of bedrooms(design) Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (yes or no): If yes,separate inspection required Laundry system inspected(yes or no): Seasonal use(yes or no) Water meter readings,if available(last two(2)year usage(gpd): Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: YES Type of establishment: OFFICE CONDOS Design flow: Gpd(Based on 16.203) Basis of design flow Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no) NO Non-sanitary waste discharged to the Title 5 system:(yes or no) NO Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1997,1998,1999 BARNSTABLE PLANE System pumped as part of inspection:(yes or no) If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: 1982 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: YES (Locate on site plan) Depth below grade: 20" Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,000 GALLON Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: N/A How dimensions were determined TAPE&AS BUILT Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TANK AT WORKING LEVEL,INLET TEE,OUTLET BAFFLE BOTH COVERS 18"STEEL AT GRADE GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised 9/2/98 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: N/A (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) PUMP CHAMBER: N/A (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 1 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ONE PRE CAST PIT.12"WATER IN PIT,NO HIGH WATER MARK PIT T BELOW GRADE 18"STEEL COVER AT GRADE CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) O � o SYSt revised 9/2/98 10 " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1645 ROUTE 28, CENTERVILLE Owner: BAYBERRY CONDOS Date of Inspection: DECEMBER 14, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date websfte visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater 13+ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health } J Check FEMA Maps r Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: GROUNDWATER DEPTH TAKEN OFF REPORT ON FILE AT BARNSTABLE HEALTH DEPT. revised 9/2/98 11 7 CERTIFIED SEPTIC SYSTEM REPORT "• - Rfc�vE0 M` JAN 3 1997 �d LOCATION BUILDINGS B,C;D, AND E . BAYBERRY SQUARE 1645 ROUTE 28 CENTERVILLE, MA 02632 PREPARED FOR MR. A. WITTER FIRST PROPERTY MANAGEMENT 832 MAIN STREET OSTERVILLE, MA 02655 BUYER NONE AT THIS TIME PREPARED BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 y 0 BAD Commonweattn of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WORM F.weld Trudy Cox* Anso Paul Ce luml David B. Struhs ti 3orseior Commeroner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION broperty Address: /G y� />4�J� 8 G Address of Owner. )ate of Itupsodon: (If different) }oZ �ijrly 5i: dame of Inspector. :ompany Name,Address and Telephone Number. ✓JGa /�' 'X o71-7 CERTIFICATION STATEMENT (cutdy that I have personally inspected the sewage disposal rystem at this address and that the information repor.,ed below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and ma;.,engn of oasite sewage disposal systems. The system: �asaes Conditionally Passes _ Needs.Further Evaluation By the Local Approving Authority _ Fails Inapeotor's 9lptatw.t: ���6�e��, Date: /;I The System Inspector sba.0 submit a copy of this inspection report to the Approving Authority within thirty(30)days of complaLing 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&hall submit the —pat to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Cb..� .C,orD: Al SYSTEM PASSES: lea not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Azq fal2are critarm not evaluated are indicated below. Bl SYS M CONDMONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,prsies Indus&yes,ao,or not determined(Y, N, or ND). Dewribe bass of deter^+ tion in all Uumances. If"not determined-, explain why sot) _ The septic tank is metal. cracked. strut uraily urtsound. shows substaatal uifiitration or ezfiltratron. or tank failure is imminent. The system will pass :nspect.on •!the ea:stmg septic tank :s epiacri wtt:^. a;oafarmutg septic ink a&approved by the Board of Health. (revised 11/03/95) 1 One Wlrteer Street a Boston, Massachusetts 02108 a FAX(617) 556-1049 • Telephone(617) 292-55M w Pr,nt@O On R@cycud Popp SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �Wxevv, �, s CERTIFICATION (continued) Property Address: 4 y /'T_' a r ) Owner. 7,v F/WSi F'.Qo� <T Y �i.9,�r�� Data of Inspection: Bl 9YS M CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions curt which require further evaluation by the Board of Health.in.order to deter=e if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A ILANNER.WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Caaspool or privy is within 50 feet of a surface water Gsspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND BAPETY AND THE ENVIRONMENT The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or mote from a private water supply well,unleas a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free hom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or lesa than 5 ppm. 3) OTHER (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) roperty Address weer. �� f�/SST PRo�°�/�1 y late of Inspection: /a .e. i!�fr�]t�.v7 )1 SYSTBM FAnz: I have determined that the system violates one or more of the following failure criteria as defined in 310 C3LR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of 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 averioaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than L'2 day flow. Required pumping more than. 4 times in the last year NOT due to clogged or obstructed pipets,. Number of times pumped Any portion of the Soil Absorption System, cesspool or prny is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a sur."ace water supply. Any,portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,.attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. . El LARGE SYSTEM FAILS: The foDowing criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10.000 gpd or greater(large System) and the system is a significant threat to public health and safety,and the environment because one or more of the following conditiors exist: 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 Protecion Area (IWPA) or a mapped Zone II of a public wasar supply well) The owner or operator of any such system shall bring the system and facility into full compiiance with the groundwater treatment program regniremsm a of 314 CUR 5.00 and 6.00. Please consult the local regional office of the Department for.further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ProPe*ty Addr"Ic Owner. �� JS�G�i'S /c'T� o?F� G�,C/ G�IG�/__ / Dole of Inspeetlon 'Chsck if the following have been done: .i,--Pumping information was requested of the owner, occupant, and Board of Health. _L--Now of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as par- of this inspection. As built plans have been obtained and ezarained. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow, yThe site was inspected for signs of breakout. -All+ystem components, eluding the Soil Absorptior. Svate:a, have been located on the site. C—The septic tank manholes were uncovered opened. and the interior of the septic tank was inspected for condition of bates or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of aatm. v The size and location of the Soil Absorption System on the site has been determined based on existing information or appram ated by non-intrusive methods. �Tbe facility owner(and occupants. if different from owner, were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION '77 A1.C'C- T Date of Inspection: FLOW CONDITIONS REMENTIAI- Desip Number of bedrooms: Number of Comsat residents:_ Garbage render(yes or no):_ Laundry aonneeted to system(yes or no):_ Seasonal ma(yea or no):_ Water meter readings,if available: Last date of occupancy: COMMER.CIAL/INDUSTRIAI.: Type ci establiahment: Di W16'' Design flow:8�- p1lonsiday Gresse trap present: (yes or no),L' Industrial Waste Holding Tank present: (yes or no) Nonasnitary waste discharged to the Title 5 system: (yes or-no) Water mew.readings, if available: Ian data of omapaacy:f�R .r fLy OTSEA Mucribe) Iaat date of omapanry. GENERAL INFORMATION* PUMPING RECORDS and source of information: I191 y / If- /yx/wl/�m System pumped as part of inspection: (yes or noi_ If yes,vohrme pumped: gallons Reswa for pumping: TYPE OF SYSTEM L/Septic tankMistrsbu=on boz isoil absorption system Owsflow asespool M%ared system(yes or no) (if yea.attach previous inspection records, if anv) Otbsr(aplain) APPROXIMATE AGE of all components, date installed(if known) and sauce of information: Via Sewage odor dstaated when arriving at the site: ayes or no i (revised 11/03M) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION (continued) � .c/ /-:XG.OG-. /; C� Property Addrer: Owner. 9v f/ T /���'�i'/�Ty ,cif v�G�,a2i�.vT Date of Inspection: eEPnC TAhIX v (looats an site plan) Depth below grad.: 8'V" Material at n: (Zooncete_metal_FRP_other(esplain) Dimea i ms:_WS' D,CBP 8hs3ge depth: O Dirt nts from tap of sludge to bottom of outlet tee or baffle: � scum thiakaeas: O Disuaa from top of scam to top of outlet tee or baffle: 6 Dktanes from bottom of scum to bottom of outlet tee or baine: ?,e: _ Commsmu: (raommsadation for pumping, condition of inlet and outlet tees or battles, depth of liquid level in relation to nutlet invert, st uctusl iaugrity, -ids=of kakage, etc.) 7,4e-Y GREASE TRAP:_ (beau on site plan) Depth balm pv3e: Malarial of aoastn=ion: —concrete_metal_FRP _,othene:pLwn Dimensions: so=thir�aess: DWbu=from top of scum to top of outlet tee or baffle: Disunas from bottom of scam to bottom of outlet tee or baffle: Comments: (rcommsndation for pumping,condition of inlet and outlet tees or balMes, depth of liquid level in relauon to outlet invert, strueural integrity, evidews of leakage, etc.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION TORM PART C SYSTEM INFORMATION(continued) PropertyAildreew L O.ner. 9d F/SST Date of Inspection: TIGHT OR HOLDING TANK_ (locate on sits plea) Depth below pods: Material of aonsuuctwn._concrete_metal_FRP _otheeexplam) Dimsnsians: Capacity: 1�llons Dam llow SaUons/day Alarm keel Comments: (aomditon of inlet tee, condition of alarm and float switches. etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid kval above outlet invert-' Comments: b �� (note if level and diambution is equal, evidence of sciids carryover, evidence of leakage into or out of box. etc.) Q (-,X L,e%G17 `Ad- �L�✓1��'Ti�/ [�x�K�v L��v�.'�. !T /fS i/ Th'E Zvi L,CT �i�'aS Le/�JL✓L C,E c-'e L /3v/ Tfi�c 'I� LEA /S /�/.•ri> 11'4-y 17, C✓FIS /�'ffiP/J Se L �✓/?/> /�v'c=ice �,G T/�/G, PUMP CHAMBSRs_ (beats an sits plan) pampa in working asdan(yes or no) Coaamimts. (ma aoodition of pump ebambar,ooadition of pumps and appurtenances. etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION•(continuerd) Property Aaareost ��5%� 1�71Y Owner. /o �//'Si OZ .��T/�/'�!//LGL Date of Iespootion ��o�'�/'TY BOIL ABSORPTION SYSTEM (SAS): ri (loots an she plan.if pooable:excavation not required,but may be appr=,,..eted by non-intrusive methods) If not drterminsd to be present,explain: Ty": 'hlaBpers, number._ SLE O11q,l/iA1ti leeehine chambers, number._ Laehing Fdkries, number: Inching tt+mches, number,length: Laehiag Holds, number, dimensions: owr}Iow compooL number: Comments:(note condition of soil. sig=of hydraulic failure, level of ponaing, condition of v _ T e6etation etc.) /nl c�s95 CBBSPOOL9:_ 0acue an ate plan) Number and oaaggnraticu: Depth-top d liquid to inlet invert: Depth of solids layer: Depth of seam layer: Dim.000ns of coespooi: Materials of mmatrnCtim. Indication of g:otmdwate. bdkm(aosrpool must be pumped as par-of inspection) C Mfint•(note condition of soil. signs of hydraulic failure, level of pon ding, coalition of vegetation, etc.) MVY:_ (bate an site plan) li(atarisL d eoms�oa: Depth of=fib: Dimensions: Ca MMC(note aamdidon.of sciL signs of hydraulic Mu re. level of ponding, condition of vegetation, etc.) (revised 11/03/95) e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) PftpwtY Address: / 07 d Si®,' E OF SEWAGE DISPOSAL SYSTEM: iachds tied to at least two permanent references landmarks or benchmarks beats all walls within 100. G r !J i ` s s o_ D&P'I'H TO GROUNDWATER Depth is Ra®dwasr. 7 7- fec satdod of dstaemmation or apprte>amation: /�A/�L/�i�_/_�i'.� G/5 -s/iv�.� T�y,�' SiTi� /�/�>��`_THi= G i L. fl?7�ry a H� dL•b'/�'s. �i/ ��J /" %&Z )5 415 (revised 11/03/95) g d tl-Z r CERTIFIED SEPTIC SYSTEM REPORT �� � Rfc�ivEO N 3 1997 LOCATION BUILDINGS B,C,D, AND E . ���;6 BAYBERRY SQUARE 1645 ROUTE CENTERVILLE, MA 02632 PREPARED FOR MR. A. WITTER FIRST PROPERTY MANAGEMENT 832 MAIN STREET OSTERVILLE, MA 02655 BUYER NONE AT THIS TIME PREPARED BY HILLIARD HILLER. P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 y iA �S Fr1 G • Commonweatm of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Coze 1110M F.WNd Trudy Gorwm AtIo Pwl Glluoei David B. S_trs+hsr U.0OMM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Address �`y� /Qr� GT.���;!'U/GG� Address of Owner. i �iffll� 5 Prop" /. Date of Inspection: (If different) �- a �ala9/9c: Name of Inspector. Company Name.Address and Telephone Number /G' X o?S G CERTIFICATION STATEMENT I oertify that I have personally neDec.,,ed the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my Mining and experience in the proper function and of=-a u sewage disposal systems. The system: _L_ aes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authoray _ Fails f Inspector's Signatturown ?/210 Date: The System Inspector&hall submit a copy of this inspection report to the Approving Authortv withM thirty (30) days of complaLing this ;"dpsctioy If the system is a shared system or has a design now of 10.000 gpd or greater,the inspector and the system owner shall submit the t part to the app apriate rgional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. DMECTION SUMMARY: Q.&S,C,or D: Al SYSTEM PASSES: 10000"I baye not fm=d any information which indicates that the system vioiates any of the failure criteria as defined in 310 CIt 15-303. Azq WI:•crnwia not evah:ated are indicated below. Bl SYSM CONDMONALLY PASSES: One or mom system components need to be repiaced or repaired. The system.upon completion of the replacement or repair,pmees inspemon- Indiaets yes,no or not detarmined(Y, N, or ND). Describe bass of determination in all lnatances. If"riot determined". explain why not) _ The, septic tank is metal. cracked. at:sc_urai y ussouad. shows :ui�atanrai :sf itration or esfiltrat:on or tank failure is imminent. The system will pass -:spec--.on :he eassg septic tarts is repiacea with a;anformmg septic tank as approved by the Board of Health. (revised 11/03/95) 1 One WitttaK Street a Boston, Masaaenusette 02108 s FAX(617) 556-1049 • Teephone(617) 292-SSW w • �vnnll0 on R@cycNa Vapr, • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) % S 11-';�v/f241 Property Addrasa: ,(`ys /'T.4' Owner. 7v FIA'S% Date of Inspection: BI SYS'TSM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(&) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C1 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 protec the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY•AND THE ENVIRONMENT. Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. S) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF APPROPRIATE) DERI WINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT`. The system has a septic tank and soil absorption system and is within 100 feet to a surface water suppiy or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply Weil,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free ikom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leas than 5 ppm. 3) OTIECR (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOPUM PART A CERTIFICATION (oontinued) Property Address /G y5- /(�r a / c L Owner. �� f=/25 i oi�'o�°�/,�Ty �j�.��"�r� .�.v 7- Date of Inspection: D) SYSTEM FAnS: I hsve dstsrmined that the system violates one or more of the following failure criteria as defined in 310 CAL 15.303. The basis for this&Wmination is identified below. The Board of Health should be contacted to determine What will be necessar9 to cOrr- the faihrre. Backup of sewage into facility or system component due to an 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 1,12 day flow. Required pumping more than: 4 times in the last year NOT due to clogged or obstructed.pipets;. Number of times pumped Any portion of the Soil Absorption System. cesspool or pray is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a su lace water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable. attach copy of well water analysis for eoaorm bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the c^ter a above: The system serves a facility with a design flow of 10.000 gpd or greater(large System) and the system is a significant threat to public broth and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a trbutary to a surface drnlcng water supply _ the srstsm is located in a nitrogen sensitive area(Inters=Wellhead P atecion Area (IWPA) or a mapped Zone II of a public —am supply well) Ths owoar or operator of any suck system shall bring the system and facility into fill!compiiance with the groundwater treatment program tequircmnts of 314 CUR 5.00 and 6.00. Please consult the local regional office of the Department for .further informauon. (revised 11/03195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Pegssrty Aaar� Oweer. Date of Inspection: I a/,y/y6 'Cbsek if the following have been done: .A,_-Pumping information was requested of the owner. occupant, and Board of Health. LNoae of the system components have been pumped for at least two weeks and the wntem has been receiving normal flow rates ddurmg that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. LAt built plans have been obtained and examined. Note if they are not available with NIA. _The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or induct—al waste flow YThe site was inspected for signs of breakout. uAll system components, 4 �uding the Sou Absorption. System. have been located on the site. vThe septic tank manholes were uncovered opened. and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid. depth of sludge, depth of scum. 1=The size and location of the Soil Absorption System on the site has beer.determined based on casting information or approrimated by non-intrusive methods. The facility owner(and occupants. if different from owner+ were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addeeec /��5' %T�' o?a- � G�yT��GyLZ�' Owner �.� %//�5% /�li'o'O�%�Tj /�i ,�/3 6/c"�Y.Eti 7- Date of Impaction: t FLOW CONDITIONS RZO DENTIAL- Design dow:­--pllons Number of badreams: Number of wrent rodents:_ Garbage gbkdw(yes or no):_ Latin b7 aoaaated to system(yes or no):_ Seasonal=0(yes or no):_ Watar meter readings, if available: Last date of m apancy: COMMERCIALMMUSTRIAL- 'type cf era&hmmt: Design 11o. day Grsess trap present: (yes or no),&s ' Industrial Waste Holding Tank present: (yes or no) Non4mnkary waste discharged to the Title 5 system: (yes or-no)�c� Water meter.readings, if available: Lan date of oeenpancq: �'Rx', -fLy OTHER:(Describe) last date of ateapancy: GENERAL INFORMATION pUMpING RECORDS and source of information: 87a m pumped as part of inspection: (yes or noi_ If yes,vcbtme pumped: rrallons Beason for pumpmr TYPE OF 8Y8TEM �Septie tankidiserIbution bos/soil absorption system Bb*eeespool Owwaow compool 8ored symmn(yes or no) (if yes.attachprevious inspection records. if any) Other(e:plain) ApPHOIDIATS AGE of all campoaeats. date imstalled(if known) and source of information: GN/L%. ©IQ i01/L1 FV Sewsp Odom detected when arrmv at the site: ayes or not )/l� (revised 11/03M) 5 i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.%1 PART C SYSTEM INFORMATION (continued) ,Oa E, PropertyAdd:ese: D°Q te f Ins y �i��/�G�,r2��.,v T p�oa. SE[PnC TANK </ (bate on site plan) DepCD below : L Yaterw of construction: .4eooaeete_metal_FRP_other(e:plam) Dbwzwi as: 4k MZX' Sbtdge depth: O Distance from top of sludge to bottom of outlet tee or baffle: ,;)2 Sawn thwkness: O Distance from top of scum to top of outlet tee or baffle: 6 Distance&=bottom of scLm to bottom of outlet tee or baMe: dee Comments: (teoommsndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, rtrucural integrity, evidence of Lakage, etc.) 2E1. -f, f�./�s" T S Lrx�c'.E✓ ��u'� �li�� S/G•c/ O/`` L��4A1.E GABASE TRAP._ (locate on site plan) Depth below Pade: Material of const rucuon: _concete_metal_FRP _other explain, Ditoeasioas: 8azm thie>mees: Disumos from top of safm to top of outlet tee or baffle: Distance from bottom of sal-to bosom of outlet tee or baffle: Cammeats: (recommendation for pumping,condition of inlet and outlet tees or baiMes, depth of'.igwd level in relation to outlet invert. structural integrity, evidence of 1sskage, etc.) (revised 11/03/95) g • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PmpertyAd6-0 /LVS� owner Date of Inspection: TIGHT OR HOLDING TANK:_ (brats on site plan) Depth below aide: MstaW of mxtm ion: _coacsew_metal_FRP _other(ezplain) Dimansioas: Capacity: Gallons Design Aaw. __pllona/day Alarm level: Comments: (aoaditioa of islet tee, condition of alara and float switches, etc.) DISTRMtMON BOX:j Gloc&A an site plan) Depth of liquid Isvwl above outlet invert- (note if level end distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) .0 7 JjG.L� �� L.t'11G,/7li'/� f'//�'iLL.l'rJ�'l-'Tirl� c� �•�`�y sc�c�v". >T PUMP CHAMSA:_ (loans on sits plea) pwaps in wm}ing order.(yes or no) . Comments: (nets aoodh=of pump cbamber,condition of pampa and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION•(continued) Owner. Date of Iaspsotioo: 801E A880RPTm /SYSTEM (SAS): r✓ (loot*on Mika plan, if poes>ble;exctyau0n,not require(L but may be approximated by non-intrusive methods) If not deamiasd to be present,explain: Type lw-b4n6pits, number-_ lsaehing chambers,number_ Lsehing pileries, number. Leciriag trenches,number,length: 6-;%iag 56lds, number, dimensions: overflow aaespool number: Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation.etc.) f l /G%0 %&IC /L y CFBSPOOIA:_ (locate on site plan) Number and configuration: Depthtop of liquid to inlet invert: Depth of solids kyer Depth of seom layer: Dimensions of cempocl• YateriaL of construction: Indineioa of groundwater: inflow(osespool must be pumped as par:of inspection) Comments (not&condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PSIVY:_ (lozase an site plan) Yatarials of Dimensions: Depth of sabda: Cammmts:(n to ooadition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) e I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Pvop@Y /Gyg� XTx c7 a/ GFowsw gTsr?L�rGLf Do"of Inspection: SZZME OF SEWAGE DISPOSAL SYSTEM: iaehde ties to at)pest two permanent references landmarks or benchmarks lama an vans Within 100, I u \ i P DEPM TO GROUNDWATER Depeh to Qa®dwww-- 7 7- feet sstbod d&wr= b=or arr—mation: l'A/'/lsii�/'GL G/5 `C1v�✓� Th'� 5i7/_� /�/'s���.� rHi� Ti4/'Gf /�1- r L�-�-AT7o'/r/ ��C I H.E b`�'/ls'sT �ii /S I�/'/".. !N,� !/"G.: �'c�s✓'/c�e-�� (revised 11/03/95) 9 on CERTIFIED SEPTIC SYSTEM REPORT REcErvEO 3 AN J LOCATION BUILDING Fes ' BAYBERRY SQUARE 1645 ROUTE 28 CENTERVILLE, MA 02632 PREPARED FOR MR. A. WITTER. FIRST PROPERTY MANAGEMENT 832 MAIN STREET OSTERVILLE , MA 02655 BUYER NONE AT THIS TIME PREPARED BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE , MA 02632 508-778-1472 y k . X 43 CL �I FrT J G Commonweatm of Mossochusetts j Executive Office of Environmental Affairs Department of Environmental Protection MlEw F.Waid Trudy Coxe Genna �� M9so Pali CNIuCcl David B�8�of U.Gomm SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / r. PART u 611" tYl ( CERTIFICATION CY,G'�Q�y 5QG'f1�'� Q��G �' /=//t�ST �i(o�'r.CTI �iF. 'GCfJ�,c•; P rapt,h,Address: 16 y; /QjE P G��.���.'-'L!GLF Address of Owner. Dal•of Isapecdoar I o�f�J/9c (If different) �'vt ,aif1J,v Si— Name of Inspector. Company Name.Address and Telephone Number. 7 SG CERTIFICATION STATEMENT I certify that I Lava personally inspec.,ed the sewage disposal system at thus address and that the in iornation reported below is true. Accz=zte and complete as of the time of inspec-ion. The inspection was peno ned base? or, my t—'Uri.^g and experience m the proper function and +�•:� e of cm oil sewage disposal systems. The system: !'asses _ Conditionally Passes _ Needs Further Evaluation By the Lora:Approving Authorty _ Fails Inspector's 9lplatw.� � Date: The System Inspector&hall submit a copy of this inspecton report to the Approv<.,g Authorty with_.thirty(30)days of compi.eLing this inaperion If the system is a shared system or has a ciesig:flow of 10.000 gpd or greater, the inspector and the system owner shall submit the rspce to the appropriate :eg=al office of the Department of Environmental Protection. The ongmW should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. ViSPECTION SUMMARY: ChW4 B.C,or D: Al SYSTEM PASSES: t✓hme not found any information which mcirates that the system violate*any of the failure criterur as defined is 310 CUR 18.303. Any f a,"arm sat wwaivased are indicated below. Bl SYSTSM CONDITIONALLY PASSES: Oy or roam system components mesa to be replaced or repaued. The system.upon mmpie=n of the replacement or repair,posees Indiosts why yes,am or not determined(Y. N, or ND . sc-be ha*u of deteraiaatwn in all itutaaees. If"not derermiaed', explain am) _ The septic tans in metal. aackea. Rnucrurwily u souna. shoes ruDr=t ai L-:hr'at:on or mfilt-at:or or tank failure w imminent. The system wilt pass -.spec.:on . :he exin=g septic tars :s repiacec w:: a;onformuag se;t:c auk as appiwed bw the Board of Hsalt:.. (revised 11/03/95) 1 One wlnear Street • Boston, Massacnusetts 02108 • FAX (617) 556-1049 • Telepnone(617) 292-5&X w • � v—led an a.e,ene aZa. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) t'. Property Address: 4 y,•5 1,"r.0 a �' , c owner. T' F/,�s� /ni{'o�'�.�T Y Date of Inspection: BJ SYF= CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obam=ed pipe(s) or due to a broken. settled or uneven distribution bum. The system will pass inspection if(with approval of the Board of Health): broken pipe(&) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass nurpecaon if(with approval of the Board of Health): broken pipe(s) are repiaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Heaitlh in order to determine if the system is faiiing to protec the public haalth,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY•AND THE ENVIRONMENT. Coespool or privy is within 50 feet of a surface water Carspool or privy is within 50 feet of a bordering vegetated wetland or a salt mania. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER IF APPROPRIATE) DETBRK NES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONME%rP The system has a septic tank and soil absorption system and is with-,:. 100 feet to a surface water suppiy or L-ibutary to a surface water suppiy. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is withi:. 50 feet of a prsvate water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply wail,uni--. a well water analysis for coliform bacteria and voiatile orgaau compounds indicates that the well is Etta 4om poi ution from that famlity and the presence of---oars nitrogen and nitrate nitrogen is equal to or lass than 5 ppm. 3) 011M (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIat PART A CERTIFICATION (oontinued) Property Address: it'r� a c Owner. `jam f/�5T OiPo��l,�Ty �'j/�f��'lsl� 7- Date of Iaspeotioa: D) SYBTSI►t FAII,15: I hive determined that the system violates one or more of the following failure criteria as defined in 310 CJa 15.303. The basis for tbis dwr=nation is identified below. The Board of health should be contacted to determine .chat Will be zeceseary to correc the fulu:t. Backup of sewage into facility or system component due to an overloaded or clogged SAS or caaspool. Dieessarge or ponds:g of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or compool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or eeaspool. Liquid depth in cesspool is less than 6"below invert or available voiume is less than 1,2 day floe. Required pumping more that. 4 tunes in the last year NOT due to clogged or obstructed pipeks:. Number of times pumped Any portion of the Soil Absorption System. cesspool or pn—is beio-the high groundwaterelevation. Any portion of a eesspooi or privy is within. 100 feet of a surface water suppiv or tr:butary to a surace water supply. Any portion of a cesspool or privy is wit'un a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a prvate water suppiv well. _ Any portion of a cesspool or privy is less than 100 feet but greater that:50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for ooUarm baceris. volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E1 LARGE BYYMM FAILS: The follnwiag eriuera appiy to large systems in addition to the criteria above: Tbs system serves a facility with a design flow of 10.000 gpd or greater(Large System') and the system is a significant threat to public bsaltb and safety and the environment because one or more of the following conditions exist: the syeram is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface dr in3cag water suppiv the system islocated in a nitrogen sensitive area (Interne Wellhead Pteteaion Area (IWPAi or a mapped Zone 11 of a pnhli atur sstpply wail) The owow or operator of any each system shall bring the system and fac hry Leto full compisnce With the gmundwater treatment program ngair�ta 0(314 CUR 5.00 and 6.00. Please consult the local regional office of tee Department for further iaformsuon. (revisev 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PROW!, Andress: x1ai'lclo y S��v/�,e,�- , yGOlr . f=. o.�.t /c. ys /t1rx a., Date off asT "V-C v7- 1a/�y�� 'Cbeek if the following have been done: �L—Pumping information was requested of the owner. occapant. and Board of Health. None of the system components have been pumped for at least two weeks and the eystem has been receiving normal flow earns during that period. Large volumes of water have not been introduced into the system recently or as par- of this inspection. As built plans have been obu=ed and examined. Note if they are not available with NiA. _The 6=1it7 or dwelling was inspected for aigns of sewage back-up. The system does not receive non-sanitary or industrial waste flow vThe site was inspected for signs of breakout. /v All system components,lscuding the SOL Absorptior. System, have been located on the site. vThe septic tank manholes were uncovered opened. and the inter-or of the septic tank was inspected for condition of baffles or tws, material of mnstrucion, dimension, depth of liquid. depth of sludge, depth of scam. _`''-Tha sits and location of the Soil Absorption System on the site has beer,determined based on existing information or appr ci=atsd by non•intrumve methods. fadiity owner(and oceapants. if different from owner+ were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 r� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prop %y Address: Owners 9J i//ls i %ems vow-?Tr �/¢�/f G.� ,er,E•� 7- Date of Inspeadon: FLOW CONDITIONS RESmZNTIAL, Deep flo.__pllons Number of bedrooms: Number of esrremI ra ddents:_ Garbep Rinder(yr or no):_ Laoadry cmaemad to system(yes or no):_ Seasonal ase(Tom or no)- Water msar ieedinge, if available: Lsst data of occupancy: COhOlERCIAL/INDUSTRIAL Type of anablishment: 0�/-�x GU�i�os Design Dow: - plic"xiday Grasso trap present: (yes or no).AL, Indttst:sal Waste Holding Tank present: eyes or no) AA-1 Non.&artary waste discharged to the Title 5 system: (yes or-no)-,L4.' Water maw.readings, if available: Lon date of ooeapaacy:,. �A� >G y OTHER:(Daschbe) Last daft of oourpancT GENERAL INFOILMATIO N PUMPING RECORDS and scums of information: 9yetem pumped as pars of inspection: tyes or no i_ If yes,vah me pumped: -?ellons Rseson for pumping TYPE OF SYSTEM Sapm tauk/distssbution boslsoil absorption system Oase4ow ampool Shared syea un(lee or no) (if yes. attach previous inspection records. if an?i Other(explain) APPROXWTE AGE of all coanponents. date installed (:f)mowm) and sourer of iaforaation: adore dacacted when an vtng at the site: (yes or no ' (reviaad 11/03/9S) 5 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add um Deer. T Y Dat.at Inspection: SEPTIC TANK; Z (locus on dL plan) Depth below Res: 4 Materiel of coetuvesion: _ooacete_metal_FRP _othen explain) Gz�TG.�r c or/,��r �,�r✓,c:2 /�S✓�i�/.J�T Dimsesicros: 81ndP depth: / T DW ms from top of sludge to bottom of outlet tee or baffle: Sett=thic3ms: C) A1- /.tv4i£r Dieteaa from top of scam to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle. Caet►msate: (reao==sodation for pumping, condition of inlet and outlet tees or h&Mes. depth of liquid level un relation to outlet invert, st-ucural integrity, evidence of ke"P, etc.) ItEULI E Gov'G,� U.�l�r1.� g LT L�r i=�GF GREASE TRAP:_ (locate on eita plan) Depth below pad•: Material of caaetsucuon: _conclete_metal _FR? _otherezpiaLn! Dimensions: 8enm thir�: Distance from top of scum to top of outlet tee or baffle Distance from bottom of s.:m to bottom of outlet tee or baffle: Cammmts: (recommendation for pumping,condition of inlet and outlet tees or ba nes. depth of'.-quid level in relation to outlet invert. structural integrity evWsaos of la skage, sm.) (revised 11/03/95) 6 f. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,676-, t. Owner. Date of ImPsed0m TIGHT OR HOLDING TANK_ (Iomm on site pica) Depth Wow Fade: Malarial of=mww=ion:_ooncme_metal_Fu _other(e:plain) Dimmxkw: Capacey owllons Delia f o day Alarm level Commaata: ' (ooadit=of inlet toe,condition of alarm and float switches, etc.) DISTRIBUTION BOXY A/4:4,- (ksata as eaa plan) /li/�� �6'OrtcJ /2"' SYS/L"-.GJ Depth of jk*lewal above outlet invert: Qmmmt+: (tote if veal and distribution is equaL evidence of sciids car,;vover, evidence of leakage into or out of box. etc.) PUMP CRAMBSA_ (loose m sae plan) pampa in working order-(yes or no) Cemmmta: . (sots esaditian of pump chamber,coodition of pumps and appurtenances. etc.) (rfvisad 11/03/95) 7 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Dataof L•p•adam: BOIL ABSORPTION SYSTEM (SAS)•_ Uotata at site plea, if poaatbL;eresvauon not required, but may be appr=mated by eon-intrusive method-) If not dstarmined to be prseaat,arplain: Type: Laehiag pits, number. inching Chambers, number_ yaehi" galleries, number leehing hunches, number,length: lesehia8 salds, number, dimensions: cmdow casepooL number: Comments:(note condition of soil. signs of hydraulic.failure, level of nding, condition of vegetation.etc.) )VO P?G,E 9 /o i i A .✓,�a." IC5:T Ths�,�,� c�.�r ' o L/�tiio >�✓ /�/ �,�D t1�'' >y �'02 � 4ii9s THE �-�'iG.,c�sl� /��ufvvr�yDTi.t�c /Ts,�c,c CRUPOOLS:_ (bate an sits plan) Number amd configuration: Depth4ap of Uquid to inlet invert: Depth of a"&layer Depth of arms layer. Dimensions of compooL- YatariaL of a®atavctim. Iadiation of Fwandwaser: b&m(eaaspool must be pumped as par: of inspection) Com• ent-•(note aoaditioa of sciL signs of hydraulic failure, level of ponding, condition of vegetation. etc.) PRIVY'_ (bate as cos plan) Yatenals at Dimensions: Dspth of nbds: Ca®msntsc(noes e> -Won of soiL signs of hydraulic failure, level of poading, condition of vegetation, etc.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Owner. Data of Inspection: SHSPCH OF SEWAGE DISPOSAL SYSTEM: ioehtde ties to at least two permanent references]aadmarks or benchmarks locate an walls Within 100, fyS�/fs�LT. c� G DEPTH TO GROUNDWATER Depth to Qamdwsaa .. /3 r fees sestlsod d dscemia.tioa or apprtmmation: �slsUlt�5 Tf1F SiT% J�/�o1/r Ti`1f_ Tlf� GAG S Cv/_f��c-ri�.v 15 y 5' (revised 11/03/95) 9 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: Mail To: BUSINESS LOCATION: T���,t� F+c 1--i v v-t 5 Board of Health MAILING ADDRESS: cawttFA v .-/e4-0 Town of Barnstable P.O. Box 534 TELEPHONE NUMBER: . �Z Sr" ��"" S—Z- Hyannis, MA 02601 CONTACT PERSON: t—&`d I`�•�/;�c610 L?2 144 rY EMERGENCY CONTACT TELEPHONE NUMBER: `7 7,57 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES'above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS _ The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) � GQ Other cleaning solvents12 Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business TOWN OF BARNSTABLE COMPLIANCE:YCLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY '[-ics (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS /X'� `69� Qass: 7.Miscellaneous 6e,4 � �/ ANTITIES AND STORAGE (IN=indoors; OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: G I DISPOSAURECLAMATION REMARKS: 1. Sanitary Sewage 2. Water Supply O Town Sewer Public ! A'On-site OPrivate / ,4 l ' 3. Indoor Floor Drains YES NO y _ O Holding tank: MDC 444 O Catch basin/Dry well " O On-site system 4. Outdoor Surface drains:YES NO O"'ERS O Holding tank:MDCi�dl� i O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product YES NO 1. 2. Person (s) Interviewed Inspector Date Z No. .l..� .. s� Fics.............................. eW o�t OMMONWEALTH OF MASSACHUSETTS .._...._..�.._1Xa A. _ OARD OF HEALTH s TOWN OF BARNSTABLE . Appliratiun for Dirpwial Work,6 Tonfitrnrt"inn ramit ''"Ap ication is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: -k. catt n-::\dd css or Lot No. ...... �_.l.r. d._r' _..__. ..v(................•----^--------•---------- -----...---•----------------------........--------------- - *------ .......------------- .--------- w r � Addres Installer Address UType of Building Size Lot............................Sq. feet .-t Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------..-----..-.-------- Showers ( ) — Cafeteria ( ) 04 Other fixtures ............................... d •------------------...... w Design Flow............................................gallons per person per day. Total daily flow..-...-.---.-.-..-__.-.-.-.-................gallons. R: Septic Tank—Liquid capacity....---.....gallons Length---------------- Width.....-..-------- Diameter................ Depth................ Disposal Trench-- No. .................... Width.................... Total Length.................... Total leaching area.....................sq. ft. 3 Seepage Pit No-------------------- Diameter...--.--............ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1-4 Percolation Test Results Performed by.......................................................................... Date........................................ 1 Test Pit No. 1................minutes per inch Depth of Test Pit......-.-----.------ Depth to ground water......................... Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•--------------------------------------•----------•••---...---•-----••-....-•--•------•-•-••................---------••-••--•-•........---.................. 0 Description of Soil........................................................................................................................................................................ x U w UNature of Repairs or Alterations Answer whe applicable----------------------- ...................................e._ch /34s:NJ Agreement: 4 j w s-4,,e C€.1o�-� i�4_ The undersigned agrees to install the aforedesc if bed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued by the board of health. Signed1....... . ........ ........ ............................................................... Dace Application Approved B ....... ..... Dare Application Disapproved for the following reasons: ...................... ... ... .......... . .......................................................... ........................................ .................................... . ............................................................._.._......._................. ........................................ / Date Permit No. ..... '..E...... ------------------- Issued .......... "� .�'..�� Daze 0 No................._. I T FEz. THE COMMONWEALTH OF MASSACHUSETTS wrN19JBOARD OF HEALTH TOWN OF BARNSTAB-LE Applirativit for Diripwial Work,6 Tvimtrurtion ramit A Ff�Ltion is hereby made for a Permit to Construct or Repair ( L)-_an Individual Sewage Disposal System at: T C 2- ................................ c ............ .. ............................................................... .... ................................... Address or Lot No. ................ --------------- .................................................................................................. Addrew P....................... .. ....... .... .................. Installer Address U< type of Building Size Lot............................Sq. feet Dwelling—No. of'-Bedrooms----------------------_------------------Expansion Attic Garbage Grinder aOther—Type of Building ---------------------------- No. of persons____________-._--_----_..._. Showers Cafeteria Otherfixtures ---------------------------------------------------------------_------ ............................................................................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. C4 Septic Tank—Liquid capacity------------gallons' Length________________ Width----------------- Diameter.-._-._-_.__-.__ Depth........_...._.. Disposal Trench—No. .................... Width___--__-_----_-____- Total Length_.____............_. Total leaching area....................sq. ft. Seepage Pit No..._..-_-_----_.___- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) - Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit__..._._......_.__.. Depth to ground water.......___...._......_.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit__._____...._._.._.. Depth to ground water........................ P4 --------------------------------.......................................................................................................".....­­­­,", 0 Description of Soil........................................................................................................................................................................ U ...................................... .................................................................................................................................................................. W 114 ......................................................................................... ........................................................ ..................................................... U Nature of Repairs or Alterations Answer h . applicable.____._--_------------------ -3,5-FW L 4 I- i--ck *w" ......................... ......... -----------*----------------------------------------------------- C _5� -_." ........................................... ----------------- . .............14 -/a^(- et",�_X, I,I-/ Agreement: CA_1 :� -- - The undersigned agrees to install the aforedescZbed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued b the board of health. Signedcrd d 001,',K_---------- ------------------------------------------------------------------------------ ....................................... Dam ApplicationApproved B .......... ......--------- I.........V- ----- -------------- --------------------------------- ...................... ... .....ia .................. re Application Disapproved for the following reasons: ---------------------------------------------------------------........................................................................ ..............................................................................................................------------------------------------------------------------------------------------------------- ........................................ D,,c Permit No. ..................... Issued ........... ..... ...... .... Dace --—————--——————--——————————--————————————I———————————— ———————————————— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertifirate of Tontpliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by ..........07.m ---.w-------6,1...e,/_V�_0-------------------------------------------------------_- ------------------------------------------------------------------------------- Installcr at ------ ?...9.... �?-------------- .................................................................................... ,,,� Sign has been installed in accordance with the provisions of TITLE, of The State Environmental Code as described in the application for Disposal Works Construction Permit No. dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 7 . ...... .....................v:�.................................... DATE----- .. ................ Inspector ...__--- ------ ----------1—------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE " FEE... Displisal Workis Tomitnututt ramit Permission is hereby granted------ ... 7 ............................................................. to Construct ( ) or Repair (4,,) an In/clividual Sewage Disposal System at No.....�-_--�S ....... .... ....................................................................................................... ....... Street ti ��mm ................................. X06 as shown on the application for Disposal Works Construction P it .......... ..�Dated..... .....4_� 0'W17..... ...........-./......................................... Board of Health DATE--------.!.... ......... .............. FORM 36508 HOBBS&WARREN.INC..PUBLISHERS LCR, INC. ENVIRONMENTAL CONTRACTORS Site Remediation • Site Assessment • Tank Services (508) 778-6002 .-Fax (508) 775-6646 December 69- 1989 CERTIFIED MAIL Department of Environmental Protection. Southeast Region Lakeville Hospital Lakeville, MA 02347 Attn: Gerald A. Monte, Section Chief h/ Dear Mr. Monte: This letter is in response to your notification of noncompliance dated November 21, 1989. I will respond point by point. 1. Large Quantity Generator Status — In early September of this year, I had contacted a Ms. Nancy Wren of the Boston Office to notify her that we were requesting our status be upgraded to that of a Large Quantity Generator (LOG) . At the same time it was requested that any and all paperwork or forms necessary to effect this change be forwarded to my attention. At the time, Ms. Wren indicated an uncertainty as to whether or not any such forms were in fact necessary. We received no confirmation or documentation and assumed that nothing further was required to report our change in status. Subsequent to his inspection of our facility, Mr. Ken Anderson of your office had checked with Ms. Wren and corroborated our communication with her. By virtue of your November 21, 1989 notification of noncompliance to us, it is obvious that what we were led to believe through interaction with the D. E. P. Boston Office is not sufficient to . satisfy the regulations. I do, however, wish to stress that LCR did attempt to take the necessary steps, Prior .to your inspection, to change its status with the D.E. P. Per your notification,. I have attached a copy of a certified letter to the D. E. P. Boston Office which formally. . announces our status change and requests the necessary forms and applications. Once again, however, I received an indication that there were "probably" no further forms to effect this change. 2. The waste oil storage area has been posted with a sign per 310 CMR 30. 253 (5) . Bayberry Square - 2C 1645 f�oute 28 Centerville, Massachusetts 02632 :w 4 Department of Environmental Protection December 6, 1-989 Page Two 3. The waste oil storage area has been marked off as a clearly distinguishable area per .310CMR 30. 340 (1 ) W .` I will be requesting Mr. Kenneth Anderson to schedule a follow up inspection to verify the implementation of these changes. Very ly , Louis F. Chong President LFC:klw cc: Board of Health, Town of Barnstable, Hyannis, MA 02601 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M A DATA INC"LCR, ENVIRONMENTAL CONTRACTORS Site Remediation • Site Assessment • Tank Services _. (508) 778-6002. Fax (508) 775-6646 December 5, 1989 CERTIFIED MAIL Department of Environmental Protection Division of Hazardous Waste' One Winter Street Boston, MA 02108 Attn: Rosemary Healey RE: Large Quantity Generator Status LCR, Inc. MAD# 985266683 . Dear Ms. Healey: This letter confirms a telephone conversation I had with your office this afternoon. We are requesting that we be classified as a Large Quantity Generator of Waste Oil. Our current status with your department is that of a Small Quantity Generator. Our volume has exceeded 265 gallons per month. Accordingly, we are requesting a change in status. Please send to my attention any and all forms which are necessary to document our new status. Please contact me if there are any questions. Very r y yo r-� PS Form 3800, June 1985 N O R C S C N cD a 0 WO O - t ' 3 a �. _; m cn (D m d 3 °3 d m o. Nm N �S m �4 a o T co It-'m o m ° O° LQ td ` m Louis F. Chong ° t� CD ov m �3a I-' o z� ' President ��+ o " ��� -n �''„ Lj rt � o CS a ° �. �n (D LFC:klw a N ,2 N r-F -� cD W O' m 3 0 (D 0) ` O 00 fD N L< m -] rt o 00 N u, Bayberry Square - 2C 1641 m AL Gil ert 1:1oty , Regional Director e 2�R%cEl�lllPi��zG e���i�CEIRIIIP�, N f w • ,- may'• is 33 ENVIPtGlV�1lENTAL FROTEC-770'd"jN i November 21, .1989 P,dmy J, " i 7 LCR, Inc. Y t RE:. BARNSTABLE--Hazardous Waste 1645 Route 28 , `nfi °. ti. gw 310 CMR 30:000 }Bayberry` Square-2C " t - s.' � gf* Site ID# MAD985266683 -BarnstableI ,Massachusetts 02632 - ATTENTION: Louis F. Chong, President f - NOTICE OF NONCOMPLIANCEOt c+.r t. ` a THIS IS AN IMPORTANT NOTICE. ` FAILURE .TO TAKE ADEQUATE ACTION IN RESPONSE TO THIS NOTICE COULD,RESULT .IN,SERIOUS LEGAL CONSEQUENCES. The Department . of Environmental� Protection ' (DEP) personnel have observed thation_September_"26, 1989', activity_ occurred at LCR, Inc. , -16.4:5=Route-2-8�and=at--Unit-4Old-✓Falmouth Road; Barnstable;Massachusetts, in noncompliance with one or more laws, regulations, orders, licenses, permits„or.approvals enforced by the Department. ,. The purpose of this inspection was to determine the status of your facility relative to ' compliance with the Massachusetts . Hazardous Waste Regulations as contained in 310 CMR 30.000 which were adopted under the provisions of Sections 4, 6 and 9 of Chapter 21C of the Massachusetts General Laws..as applicable. Attached hereto is a written ' description , of: 1. each activity referred to above, 2. " the requirements violated, * 3. the action the Department now wants;,you to take,. and. 4. ' the deadline for taking such action. ` If you fail -to take any action. the Department now wants you to 'take by the prescribed deadline, or if you otherwise fail to remain in compliance in the future with requirements applicable to you,, you-.could could be subject to 'legal action, "including but not Y � Y J g ikF Original Printed on Re dell Paper. 4 h! .�' —2— i limited to, criminal prosecution, court imposed civil penalties or civil administrative penalties assessed for every day from now on that you are in noncompliance with . the requirements referred to above.,.: t ,,. J•.4x. ..i3;f r x- Very truly yours, rl� t '�.}� .47 �1 '�.'l � tRti.'+ 4:Y }�-TM s'• ' Gerald A. Monte, tion Chief ,-RCRA f.Section h M/KA/rrg; .�� t:�:.,�",�4 E-•.� x�~� �,;>a�t Attachment r. r . , t Y•x a1,,. ,. :;; ;t s. CERTIFIED MAIL #P904 976 580 ''"l RETURN RECEIPT REQUESTED f•, �?,� t5, �y rti. .a ;�. i s Y cc: Board of Health f 367 Main Street st r a Barnstable, MA 02601,E ,.L.. ,.+ , of fi ,e, g , DEP — BWP ATTN: Al Nardone .. '"a4" e.`. s^Y$''?YS 4 'stif•4 f�s e'�'2• t- � "fin a3 + �,_p ���� .�����. � i"+ ..Y(�,3 ., t +t7,7• ' _ � 1 w � *',.:; � Y`.t'f,S f'y-4•'"�'cyi��� , {4t�� �'t. .� Y,' F r'�� r I ' c:t Y �,':� .e,,,� ,•{1atit.:`9,' i. ?1 .. �' + .3j1 6 'Lr=a•r••..- sr•.1»r.' - y -;s. ?k rit '!P�.'. •.�t .. Y-'€ . �y, _. .. - '1'Tr':., s f�El�R8 ,�d' ���y,,.4.fx' ru�}th.�i,��s dirt�,i„t}.. �.1� 1� a 4 - • R • � � ,f . + Y.�t3p,r $��` �" }�7" C'}a�±.4a�P�i4..1 :Z.j L;.,:1. a e-.• .. `�. 4 - ,: ,..ti eY'•, fz�,. {y'3.�" i�rifr �`"k �''+.i'�;�3• Y 'A�� E? ' 'S i. a rl ? (p!•�, zi - a � '�. 1'a 11s t�y�'3 '� :� � �i j,t�k r.•}� ,"� t{Er r �J.Y'd } t r , l4 NOTICE OF NONCOMPLIANCE / NONCOMPLIANCE SUMMARY NAME OF ENTITY IN NONCOMPLIANCE:° „t LCR, , Inc. , ,-;' LOCATION WHERE [NONCOMPLIANCE OCCURRED OR WAS OBSERVED: t is r'1 t y4 `.f t Wit. �.�_�1$r 'Y+ y �S {Y.3 'x�'4' 1 Y.j !t�A'.a • 1645 Route 28 •;;; ; _ + z; .,._ , Bayberry• Square-2C+ & Unit 414 381 Old Falmouth Road Barnstable, Massachusetts 02632 DATE WHEN NONCOMPLIANCE OCCURRED OR WAS OBSERVED: September 26,1989 DESCRIPTION OF NONCOMPLIANCE.' REQUIREMENTS NOT COMPLIED WITH. ACTION TO BE TAKEN AND THE DEADLINE FOR TAKING SUCH ACTION: LCR, •Inc. , -is a Large Quantity Generator (LQG) of a regulated recyclable material (waste oil) i.e. , one who generates greater than 1000 kg per month and may accumulate waste oil on-site for • ninety , (90) days or less without obtaining a storage' license from the Department. During the course of, the inspection the following violations were observed: "�"` ; ,• ; ;ig, 1. On a previously submitted notification form, LCR, Inc. , certified that it was a Small Quantity Generator (SQG) i.e. , one who generates less than 1000 kg (approximately 265 gallons) of waste oil. However, upon reviewing the manifest records for your off-site removal of waste oil, it was revealed that your generation rate is that of a LQG and that you had failed to submit a change of status notification to the Department. This is a violation of Massachusetts Hazardous Waste Regulation 310 CMR 30. 303 (3) (a) , and 30.303 (4) which requires that a SQG .who becomes an LQG shall promptly submit in writing a change of status request to the Department. Therefore, effective immediately you shall submit a written request to obtain j the prescribed form from the Department of Environmental Protection, Bureau of Waste Prevention, One Winter Street, Massachusetts, 02108. or by telephone by dialing 1-800- 343- 3420. ;2. The waste oil storage area, located inside Unit 41, 381 Old Falmouth Road, was not posted in violation of the Regulation 310 CMR 30.253 (5) which requires that a LQG of waste oil shall post : all'. areas in which waste oil is j accumulated by displaying a , sign with the words "WASTE OIL" in capital letters . at least one inch high. Therefore, within ten (10) .days following the receipt of. this Notice, you shall come into and remain in compliance with this Regulation. ----.._._ ___._.._... ..,.- ___......:...: ..... lI iw tt {rf 4 , 14 e, The waste oil'' storage area was.4 not clearly outlined in 3` violation of the I Regulation,*.3 10• CMR ' 30.253 (5) which references w 310 CMR 30.340(1) (k)``which requires that all . ' - _` ` y'*-areas where wastes are-accumulated shall be clearly marked e.g. ,' by a, clearly�ivisible line or. piece of tape on the floor at the boundary,--of a, clearly distinguishable area. * :t Therefore, within tens` (10)Jdays.''following the .receipt of ' this Notice you shall-come into- and remain in. compliance r . 'with this ;Regulation. ' ?, In addition, the Department requires a response to this Notice of Noncompliance, in writing,w,withinsfifteen (15) days `of receipt .4 Yi. �.R f F;•S of this., Notice. y.;.( 4; ,o•. . s.- ,tfi. kt ac i t� ,f w, r ;-t o.. +-�.` -, x. z If you . have ., any" questions°=, relative , to .: hazardous waste ` t management at your facility,{v�,please .,contact. Mr.. Kenneth Anderson of this- office- at "(508) ,• 946-28l7.- �p z , e.... .'[ S• `'� F r•�i� �"a<-, '4 r} .,±5• r ;� .�#��,� ' �,m'� �t��q7�t� �'t�'�"s t +� �..'' xx'.�-, .. ;19 BY DATE: R / �x Taw' �t Gerald A. Monte ief } ; RCRA"Section • ti ��� ,;r ��,y Y {;{ �, 'r `c � yt� ;Y� '�-# t� '`r *y • �.' e. ,$ 7 tf.N�'' # :h ¢ 4 � '�"'� �'.�'�G�f4 I., t'i 3x.�i.• i,K'�`� -� y r. s ^ , `� A{erg"`�«'R"r •iys� .� g' y � F � t{ x '�• � �'��der�� Y,� s ,. ' Y' t7. f �t�'�ji r Yw, >, t„ ,� t� � .•�k•}u r � � -ra �;�.e ;� '3 ry ,. fr "�'�. .t t a t'.,- a"' i � ��r�t�3 * f�1�sF ••-���t v rR�ti � ,Z:'� �: .Ss a ,��.i�wd��,��.i ,R t r•Y t f .t,�� �bF1•YiA�.a '�t�r {�<:.`�P'^tt�• skg''' s ri! fps ' Y J 3 7 �+; t� �t�� r+xT+' v '` �a ;a •ter t= a: ! . RA P v ,§r'7`-s•- ,�;i !:� �f'c t »`) *..,•ia'. •r s f h . .* +, a Y ,'� ,� .xc ,.i y,c��;:�t',r+�7.} �•t . - 1` 1^ f r'" 'd.=s Z•e r•.:a " 9 t' i t .. e & Y •t sir �+ { � �..:� ��� m�„t � v Fx� r v r'° r ' ke v - "s N .. " ;;.�7 '�, 1�•,� '�C�<:,'} ��°,L we•ra rt r{��'�a c '�y°'� ,t� �I , �.Sr.., "*9t,�",.r 't •-P "§.'`✓,„.'i` " ;�#�' 6 e'�y`"X'M1e ..•r' - - R i " Fra i. `aui w{'',� -•✓ t dF s, _ ., t t t �q'.:utc s�; a� `r A r 41 - 9A h. ti\. w7lqrl-w q4w I I �P��FTHFt��"Y TOWN OF BARNSTABLE e OFFICE OF NA8& BOARD OF HEALTH y 0 oo 1639* om p�9� 367 MAIN STREET HYANNIS, MASS. 02601 March 13 , 1989 Ms . Beverly Harrington Centerville Cleaners 1600 Falmouth Road Centerville, MA 02632 RE: EFFLUENT FROM DRY CLEANING MACHINE Dear Ms . Harrington: The Dry Cleaning Establishment doing business as Centerville Cleaners , operated by you located at 1600 Falmouth Road, was inspected. by Donna Miorandi , Health Inspector for the Town of Barnstable on February 10 , 1989 . During the inspection you were directed to test the effluent discharged into the ground, from your dry cleaning machinery. Test results from the volatile organic analyzed by Groundwater Analytical Company indicate that the effluent has a concentration of 150 , 000 ug/L (ppb) of Tetrachloroethene (PCE) . You are directed to cease and desist the discharge of this effluent into your septic system via the sink or toilet upon receipt of this notice . You shall collect this effluent into a container kept indoors and have it picked up by a licensed hazardous waste hauler such as the company who now currently hauls your sludge from the dry cleaning machine . Failure to comply with this order may result in a fine of up to $200 . 00 . Each days failure to comply with the order shall constitute a separate violation. PER ORDER OF THE BOA C)F H ALTH T Tomas A. McKean CJ Director of Public Health cc : Brett Rowe, Department of Quality Engineering, Lakeville Ginny McHugh, DEQE, Division of Water Pollution Control Stephanie 'Oyler, DEQE, Hazardous Waste Division BAXTER & NYE, INC. Registered Land Surveyors and Civil Engineers 7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131 W LLIAM C.NYE,R.L.S.-President RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering May 13 , 1985 Town of Barnstable Board of Health 367 Main Street Hyannis, MA 02601 RE: Plot Plan of Land in Barnstable ( Centerville ) , MA for Bayberry Square Realty Trust Dated 1-18-85 by Baxter & Nye, Inc . Gentlemen: This is to inform you that on May 10 , 1985 a deep test hole was dug at: the location of the proposed septic system for the Bayberry Square addition. The test hole was 17 f-eet deep and verified that clean suitable material is present for 4 feet below the bottom of the proposed system. No water was encountered . I trust that this meet's your present needs . Very truly yours , at� Peter Sullivan, P . E. PS/bc cc: Bayberry Square Realty Trust MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSErrS ASSOCIATION LAND SURVEYORS AND CIVIL ENGINEERS r Fimic 4 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH j _...... ............................OF.....B.M'r..n. 1.aAL e..............._...----•------•--.. Appliration for UhipaaFal Works Tonotrurtinaa runfit Application is hereby made for a Permit to Construct k) or Repair ( ) an Individual Sewage Disposal System at: t..1 eA-P 1e-Il. VA.1�>.n. ...--�-.C ....................................................Loc n-Address •� or Lot ....�r_.u. "----------- --- ..... � .. �.. ¢ �r .. i Owner d ress W m'.r.L'.1.sco...1-Q.lUCL.ICja.$........................................ rJ ... .Ea--faj"Mbu .1 r -1.�e1.n.- nays t a Installer Address / Type of Building , Size Lot----- L..2.AQ.&. U Dwelling—No. of Bedrooms_._..._..o.................................Expansion AAic ( ), Garbage Grinder pa., Other—Type of Building i...,9......... No. ef-�s....... . t.QV_r5Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------------__-__ __ d 6-------------------------------------- --------------------- W Design Flow........................qs..�..........gallons per 1 per day. Total daily flow______---�A.-T....................gallons. WSeptic Tank—Liquid capacity)M.O-gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area------------..__----sq. ft. Seepage Pit No...../------------- Diameter...../,7_.'_-___- Depth below inlet.3,.si.._...... Total leaching area,-P.- ...sq. ft. Z Other Distribution box (p-) Dosing tank ( ) Percolation Test Results Performed by.._ a, ¢P�'•• .....1g{C.__ZNY..................... Date-----������--------___. 14 Test Pit No. lc2cst'_4ssminutes per inch Depth of Test Pit------/.f....... Depth to ground water....... _•__-__-___. r%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ........................................................................................................._............---•-•••............•--••--••---..•---- O Description of Soil----- ,ljet. ..._ ._�Cz_b_ ta.i..�..---•- # ---a-� 1--1---- - ,n----J -•- -�'*k.a� -••• ------- va 1 = L-4-- ------ 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 TITLZ 5 of the State Sanitary Code— The undersigned further rees not to place the sy em in operation until a Certificate of Compliance has bee 's /ed by t of h / r— s/� , Signed......4----• V-__AV•-- . ................... Application Approved BY --�="-•� . ------ -•------- Z' Dd Y N. ���ttt .q .s Application Disapproved for the following reasons-------------------------------------------------------------•-------------------------------------._......_..... ' :"- .y ..............................•••-••••••......__...----------...-•---------------.....••---•-•-•-•••••••---•••-•••-••-••-•••••--••-•-------............................................................ Date Permit No......... -(A.......................... Issued-......... ------ Date t No............... - Flzs....... 011— THE COMMONWEALTH OF MASSACHUSETTS r BOARD OE HEALTH .............OF...I'j.C. : .p' S$ - .f ................................ Applira ion for Uiopooal Works Tonotrurtion Wrmft Application is hereby made for a Permit to Construct O or Repair ( . ) an Individual Sewage Disposal System at r' _ lz LocA' n Address or Lot Owner d!lress Installer Address Type of Building Size Lot...A.t... .. _ �_ S Dwelling—No. of Bedrooms............................................Expansion At is ( ) Garbage Grinder. p-, Other—Type of Building � 't_�`- ......... N. s�pe s..... ..-_.£.O-w`showers ( ) — Cafeteria ( ) w Other fixtures ------ ............................. -•--•------•----------- -•- W Design Flow........................ '..._.._._gallons per per day. Total daily flow____._ s ...................gallons. 1x Septic Tank—Liquid capacity , .gallons Length................ Width................ Diameter__.__ _-___._.. Depth--•-____-------- Disposal Trench—No. ................_. Width...................... Total Length .._ Total leaching area.._ ....sq. ft. " Seepage Pit No .. . ... Diameter...../ Depth below inlet.; ..._.... Total leaching area.f..........sq. ft. 'Z Other Distribution box 4or" Dosing tank ( ) ,. Percolation Test Results Performed by._. . t ... ... ±V.9...&A. ............... :.,_.___.. Test Pit No. 1 &_r.kss.mmutes per inch Depth of Test Pit______Lif___..... Depth to ground water-------".�'"`............ (% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... -• •--• •-••---•-•---. .-- - ------------- Description of Soil Io.a YK ! x z.�..� a ! ¢ t m w. - .ofx -- U `l: �t-k! .. ................................................ . •• ... ---•-•-- ----..... .. .--•• ......---....................................... " W UNature of Repairs or Alterations—Answer when applicable------------------------- ;t ..........................................•.......................................•--.................................................................................................................... ..Agreement The undersigned agrees. to install the aforedescribed Individual Sewage Disposal•System in accordance with- the provisions of TITLE 5 of the State Sanitary Code The unders fined-further rees not to place the sy�em in P operation until a Certificate of Co')fiance has.bee s ed by of h t >Ire lr , -Sighed j �� t . •......... - ----- Application ApprovedBy 'Dae i,t Application bisapproved'f or the f ollowang.'reasons.: ...................................... '__ --- ... .................................................. ..... ....... ..:..... ..._ . ...._..------------------------------------------------------------......---......_ `+ Date { Permit No ._....5--- ..6 1 8S ------- Issued-................................................... Date e THE COMMONWEALTH OF MASSACHUSETTS n BOARD` OF WEALTH ..................................OF..... ............................................... ............ .......... is (9rdifiratr of Tomplianrr . . THIS jS CERTIFY, That the Individual Sewage Disposal System constructed ( ) or'Repaired ( ) 1•. by +. 1 at ¢---- ----•- - - �, -has been it sled in accordance with the provisions of TITLE 5 of The State Sanitary.Code as d scribed in the lCp application for Disposal Works Construction Permit No ¢ ..... ' dated_...._ :1 ': .-................ THE ISSUANCE OF,THIS CERTIFICATE SHALL NOT BE COMSTRUED^ A GUARANTEE THAT THE �.. SYSTEM WILL FU CTI N SATISFACTORY. DATE ::. ....Z.�.... - Inspector THE COMMONWEALTH OF MASSAC U$ETTS BOARD OF HEALTH No...-'...".::.............. FEE....... Uiopollal Works Tonotr ion rrmi# r Permission is hereby granted.......... ................. to Constrt;)t.( '"�or Re it ( ) an Individual tewage Dis-osal ystem ., / J Street as shown on the appl'cation for Disposal Works Construction Permj_b_co 'Y'.��_�a. Dated.._.� �{`�~�.............. •.•--- Board of Health DATE.................... ••---•--- ................. FORM 1255 HOBBS &WARREN, INC., PUBLISHERS TOWN OF BARNSTABLE �'�6Z _ ,�ylv�Qy 66 11 4-41G /9,- 0 LOCATION . 16ti I?C 27 SEWAGE # 1; 6 VT,,*.AGE 4—4rTd./ 1&4,E A,? ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /= T,194—I ALE SEPTIC TANK CAPACITY lea (/9L ��) 4 G 1 LEACHING FACILITY: (type) / A/T (size) � 13L O QF EDJ10n MS BUILDER OR OWNER PERMITDATE: a�G�k>� COMPLIANCE DATE: �Q'/�rf7� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ���" Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i. I I n , L i . FRovf /�L©G A •E` t BOOK4635 PAGE 109 G ' �v1174 r- r , 1 ; 1 ywIT It o d Q MAW N eN �►IeE II zl 0 I , U fl I tJN11T gig G I • I T{ A.RIC S A. � BAX7ER. a No.24AS- D4e O l✓1L�01� N uR'+ sLav• 40.3 LXLl-r AIZM . 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SAO PLCOC vam AMA& d2l IW ; � t C��IFY 141AT'Ti114 R1,L1 irrbMri G °10 SG V6lIT.d1.Y.CdINb!!s0 AAI�'B>II, ': �1 '. �MM� aIAT'ryI AWau�a1`ualtTi,Ayp NAT (t FU L�fr:. 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App iratio c for Uiipnial Workii Tomitrurtion jWmit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: -•- 1.�. ...RoutQ 28.,... entanuille............... .................................................................................................. Location-Address or Lot No. ---•---•Bayb�zxy---jg-qLtare...malty.._-Truat......... .16.4.5..:Rnute..2.8... ............ -- r Address a •---....�: -�......� �4.Alf-Alf- -------------------------- HarlQx�s Laniding..Rd._..----Pacc-szp-t-,•..M -- Installer Address dType of Building Size Lot_1...6.8---A---------Sq. feet V Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building —p� yp g ...9�.�a.cs______..�r-of•per5vns11.,2.3.Q3�_._F�howers ( ) Cafeteria ( ) a' Other fixtures ................................ d I t7 Q Q Sc� �--------------- --•-•------- W Design Flow...75•__Gal.......................gallons per�rersmrgXr ay. Total daily flow--__-___8.42...._.......................gallons. WSeptic Tank—Liquid"capacity15.0_0_gallons Length...._---------- Width._-............ Diameter--.---=....... Depth----.-......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..... Diameter-----1_Q_'_______ Depth below inlet....6.............. Total leaching area....534.....sq. ft. Z Other Distribution box (x ) Dosing tank ( ) '-' Percolation Test Results Performed byBa.Xte ___&...kTYP...A,....,TQ.UP_S............. Date... .231.82._.._.........__.. ' Test Pit No. 1._-2---------minutes per inch Depth of Test Pit.....14......... Depth to ground water....1.4............... G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---________-.._--_--_.-. ------------•--•------------------------------------•-•----•-------••----•--•--.....------•----.................--•-----------------------------.....-------- O Description of Soil 2�z........ oort...&...Sub-•S4 1-------------------------------------------•--------------------------------------------------- x 21-' x 14'___C lear__med__sandy___gra- e l_,___no__water------------------------•------------------- V .........................................A....... ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------- U Nature of Repairs r lterations—A wer when a plicable............................................ .............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI:� 5 of the State Sanitary de The u dersigned further agrees not to place the system in operation until a Certificate of Compliance h bee iss d by h board of kealth. ned---- ---- -- ----------------------------------------------------------- Applica Approved : .... . ...... ..........•-------•--..__...................................... Date Application Disapprov f o he following reasons----------------------------------------------------------------------------------------------•----------•..... ..............•--••-••-----...----••----...--•--•----------------------------------..........------------.-_.. Date PermitNo......................................................... Issued....................................................... Date F�s.............................. + THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............Town ...............OF........Barnstable Appliratiou for Disposal Works Toustrurtiuu Prtinit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: .........1.6 0---Route...28.0...Center-zri.11a............... .....•-•------------...-----.......--------•-•--------•---------=------------.--..-.....------. Location-Address or Lot No. ........BaYb..X.Y.._2_WaLre...Realu... tat.--••--•-- -15.4,5---Route...28...Genterville.,m.............. Owner Address aGary.--winq---•...............•-•-•--.............--------•---------------. ...Landi.ng..Rd.........Pocasset, -.. Installer Address d Type of Building Size Lot_1,.6A---A_.........Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( .. ) Garbage Grinder ( ) Other—T e of Building Off:i._Ce---------Nv.-ts ersnns:ll i•2. OS_ .Fthowers Cafeteria Other fixtures W .----•-••--•-•.... Design Flow..75__-G31. .i. .ft. -----------•-----------------------•---•----------:-•----•--•-•-•-•••-•-.........-•--•- ______.__•.__.�------gallons er Mrper day. Total dailyflow........SA2-----------•----------------gallons. WSeptic Tank—Liquid cap city15.OQ.galloris ength...._-......... Width.-.._________ Diameter._.__.-'....... Depth___-____.._.. x Disposal Trench-"No. .................... Width.................... Total Length.................... Total leaching area..,.................sq. ft. Seepage Pit No...z_______________ Diameter..... Depth below inlet.... Total leaching area4_._. 24.....sq. ft. Z Other Distribution box (X ) Dosing tank ( ) 1 Percolation Test Results Performed byBaXter... ...Nye.-A._.•JonQS_____________ Date._$123182.................. �7 Test Pit No. L.'a_........minutes per inch Depth of Test Pit-----14.......... Depth to ground water----1.4.............. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-•••-••--•-------------------------------------------------------------------------------------------•-----------••--•--------------•-----------------.---•- D Description of.Soil..._0...- 2 ! Loom & Sub Soil -------- --•--•--•-••••-••-•-----••--•••-••--�.? ---x..14....Clear._med__sand_y---grayel, no water W 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 TITLE 5 of the State Sanitary C e— The undersigned further agrees not to place the system in operation until a Certificate of Compliance bee ss d by th oard of`health. 1 /(/!�+'"'� •�I -r:. r ned.... '-- .." ......................................... f � o Appli*ca Approved . �Date Application Disappro ft'he following reasons:---•-••••--•••••--_-............................................................................... ...-•----------------•-----•----------------------••--------•-------.........--------........-------•-•---•---•••--••-•-•-••-•••--•••---•-•---•--••............--••-•......---- ......_..' Date ti a PermitNo.......................................................... Issued------•-----•------ ----------------------------------•--Date ` THE COMMONWEALTH OF MASSACHUSETTS f BOARD OF HEALTH 1 Trrtifirttte of Toutpliatta TH;[�' 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) v. ..._----••---- bY------G� -11- .. ........... y= Installer at................. . fry _. .✓'--'j ---•--...•..-•----------------------•-----.----•------------------._.........................-----••.... ... -------- - has been installed in accordance with the provisions of TI .LE 5 of The State Sanitary Co /a , 6cribed i� the application for Disposal Works Construction Permit No� __.-t __�7............... dated_% ._ ...:-.__. __........_..._._........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................1A-_.Z. ._11•---•--••-------• Inspector- .- Z.....•---•••-•-••-----•--•-----•--------•-•......--•--....------•=- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF/­HEALTH ...OF............. ---------.............. d Nlr:. ....:.............. FEE.T�................. Disvo,oqIn .vidual s Tuuu#rudilau autit Permission is eby granted-- --- .Y _IL.L' ....----•---------------•-•-----------•---••----............ to Construct ) or Reepair,( nan Sew=age Disposal Systemat No... =j==�•�=` 'l .-•----.... ....................---------------------...-----------------------------------------...----------•---•-•--•-•-•... Street -- y ^• as shown on the application for Disposal Works Construction Permit Now _. ....... Dated.......................................... ...................- -Y� DATE. 14 " !f t Board of Health FORM 1255)•Hoses & WARREN. INC.. PUBLISHERS sTOWrN OFF BARN QT�A�Bs�E ''0-C-A TON fG5'S X�rZ 91F SEWAGE # _V111LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. fl e,- fIfZ-r SEPTIC TANK CAPACITY /5 61A_ LEACHING FACILITY: (type) /1S (size) �9L -N MS F BUILDER OR OWNER :;241`ArX G PERMITDATE: f/,���3 COMPLIANCE DATE: /oli��y ,-.,Separation Distance Between the: (Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7't Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet. ,j Furnished by 171///Ge." r� . a i -' L-0 vA T 10N S E.W-A,G E ' PE RM1T N0 //` ? /fin — 90 . ..VILLAGE IN,S.IA LLER'S NAME i ADDRESS e'.U i l D OR OWNER f� .`, DA T' E PERMIT ISSUED //4-dr WATE; COMPLIANCE ISSUED% n I l'�� 1. � � � � � � �. � �. � � � � i ��° g� —�coo� No...s9 `. : Fua..jr................ THE COMMONWEALTH OF MASSACWUSETTS BOAR® OF HEALTH ..................... ....................O F............................._.........------------------........... Appliration for Disposal Workii Tonstrnrtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: $ .......... .r�z. >? �...._. c<l .. ... ................ -- ................ Locati Ad ess or Lot No. .., � 1._ ------------------------ 1.�. ....... _ -... ------ owner Address c�� ,Wa a ... �. o....... 1 ....�..�. . ... ---- ............... Installer Address Type of Building Size Lot.................:.`:._...Sq. feet (;!'. . __--__-.Expansion Attic ( ) Garbage Grinder ( ) pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ................................. W Design Flow............................................gallons per person per day. Total daily f ow... WSeptic Tank—Liquid capacity gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___--___...:`.._.__.sq. ft. Seepage Pit No--------------------- Diameter---42-7........ Depth below inlet---6.............. Total leaching area..&. o....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `4 Percolation Test Results Performed by.......................................................................... Date....................................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-. -._____-___•-______- GY •---•-•-•---•--•-•--••......--•--••••--.....--••------••---•-•--••-........-•----------•.....•••----•---------------•-....-•--•--•-••-•..............•---•-- ODescription of Soil.........................................................................................................................--------------•-------•----------------••-•--- x W UNature 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 il'112 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been •ssue by the b and of health. t Signed.. �,t1 ... ....... . ................................................ D to Application Approved By... !l �� �21AZ--------•---. Date Application Disapproved for the following reasons:..................... ....-----•-•-•--•-----••---•----••-----•----••-•-----------------------•--•----•------.......------........-•--------------------------•-------••------•-----•-----•----•-------------------•---•••------ Date PermitNo......................................................... Issued-....................................................... .. -- — - Date _ No...Af ................... THE COMMONWEALTH OF MASSACI+USETTS BOARD OF HEALTH ..............................._...........OF...........................--..--.....-------------•------.... Appliratiou for Uh4paoul Worko Tomitrurtion thrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 16.OKI.... ...... .................................. ................. E�- Locatio -Add ss r Lot No. u.5;R "al o ....................... . ....... ......... ------- ..... Owner Address ....................... ........................................... .....W. ...5 ..... .................. Installer Address Type of Building Size Lot............................Sq. feet U ...............Expansion Attic ( ) s Garbage Grinder aOther—Type of Building -------- ............ No. of persons..................._._______ Showers Cafeteria Otherfixtures ......­.:.............................................I.........................I......................... ................................. Design Flow............................................gallons per person per day. Total daily flow............. ................._..gallons. 1:4 Septic Tank—Liquid capacity/T4aallons Length........... Width................ Diameter-_-............ Depth................ Disposal Trench—No...__,_............. Width.....___....._...... Total Length..__................ Total leaching area.............&...sq. ft. Seepage Pit No-_----------------- Diameter...42.......... Depth below inlet....(a .!.. ......... Total leaching area...3.V_._q. Z Other Distribution box Dosing tank Percolation Test Results Performed by......................................................................... Date............;........................... Test Pit No. I................minutes per inch Depth of Test Pit.._.__._._.__....... Depth to ground water_.______...._........-_. 0� Test Pit No. 2................minutes per inch Depth of Test Pit.._.._.............. Depth to ground water____._..............___. 9 *...*-------------------------------------------***---------------------------------------------------------------------=.................................. 0 Description of Soil................................................................................................................................................................z........... U ............................................................................................................................................................_........................................... ............................................................................................................................................ ...................I.................................. U Nature of Repairs or Alterations—Answer when applicable._.._._......................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescri od-,Individual.Sewage Disposal System in accordance with the provisions of T IT LE 5 of the State Sanitary Code f The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sued the b rd of health. Signed•.= ............................I 49A D e Application Approved By-----. ... ............................. . ............ ,.e-✓- Date Application Disapproved for the following reasons:................................................................................................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntifiratr of Tompliana THLE IS CEJ?TIXY, That the I (duividual Sew age -Disposal System constructed or Repaired XAA - - by------- ------------------------------------------------------------------------------------------------------------------- at. ... 7.... ..V ................................. TITLE 5 of The. State Sanitary Code as described in the has been installed in accordance with the proviZ.-s -o-i-o--o --- ----------------------------------------------------*--------- application for Disposal Works Construction Permit No..........9.....I...-_4;_................... dated_............................................. THE ISSUANCE C,M� THIS CERTIFICATE SHALL NOT BE CONSTR A A GUARANTEE THAT THE SYSTEM WILL ION SATISFACTORY. DATE............ ........ ................................................... Inspector... ..... ......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................OF.................................................................................... No.... ....... FEE FEE..._._.................. Permission is hereby granted........(Pal&w......9.... ...-&.'V . .................. ....................................... to Construct ( k1)111_0'rR9pair an lndrvidV, Sewage,,Disposal System at No...../.&!R ..... el 14D Street as shown on the application for Disposal Works Construction Permit No..................... Dated......._____...................._......... ............................................. oard of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS y �y TOWN OF BARNSTABLE n UICATION 16P!5' SEWAGE # VII.LAGE �/�.�! U'/�� ASSESSOR'S MAP & LOT ?o_ � L INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /5��o LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: _�a>,-�X COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility /3�� 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 le ac n facili ) Feet Furnished by 7 � ,r7 SOX i�i2,� !/.>✓.O.�iL �.50��3GT 4 f 1 L 0 C A Ti0 / 09.� SEWAGE PERMIT NO. VILLAGE q e/2/r-p- v, l 1 e Ali, �foi I N S T A LLER'S NAME - ADDRESS z4 z 64 is /;/ eve BUILDER OR OWNER P 2/6 /y Cc:v p- tf`'ll �147, DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 8 Z�"► � �_ � .I 3� � �� � , � C'1 ��✓ C� THE COMMONWEALTH OF MASSACHUSETTS,;i� A► BOAR® OF HEALTH ---------------------------------OF...............-...................._.....-----------------..........................._._. Appliration for Dispas al Works Towitrurtiun Prrutit Application is hereby made for a Permit,to Construct ( Iror Repair ( ) an Individual Sewage Disposal System at: r - Locatio -Add ess or Lot No. - -- ------------------- --- �-. ,. Owner T Addr Installer dress J 6., � d Type of Building Q,G�jCL �'pti e7b5. Size Lot___l.t.. eA ,.Sq. feet U Dwelling—No. of Bedrooms...........,A/_ _4------------------ Attic ( ) Garbage Grinder pa, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures . ---------------------- ---------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter..................... Depth below inlet.................... Total leaching area...._.............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------------------------------------•------•--..__..__......_.......................................................:...................... Descriptionof Soil........................................................................................................................................................................ W -------------------------- -------------------•----=------------•-••-•••-•••--•--•-•----•-•••-••-----•-•---------....--•••--•------••------••---------••--••--•-------•------•-•--•------------------- 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 iITU 5 of the State Sanitary Code— The and rsigned further agrees not to place the system in operation until a Certificate of Compliance has bee issu by the b,and of health. Q - - —Signed.__:_ _._ = ------- �•-•-- D to Application Approved By............... ..... ............................ -------c if! ;e --------- Date Application Disapproved for.the following reasons------------------------------------------------------------------------------------------------------------••••- -•-----•----------------------------------------------------------------•-•--._.....----------------•---•-----•--•-•---•-------•-----------•-•-•••-------•-•-----•---•---••-----••-••-•--•--•---------- Date PermitNo......................................................... Issue(L....................................................... Date No.A.?:_SSS_ Fm$.............................. THE COMMONWEALTH OF MASSACHUSETTS,4 • BOARD OF HEALTH ................. "-...................OF.......................................................................................... Appliration for Uispao al Works Tomitriirtion jbrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................__.............................................................................. .................................•---•--------•-------.....--•-•---•----•-••-•----•--...........•- Location-Address or Lot No. ................................................................................................. ..........--...................................................................................... Owner Address W Installer Address dType of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p l Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures _________________________________ _ W Design Flow............................................gallons per person per day. Total daily flow................................._..........gallons. 0� Septic Tank—Liquid capacity............gallons Length................ Width........_------- Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water------------------_--- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•-------------------------------•---...-----•-•--------.........-----•----------•--•---••-----...••----•----•---•-....._--------•-•----------••------••-- 0 Description of Soil..........-•-•---•--•--•---------------------•---....:.__.......-----•---•-••---------------------------------------------------------------------------------------- x W -------------------------- ---I.....................................................................................................-................................................................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: ..A- Theundersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11 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 by the board of health. Signed..................................... .._ ., Date Application Approved By--•-•-•----- •f�Af!y�i�.................. .11jl� Date Application Disapproved for the following reasons:_------------------------••------••------------------------•-----------------•--------------------...••--•-•- -----------------------------------•---------------------------•---------•------._....-•--••---------------....----------------------------------------------------------------------------•--...._..._ Date PermitNo--..................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................I—.........OF................................................................................... Tntifiratr of TuntpliFaita THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----------------- --------------...---•--------••---•-----•-•---•-----............._...._--•---•--•----------••------------•-----•---....--•--•-----•-••--_-•- Installer at '� ... 1'-�'R+E' ----• ---------------------------------------------------------------•..-------------•----------------- has been installe in adance'with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit ________________ dated_...------.-.-.-_-____---__-.___________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WfiL FUNCTION SATIS ACTORY. dd� DATE-...........................................J-D1-5 Y-.............. Inspector................. --------....--•-----•-• -y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No._ 2.-. '�5.. FEE.... ...... Disposal Iforkv TuOnstnulion ami# Permission is hereby granted _• ---------------------------------------------------------------------------------------- to Construct *,5o Repair ( ) an Individual Se�rage Disposal System at No................ " treet as shown on the application for Disposal Works Construction Permit No_______________ ____ Dated.......................................... -_--- -------- ------------------------------------------------- Bo..rd f Health DATE.................;00� L------------------------------- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Al LOCATION _ SEWAGE PERMIT NO. V1LLAGE .4 INSTALLER'S NAME i ADDRESS ® i U I L.D E R OR OWNER ' 1 . 19P P IZ Rera t1 v DATE PERMIT ISSUED + — DAT E COMPLIANCE ISSUED 14)���� y ��Y22 y �/ 'OWN OF BARNSTABLE6zw4r a. LOCA-ION 16 yS &Z �F- SEWAGE # �a V)LLAGE G11�,EiPuaG��" ASSESSOR'S MAP & LOT f 0 INSTALLER'S NAME&PHONE NO. 4: <l44W& SEPTIC TANK CAPACITY I4MP C-2 LEACHING FACILITY: (type) r (size) /moo GAL NO.OF BEDROOMS — BUILDER OR OWNER PERMTT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility l3 �- 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 L within 300 feet of leaching ffaaci/lit j Feet Furnished by L17 � C�9TGN , a� 0 +, 4 A J, f �F ,r. r Z [, - •_ mt, � r , � a .,t .�'• ' Il r !}' t r'.# }� }`l• fir .Y f. 4y ..t Y 'k! 2 +} ys""iar {, •�9 r �.. '` aMf•{w. r j itl y. r�..�. fi taa5 Z: r •° t ,r < t '! ..' rb+! iti j { at. f4 �. f{• r, i. t 6d Eli' 2 f h'yi �t ,tF' t'''-.. :'f r. .y" F. t .;7 t S.> ` i, �yt ,«. r r �,+c. a ..`r r''?•.r r. :; aahr= ♦ y S .' 3 r rr b a ,`�$ 1 y ?; k Y{.w. < ,5. r• `' rTr �.r, f_, ' b r' 1*'+.. .�•�, a ,Y r$. Al+f�,• ! u i+. f a$ 'y } • r ,. Y,rr 'r tL4{� !Y'� + r ! ~ .. �`i"� t ''•r � 'f.,�h .. `+ �. a r•.`• � # - �� t. �,. �' a .�,�: + -'t4' x S- � ? 7.. t°?r •. � a• ?.. �,. •7 e ),^' , .Y a Y �� � A ;..p*t 4 d ^ ro � ' . t d of Se tember••29 .19821'^ F t Y ,4�,,r4� R tti<•4` [J+mot+ �� ;`f+ 1> �x4 }. Y 1'.a } jr ."L*'+%r .RV '�.r .. - Kv y, w 5`t F t �: < ..� k♦ ya` f `r- y: .r:> ea .r 71 .ry. = 4 •7t rr'- '•.- 5 ..t .r "'� ti� �• 7 ... ,Cy n r 7 L '4 .1�• ] ,•1 Yfw +/ y 2 Y i. �G ys.� -.. _ !1 a ''•4 7 iS'� ,+. 1 x. t �. w. t ` { . F A' V'y 'lJ. '�'< i �]'.d { r^° y �X "e J..�4J'•' R1C I' R Y Y '1 q .s '•rr •�.i +� CC r ° i s x+r -tr Whitmore - F Das.c 1 Co. -Builderw Inc r,.C3�`•" +,Bayberryr.Squat�. a* �Rte� 28 ty;P ry.7 t'�q,r++r+ Centearville; Ma. ' 02632 7 -R +.T + t '„,Yit L r `' r k•e ,ti } t a�.. v. 7 s � r x ;'•. ,r p'•t 4�E�=` ,},� 'f °r � ,+,n yr• ft a s� F {p 'F.<.. w {+�. ,`. g � y :3 iA { ,° th' Centerville Re. Vara ance for Lot � a�.m Ro d r v a,-,�• ;E�4`�v_r` 7-• t �•.!t,Y a raj � a 1 < •'h1•��c ti4�:v:�. 1s L, ��� •F t' i-•a �a r .a ,r r_�eG4i.'st'li. �M nll�i ei. r ,.� s •� ku, ,5 F •Yu= •fi4 �r a .-,ram } � f ``x� �'�•,4* v i � w` ti •a4 t" ,��.sn 7 k r r.:Zt'',.+?�t i11j a' t • `. ' anted a variance to,.'ina�ta '`a, septfc, system .wit y s r ,< =You are gr ' leachng�pt ;14feet:;from a'`bui5ld�.nn-f2ieu��if ''the.requ3red 4 . .; ,w<24 'feet on.. 86,,'Map .209,;.of .aFa3:mojtl ��Roa& Centerville. The ` '`t�� {�° ' t building `is an ofg 64 building with`no ,cellar«y.:s7 ".R "'a'.-: F s.. • < a.rf �.. +,,a r�>,r r.h ��L xaw Wf a ay._* {! +^t a' r ` +.t.,t 4 � ^r .• �•�'i,a � �;' a '�+,. 'rAT P �; IC f•�+ �,�,t"$� s 4 vp� J �r.�}, � ,. �,° [ at •may F , 2'Yie;o]:d.system for•:thi . bui1ding= was uhcdve�re. ,. u ng�'t e 'co , , k w• < struct3on .of,fa,ndk!bu°ildin , a� vYy = 5 }.'Jxa �✓'. r � �€ A . �a a 4: �r 4 +r• i s a 1 ti r pl,I "other �Tol_A..of Barnstib e H a�.th Regulations ,and,',zegulat3.ons found,in °Title:5, :csf the StateY tnvfrbnmental Code',t,must be �r T 5 .. �,: ,,.s . strictly adhered Ito. e,t, `5' }' ••• { .a� - i t ,}r a. •= t (_.•" 5.. J.t h',.., '" vr. L -.i ., s F 4.!'t-: 7 irt4 Sas r; ,ThaB variance `expires October �,� 1983« ��< � � ".) } 4•r r r ,` .� .. * [� �� a,�,,c a. fcr`.rr � F °` s. 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' f �,.•i• � �a ^t F r'' ,f �.� y _s� ,�, n � .�� a 1 .,. .'.�} s A.. :. '1.,,, .i.. ./s��� _. ,J �5a.m,F t'4 •,t ,.a• _ 7^i t. r, .. -t,..s.°r.a.: s.. RG C 209jc� ' w Sys rzgQo � �� : i. ,► C-x 6 0� P �' -�uiLDiue,, l aao G Ci uo $AS Gt� SYSnI U15TI;k, 25�, Sop xto7S' 2f. 6K 1000 6 AL T WL D►L 6<AL PIT iulu- or l c ��t n►,�� �I►��a azs &FO L--y t S*n N Cv 1 L • •ir���1�A� J4/ n � , '3v I� ►J TCA EX 6-n0U Per. -I�VILDIw(" Uo --DTAi- X,o1S 2( .G+ �6Q �c l Soo• 39 rr Ga .: 1000 6AC. T'ANIL. OIL. �K lST I l.1 C� loon LAL PIT k:!L.� ' b T✓, l l.. a t3 5 I ST1 P (o I �� Owl No bz PrzoPostND A►zaA ` J �o P►T. �3 u�I.D�►J�. I uo �ASubu (�o k to 6X1571�J(, � 25 - D(I�fla(� boo 6Ac. TA c►4 1000 &<AL Pjr L 116— ot=r- � c �L)tLnl►JC, azS 4FD + (2uTr, lt� �v(le S 1 N t t } o � pa MOr A� d r St _ . a -oc Route 28 O q O� S 44 21'55" E 98.43 LOCUS--"A396 74' DH/FND 67 Sylvia La LOCUS MAP _ _ _ _ _ I - - - - - - NOT TO SCALE ( I I Q� Lot 1 73,043E S.F. +•� 1.68E AC. 4, �� Map 209 tK Farce/ 86 I . !� , 40f Q0JI Bldg. "A" ` I ,#1645 Bldg. dg. .E I OWNERS OF RECORD UNIT 18 (ASSESSOR: 802) KLOTZ, SUSAN A r 51 MAPLE AVE. 78. 11' _ _ 164,41' _ _ i 148.00' _ ! CENTERVILLE, MA 02632 N 42 20'48" W N 43 45'04" W N 437737" W 101" UNIT 48 (ASSESSOR: 801) cH/DH/FND I DWYER, JEFFREY F & CAROL A 549 BAY LANE CENTERVILLE, MA .02632 UNITS 2B & 3B (ASSESSOR: 803 & B04) JOHNSON, VAN B TR BAYBERRY SQUARE REALTY TRUST L _ - _ _ _ _ _ _ _ _ SEE_SHEET 2 P.O. BOX 1 100 20 SCALE CENTERVILLE, MA 02632 °F M4ss9� PROPOSED SEPTIC SYSTEM UPGRADE PLAN � y � G PETER T. M 1645 FALMOUTH RD BLDG. B CENTERVILLE MA IT o CIVIL "' Prepared for: Copewide Enterprises, P.O. Box 763, Centerville, MA 02632 No. 35109 Engineering by: SCALE DRAWN JOB. NO. Engineering Works, Inc. 1"=40' P.T.M. 163-09 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 7/18/09 P.T.M. 1. of 3 rf - LEGEND EXISTING CONTOUR ' x 100.98 EXISTING SPOT GRADE -off U UNDERGROUND WIRES L O t 1a'-f- 73,043f S.F. G EXISTING GAS SERVICE ��. 1.68± AC. EXISTING SEPTIC TANK W EXISTING WATER SERVICE Map 209 TO BE PUMPED, RUPTURED -oc TEST PIT AND FILLED WITH SAND Q Parcel 6 � BENCHMARK V Ben chm ark Set EXISTING LEACH PIT Magnetic nail set C PUMP AND FILL WITH SAND EL.=101.45 (Assumed) _G -W aw G / a i ' U O O \ �/ 3 GENERAL NOTES: TOF=101.88 Bldg. '"A" / a (Craw l)' �64- 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL � BOARD OF HEALTH AND THE DESIGN ENGINEER. O - �tX lg'� 2• ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS " " OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE o Bldg. E LOCAL RULES AND REGULATIONS. Of Pavement t 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR Paved N — 0'� DOSGN IINSPE TIONE AND APPROVAL BY .THE BOARD OF HEALTH AND THE Parking cq O O O co O�� 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 21' TP-2 01,63 'L FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN TP-1 �O� o� ENGINEER BEFORE CONSTRUCTION CONTINUES. 21 �' • -: -r :.:-�:,, :-.-_-,, �O� 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. N l ::: — ;.A 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF O� f O O O I THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. ' _......� POSE __ �s ° 40' + 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. PROPOSED 8. THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S. O• Pave iVe 6 METAL CODER '� �O SEPTIC TANK , (UNKNOWN) �� 'L 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS Edge o W ovemen W--�c�1?' W �O� AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE VENT—MANIFOLD DIRECTED BY THE APPROVING AUTHORITIES. PROPERTY LINE ALL CHAMBERS 101,1 PROPERTY LINE 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY CB/DH/FND THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING J Edge of pavement CONSTRUCTION. O O Benchmark Set 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS o� Right cor. conc. step IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 100 EL.=102.07 (Assumed) RE CLEAN SAND AS SPECIFIED CMR 255(3). �(` or 12. AREAS REQUIRING S OF UNSUITABLE MATERIALS SHALL BE jn 10 Paved i INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. Parking � 13. ONLY AND J- �,�� �„�b 00 Q1� Of MAssc IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. 99 +� +� 9 98 71 ® `99 o PETER T. a� PROPOSED SEPTIC SYSTEM UPGRADE PLAN BASIN McENTEE NoCIVIL N 1645 FALMOUTH RD BLDG. B , CENTERVILLE, MA c�0 Prepared for: Capewide Enterprises, P.O. Box 763, Centerville, MA 02632 I n Engineering by: SCALE DRAWN JOB. NO. Engineering Works, Inc. 1"=20' P.T.M. 163-09 0q 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. O0� (508) 477-5313 7/18/09 P.T.M. 2 Of 3 �� NOTE: TO PREVENT BREAKOUT, THE PROPOSED 1-4" POLYSEAL INLET FINISH GRADE SHALL NOT BE < EL:97.8 22" FOR A DISTANCE OF 15' AROUND THE 3-4" POLYSEAL OUTLETS PERIMETER OF THE S.A.S. PROPOSED SEPTIC TANK PROPOSED D-BOX PROPOSED SAS: r`..; 4" 4" INSTALL RISERS, FRAMES & COVERS INSTALL RISER & WATERTIGHT FRAME INSTALL RISER & COVER OVER ONE Y 4" EXISTING OVER ALL ACCESS MANHOLES AND SET AND COVER SET TO FINISH GRADE CHAMBER AND SET TO FINISH GRADE T.O.F. GRADE AS SPECIFIED IN 310 CMR 15.228 TO SERVE AS INSPECTION PORT. ;n F.G. EL: 101.4t F.G. EL.=101.4(MAX.) ;,> \ N EXISTING F.G. EL.=1O1.5f VENT ALL CHAMBERS CRAWLOWA SPACE : 4„ L a 21' L = 18' 14" L=10' 0 S=1% (MIN.) ® S=1% (MIN.) CROSS SECTION " 4" SCH 40 PVC 4"SCH40 PVC 4"SCH40 PVC SPECIFICATIONS PLAN VIEW 6 1. CONCRETE STRENGTH 5,000 PSI 0 28 DAYS. ® S= 190 MIN. 13" 09 pp 89 2.) CEMENT, PORTLAND TYPE II PER ASTM C750-81 WIGGIN PRECAST CORPORATION 10" 14' 1 0" 1 4' 6' 0®®BB9B 3.) REINFORCEMENT PER ASTM C1227-93 aeaaaaa P.O. BOX 1138 POCASSET, MA 02559 A' 48" LICI 6,3630 4.) 15" RISER SECTIONS AVAILABLE INV.=98.15 LEVEL INV.=97.9D TEL: 508.564.6776 FAX: 508.564.6770 •`•' ` GAS GAS INV.=97.65 PROPOSED INV.=97.48 7;EFFEC 5.2' 3'BAFFLE BAFFLE H-20 D-BOX TIVE WIDTH = 11.2' H-20 LOADING 3 OUTLETS (MIN.) INV.=97.30H-20 RATED 500 GALLON EPTIC TANK (H-201 4-500 GALLON LEACHING CHAMBERS D-BOX PROPOSED 1 S COMPARTMENT NO. 1 - 1000 GALLON MINIMUM STORAGE SURROUNDED WITH STONE AS SHOWN N.T.S. COMPARTMENT NO. 2 - 500 GALLON MINIMUM STORAGE FMODIFY INTERIOR PLUMBING TO 2" LAYER OF 1/S" TO 112" i DOUBLE WASHED STONES BUILDING AT NO LOWER TOP CONC. ELEV.=98.4 (oR APPRovEo FlLiER FABRIC)INVERT=98.35 BREAKOUT ELEV.=97.8 NOTES: INV. ELEV.=97.30 ease 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE aseee eeaae ®®®® 0 E3 E3 Ea Ea INVERTS, PRIOR TO INSTALLATION. BOTTOM ELEV.=95.30 ®®®®®® ® ®®® 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND TRUE 3' 4 X 8.5'=34.0' 3' I- 37" 3 Ea TO GRADE ON A MECHANICALLY COMPACTED SIX INCH 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 40.0. '� w ® CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). T.P. EXCAVATION OR G.W. N Z ®Lzia 3) INSTALL INLET & OUTLET TEES AS REQUIRED. LEACHING SYSTEM SECTION 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE NO GROUNDWATER, EL.=90.3 - 3/4" TO 1-1/2" DOUBLE AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. WASHED STONE 102" 5) ALL CONCRETE PRODUCTS, FRAMES AND COVERS SHALL BE H-20 RATED. DESIGN CRITERIA SOIL LOG 4" KNOCKOUT OFFICE SPACE: UNIT 1 B............ = 710 S.F.t UNITS 2B & 3B = 1624 S.F.t DATE: JULY 2, 2009 (REF#12,621) 20" DIA. COVER TOTAL AREA = 2334 S.F.f SOIL EVALUATOR: PETER MCENTEE PE(SE#1542) SEWAGE FLOW = 2334 SF x 75 GPD/1000 SF = 175 GPD WITNESS: DAVID STANTON 4" KNOCKOUT / 4" KNOCKOUT 62" DENTIST OFFICE: 200 GPD/DENTIST HEALTH AGENT SEWAGE FLOW = 200 GPD (ONE DENTIST) ELEV. TP- 1 DEPTH ELEv. TP-2 DEPTH COMBINED FLOW = 200 + 175 = 375 GPD (310 CMR 15.203) COMBINED WATER USAGE AVERAGED OVER 365 DAYS = 345 GPD (126000 GALLONS) 101.4 0 4" KNOCKOUT 101.3 0 ESTIMATED MAXIMUM DAILY FLOW BASED ON 5 DAY WORK WEEK = 483 GPD 100.2 A FILL 14„ 100.1 A FILL 14" SOIL TEXTURAL CLASS: CLASS I SANDY LOAM SANDY LOAM DESIGN PERCOLATION RATE: <2 MIN/IN 99.9 10YR 4 2 18„ 99 8 10YR 4 2 18" 500 GALLON CAPACITY, H-20 LOADING B DAILY FLOW: 375 G.P.D. (310 CMR 15.203) B SANDY LOAM SANDY LOAM DESIGN FLOW: 375 G.P.D. (310 CMR 15.203) 10YR 5/8 10YR 5/8 CHAMBERS GARBAGE GRINDER: NO 98.4 36" 98.3 36" C1 PERC C1 N.T.S. PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY (2 COMPARTMENT 1000/500) LOAMY SAND 40"/52 LOAMY SAND LEACHING AREA REQUIRED: (375) = 506.8 S.F. 10YR 5/6 10YR 5/6 PROPOSED SEPTIC SYSTEM UPGRADE PLAN •74 56" 96.6 5% GRAVEL 5% GRAVEL 56" USE 4-500 GALLON LEACHING CHAMBERS IN SERIES 96.7 C2 C2 1645 FALMOUTH RD (BLDG. B , CENTERVILLE, MA SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES MED. SAND MED. SAND Prepared for: Copewide Enterprises, P.O. Box 763, Centerville, MA 02632 SIDEWALL AREA: 2(11.2' + 40.0') X 2 = 204.8 S.F. 2.5Y 6/4 2.5Y 6/4 BOTTOM AREA: 11.2' x 40.0' = 448.0 S.F. >20% GRAVEL >20% GRAVEL Engineering by: SCALE DRAWN JOB. NO. 90.4 132': 90.3 132" Engineering Works Inc. NTS P.T.M. 163-09 TOTAL AREA:..............................................................652.8 S.F. PERC RATE- <2 MIN IN. ("Cl" I g 9 ( C 1 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET N0. DESIGN FLOW PROVIDED: 0.74(652.8) = 483.1 G.P.D. NO GROUNDWATER OBSERVED (508) 477-5313 7/18/09 P.T.M. 3 of 3 AAA" " MAP IvA A x �44 E-e?t 1-4 N t7�vvv, IF -t;�A C011311L t A. v r 4 1 x9l I L54 a 7- TrM / ., i 3 S 3 f -3Z 4.A� 37 83 (a i's c", Dt t. 36,1 Tr-T-A lvv- AP 4ti\N Cf A-1 0147 WULIN OVI '9976, z; P-13 t4 I V(L-,O S/cm 'COA6AA UQLbF- A! 4L irA VEM F oF !-70 44AP 14 2-z-o WATT TOP OF FOUNDATION = VARIES EXISTING EXTENSION RISER WITH FINISH GRADE OVER D-BOX= 46.1'± FINISH GRADE OVER CHAMBERS= 45.3' - 46.11 PROP.VENT WITH CHARCOAL FILTER TO ABOVE GRADE GENERAL NOTES MANHOLE FRAME &COVER TO SLOPE @ 2% MIN. OVER SYSTEM EXISTING GRADE (INLET&OUTLET) SECURE H-20 CONCRETE RISER AND CAST 4" SCHEDULE 40 PVC MIN SLOPE 1% 3/4"TO 1-1/2"DOUBLE WASHED STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISHED GRADE FINISH GRADE ,± IRON FRAME&WATER-TIGHT COVER TO F.G. ( METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL @ FOUNDATION = VARIES OVER TANK EL.- 46.6 2"OF 1/8"TO 1/2" DOUBLE WASHED STONE " CODE AND ANY APPLICABLE LOCAL RULES. 5 DIA. OUTLET(S) TOP OF SAS = 37.60' CAST IRON FRAME& 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE t 8.5'MAX. COVER TO F.G. (TYP.) DESIGN ENGINEER. EXISTING 7.93' MAX. SEE GEN. EXTENSION RISER------. SEE GEN. NOTE 21 36.60 NOTE 21 BREAKOUT EL = 37.1 O PLACE RISERS ON ALL 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL T- PROPOSED 4"SCH. 40 PVC CHAMBERS TO F.G. SYSTEM UNLESS OTHERWISE NOTED. EXIST. 4" SEWER PIPE --- PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN \ � ��„ 2" DROP MIN. JOINTS (TYP.) o�� ELEVATION =37.10' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. \._. 6 3 3" DROP MAX. 3" 9" 4 PVC IN FROM 0 0 O 0 CI 0 0 000 Q UNLESS A 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND o EXIST. TANK 4" PVC OUT TO oo �o �o � THE TOP OF THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. 191, . LEACHING FACILITY Op o o 0 0 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. EXIST. " " � � 0 0 0� � � � � � � o� 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. (EXIST.) 37.17 MIN. 6 37.00 00 00 000 00 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK LIQUID LEVEL 6"CRUSHED STONE oo 0 0 o c 0 o FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS I PROVIDE GAS BAFFLE OVER MECHANICALLY 4.0' 3.0' 4.0' NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH CONTRACTOR SHALL VERIFY i COMPACTED BASE 8.5' r 4.0 4 9' 4.0 AND DESIGN ENGINEER. CONDITION OF EXISTING TEES CONTRACTOR SHALL VERIFY 5 51.0 *** ' io (TYP.) 8. ELEVATIONS BASED ON APPROXIMATE MEAN SEA LEVEL DATUM. ELEVATION OF AND REPLACE AS NECESSARY OUTLET DISTRIBUTION BOX SEASONAL HIGH GROUND WATER ELEV.= _ - - - - - , EXISTING TANK TO BE H-20 AND TO BE INSTALLED ON A LEVEL STABLE ** - - 12.9 47.79 ESTABLISHED ON A NAIL SET IN TREE AS SHOWN ON PLAN. REPLACE IT, IF NECESSARY, BASE. FIRST TWO FEET OF OUTLET 1992 CONTOURS MAP GROUND WATER ELEV.= 25± 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION WITH A 2,500 GAL. H-20 TANK � ADJUSTED GROUND WATER ELEV.= *24.17� (O.W.#1 **BASED ON THE ADJUSTED G.W.EL.PREVIOUSLY USED FOR BLDGs A&FIN 2006THROUGH PIPES TO BE LAID LEVEL. 34.60 BASED ON THE TOWN OF BARNSTABLE 1992 GROUNDWATER CONTOURS MAP 1 888-D G-SAI E AND ANY OTHER APPLICABLE OAG NCIOES.MREPO T ANY WORK OSCREPANCIES N SITE AT EXISTING 2,500 GALLON SEPTIC TANK CROSS SECTION VIEW OBSERVED GROUND WATER ELEV.= 17.97 (O.W.#1) 'BASED ON THE CAPE COD COMMISSION METHOD(SEE BELOW) TO THE DESIGN ENGINEER. SEPTIC TANK PROFILE H-20 DISTRIBUTION BOX DETAIL 4 - 500 GAL. MB CHAMBERS H-20 CHAMBER DETAILS 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE STRUCTURES SHALL BE MADE NOT TO SCALE NOT TO SCALE TYPICAL CHAMBER PROFILE NOT TO SCALE CHAMBER END VIEW WATERTIGHT. _ _ SWING-TIES SCALE: 1" =20' SPECIAL NOTES: FALMOUTH ROAD(RTE 28) • a + ! L7f 48t TEST PIT DATA 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING DESCRIPTION BC-1 BC-2 O.W. (STATE HIGHWAY-80'WIDE) . r 0�1 •, AGENT:. Pit REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROMonald Desmarais, R.S. APPROPRIATE AUTHORITY. D 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF N86°30'25"E r • �. • • CORNER OF STONE (1) 50.6' 72.9' 26.1' EACH SEPTIC SYSTEM COMPONENT. 238.14' • "' ' ti" • EVALUATOR: Michael Pimentel, EIT 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS � --�-�• 4'9?, MAP 209 • • • r ��. • --., • • • DATE: July 6, 2012 LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE CORNER OF STONE (2) 47.5' 60.4' 35.8' 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF 's`'Q PARCEL 86 Q • • •' • THEY SHALL WITHSTAND H-20 LOADING. THE PROPOSED LEACHING FACILITY DOWN TO EL. =29.90'TO ENSURE '�e 1.68 Ac. • • • • �► + • TEST PIT#: 1 CORNER OF STONE 3 98.3' 67.9' 43.0' • ' 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. O CONSISTENCY WITH TEST PIT DATA SHOWN ON THIS PLAN i.e. SOIL LAYER � � ( MAP 209 ++ • �� � •• ELEV TOP = 45.80 CORNER OF STONE 4 99.9' 79.2' 35.3' "C"). REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH IF SOILS ARE BLDG G PARCELs5 :+ • *+" O NOT CONSISTENT WITH TEST PIT DATA. BLDG A + • + , ELEV WATER= 24.17 (O.W.#1) 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE . + • + + MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. #1645 tiA . d !i •• •' PERC RATE _ <2 Min/In REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, EXISTING 3.) PROPERTY IS LOCATED WITHIN THE ESTUARINE WATERSHEDS ZONE. �oAs s •` � � I�« � '+•• • o " ++ , •. LOCUS' •+ FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). COMMERCIAL A,,"fiy BLDG F s%�ss + ' , • + q r �+ DEPTH OF PERC - 42"-60" BUILDING "E" 4.) CONTRACTOR TO CONTACT DAN WIGGINS AT WIGGINS PRECAST + , • . 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN A F TOF - 46.8'± CORPORATION, 1138 POCASSET, MA(PH: 508-564-6776) FOR SPECIAL MAP 209 + • "O• TEXTURAL CLASS: 1 ORDERING THE H-20 LEACHING CHAMBERS AND DISTRIBUTION BOX AS BLDG B • • 4 a �'• SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. f BC-2 SHOWN ON THIS PLAN. PARCEL a7-1 •. + 1c BLDG E • � a •' • ' •s d• � tt 16. PROPOSED PROJECT IS LOCATED WITHIN: 86 BUILDINGS D05 ASSESSORS MAP 209 PARCEL � MAP 209 a ®M 60 `'.• •\� , '' � � 0" 45.80' - ,yA BLDG C BLDG D PARCEL 83 • • 1� ` FIII OWNER OF RECORD: BAYBERRY SQUARE CONDOMINIUMS N ��'��� +• , • + 18" 44.30' ADDRESS: 1645 FALMOUTH ROAD #1645 ,Q o° , eQChW Q CENTERVILLE, MA 02632 + a FEMA FLOOD ZONE C EXISTING �2l sss"31r25"w _- i COMMERCIAL O MAP 209 2a7.77' s ,++ B Loamy Sand BUILDING "D" AS SHOWN ON COMMUNITY PANEL# 250001 0005 C TOF =47.8'± PARCEL 87-2 MAP 209 • * 00, �� • • •� •J 10Yr 5/6 1 17. DEED REFERENCE: �ooQ PARCEL s1 _ • ; +• ; • �, BK. 3517, PG. 1 5 • • • 42" 42.30' 18. PLAN REFERENCES: INDEX PLAN �n I-f ' • • 3) y , • • • Perc 1.)PL. BK. 363, PG. 36 SCALE: 1"=80' • ' ` 60" 40.80' 2.)PL. BK. 365, PG.40 BC-1 p y�0 • (p +�` l� 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. O O a • • O 4) •• Med. to Coarse Sand 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY - + • �+. • fir►U 7 + • C 2.5Y 6/6 FOR SEPTIC SYSTEM UPGRADE. PESCE ENGINEERING WILL NOT ASSUME ANY LIABILITY 1.0 • + �\ ^ $ (20/o gravel) FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. (1 ('� 21. THE FOLLOWING VARIANCES ARE REQUESTED FROM 310 CMR 15.221(7): LO V U S PLAN g Weeping (2.1.) A 4.93 A 5.50'VARIANCE (3.00-8.50') FOR THE MAXIMUM COVER OVER THE LEACHING FACILITY. O_W_ \ No Standing, in 'VARIANCE 3.00-7.93' FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX. or Mottling Observed `�s 128" 35.13' 22. THE FOLLOWING VARIANCE IS REQUESTED FROM 310 CMR 15.223(1)(b): =r SCALE: 1" 1000' (1.) A VARIANCE FROM PROVIDING A SECOND TANK IN SERIES WITH A MINIMUM Water reading of on-site observation well#1 EFFECTIVE LIQUID CAPACITY OF 100% OF THE DESIGN FLOW OF 619.6 GPD (I.E. NO \\ XIST. CBN DESIGN DATA (O.W.#1)taken on August 30,2012; EL.= 17.97' SECOND TANK PROVIDED). rIM =43.96' �0 23. A LOCAL VARIANCE IS REQUESTED FROM THE TOWN OF BARNSTABLE'S INNOVATIVE& EXISTING �` ?�, \ \ TEST PIT DATA ALTERNATIVE SYSTEMS REGULATION (SECTIONS 360-36 THROUGH 360-42)(i.e. 1,650 gpd rule): S C\ 0 \ COMMERCIAL OFFICE CONDOMINIUM BUILDINGS D & E S, - - - BUILDING "F" `�!\ 6'j ` \ \ \ \ \ ! AGENT: Donald Desmarais, R.S. sr, I DESIGN FLOW 75 GAUDAY/1,000 S.F. LEGEND i OFFICE SPACE AREA 8,261 S.F. EVALUATOR: Michael Pimentel, EIT TOTAL DESIGN FLOW (8,261 S.F. / 1,000 S.F.)x 75 GPD =619.6 GPD DATE: July 6, 2012 50xO' EXISTING SPOT GRADES \ � o TEST PIT#: 2 EXISTING \ \ `�� �''�+ Q TOTAL DESIGN FLOW x 200 /o = 1,239.2 GAUDAY -- 50 -- - EXISTING CONTOUR #1645 BUILDING "B" EXISTING \ 40 �\ \ USE EXISTING 2,500-GAL. SEPTIC TANK, WHICH IS GREATER THAN 1,239.2 GPD ELEV TOP- 45.80' \ 175-01 PROPOSED SPOT GRADES / COMMERCIAL MAP 209 42--\ \\\ \ I NO 2nd TANK IN SERIES PROVIDED(SEE GENERAL NOTE 22 FOR VARIANCE REQUEST) ELEV WATER= -24.17' (0.W.#1) BUILDING "E" \ 4 Ica ,�Ci PARCEL 86 co 50 PROPOSED CONTOUR (Total Floor 3 9 1.68 Ac. \ \\\ 0 PERC RATE _ J� 3 Area=2,897 sf) \ \ a ! E/T/C - EXISTING UNDERGROUND UTILITIES TOF = 46.8'± ,� EXIST. CBN ` \ \\ C INSTALL 4 - 500 GALLON H-20 LEACHING CHAMBERS DEPTH OF PERC = RIM =44.43' \ \ k #1645 CBN m TEXTURAL CLASS: 1 W W EXISTING WATER LINE EXISTING #1645 \ Benchmark \ \ a ! SIDEWALL CAPACITY' TEST PIT LOCATION EXISTING COMMERCIAL Nail Set in Tree � // \ \\ \\\ (LENGTH +WIDTH)(2)(2' HIGH) (0.74 GPD/S.F.) = GAUD" 45.80' 45.80' BUILDING C„ -' Elev. =47.79 \ ( (Total Floor 39.6 COMMERCIAL .Q� \� Approx. M.S.L. " \ \\ MAP 209 (51.0'+ 12.9') (2)(2') (0.74 GPD/S.F.) = 189.1 GAUDAY Fill ID EXISTING 2,500 GALLON SEPTIC TANK \ Area=2,867 sf BUILDING "D' ?�� - , ) x44.8 PARCEL 85 18" 44.30' 47.7± (Total Floor � �� / i TOF = - \ PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE � Area=2,497 sf) BOTTOM CAPACITY'' �T � � \ ° << TOF -47.8'± � �' LENGTH x WIDTH 0.74 GPD/S.F. kn ° oQ PROP. 6 •�-PROPOSED 4" PVC VENT \ ( ) ( ) E3 PROPOSED H-20 DISTRIBUTION BOX (51.0'x 12.9') (0.74 GPD/S.F.) = 486.8 GAUDAY Loam Sand \ C/ ` 5� .� / H- 0 EXACT LOCATION PER OWNER �\ \ I B 10Yr5/6 ` �� "D-BOX" \ \ � PROPOSED 500 GALLON H-20 LEACHING CHAMBER St � � ` v1 c� EXIST. CBN \ i TOTALS: RIM =44.57' 1 10-8-12 MCP JLC ADDED 1,650 GPD LOCAL VARIANCE REQUEST WOOD GUARD RAILS / 45.4 \ TOTAL NUMBER OF CHAMBERS: 4 42„ 42.30 TOTAL LEACHING AREA: 913.3 SQ.FT. R� BY APP'D. DESCRIPTION -53- \ \ \k• ` ` O O O \ TOTAL LEACHING CAPACITY: 675.9 GAL./DAY _ o PROPOSED S SYSTEM UPGRADE x44.5 / ` ., ... . OW #1 OBSERVATION SEPTIC -X-X-X-X-X-X CB/DH +\� ` �� x46.4 TOP EL_45.37' WELL (TYP. OF 7) QX� �4 PREPARED FOR: (FND/DIST) \+\ \ >r -' H2O EL.-17.97' 1 �"'psr ¢� BAYBERRY SQUARE CONDOMINIUMS \ I-� TP 1, ADJ. EL.=24.17' h��J x FRS Med.to Coarse Sand �\ / N I ,45x8 , -- x45.2 __ - - --- _ C 2.5Y 6/6 ` -- -- _ MAP 209 o LOCATED AT JEi �� � (20/o gravel) �46� x46.3 x46 3 --'�c 45x8 L.P. A �E 44- x46.2 TP 2� \+ \ , - d ITYPE X _ PARCEL 83 1645 FALMOUTH ROAD ^247.77'5"E No Standing,Weeping BUILDINGS 'C' 'D'' 'E' N86 30'2 +\ L P __\�\ ---`--- - "_ II or Mottling Observed CENTERVILLE, MA 02632 MAP 209 +\�' - - - - - EXISTING "D-BOX" PROPOSED 4 - 500 GAL. f: FENCE (TYP) MAP 2O9 128" 35.13' 7 SCALE: 1 INCH = 20 FT. DATE: SEPTEMBER4, TO BE ABANDONED EXISTING LEn� y H-20 LEACHING CHAMBERS 2012 PARCEL 87-2 Water reading of on-site observation well#1 0 10 20 ao 80 FEET PIT TO BE PUMPED, PARCEL 91 EXISTING LEACHING PIT TO REMOVED OFFSITE (O.W.#1)taken on August 30,2012;EL.= 17.97' IJtiA1 EXISTING 2,500 GALLON __. _.._ __.. __ ____.._. ,N of rra.ss�` BE PUMPED AND FILLED AND VOID FILLED w/ N'` PREPARED BY: SEPTIC TANK TO BE JOHN L. 'BASED ON THE CAPE COD COMMISSION METHOD r° WITH CLEAN SAND UTILIZED INS d1`� DESIGN CLEAN SAND INDEX WELL: MIW-29 CHURCHILLJR. JC ENGINEERING, INC. WATER-LEVEL RANGE ZONE: D CI L 2854 CRANBERRY HIGHWAY WATER DEPTH READING: 9.32' N0. 18 WATER DEPTH READING DATE: 8-2�12 o EAST WAREHAM, MA 02538 WATER-LEVEL ADJUSTMENT FACTOR: 6.20' Iti - F ST SITE PLAN ADJUSTED WATER-LEVEL: EL.=24.17' , r, ; i 508.273.0377 (i.e.17.97'+6.20'=24.17') -- - - SCALE: 1"=20' Drawn By: MCP Designed By:MCP Checked By:JLC JOB No.2255 _. -- - TOP OF FOUNDATION = VARIES EXISTING EXTENSION RISER WITH FINISH GRADE OVER D-BOX- 46.V± FINISH GRADE OVER CHAMBERS = 45.3' - 46.1' PROP.VENT WITH CHARCOAL FILTER TO ABOVE GRADE GENERAL NOTE S MANHOLE FRAME &COVER TO SLOPE @ 2% MIN. OVER SYSTEM - _,*,�Q i SECURE H-20 CONCRETE RISER AND CAST FINISHED GRADE EXISTING GRADE (INLET&OUTLET) 4"SCHEDULE 40 PVC MIN SLOPE 1% 3/4"TO 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE IRON FRAME &WATER-TIGHT COVER TO F.G. METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL @ FOUNDATION = VARIES OVER TANK EL, 4'6.6 ±-\ ii 2"OF 1/8"TO 1/2" DOUBLE WASHED STONE ___--__ 1 5"DIA. OUTLET(S) CODE AND ANY APPLICABLE LOCAL RULES. CAST IRON FRAME& 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE TOP OF SAS = 37.60' COVER TO F.G. (TYP.) DESIGN ENGINEER. EXISTING 8.5' MAX. EXTENSION RISER-----. SEE GEN. NOTE 21 36.60' NOTE 2SEE N BREAKOUT EL = 37.10� PLACE RISERS ON ALL ! 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL " CHAMBERS TO F.G. ! SYSTEM UNLESS OTHERWISE NOTED. r� PROPOSED 4 SCH.40 PVC EXIST. 4" SEWER PIPE ----- -_7- PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN � ��„ 2" DROP MIN. JOINTS (TYP.) A ! ELEVATION =37.10' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. 6 3 3" DROP MAX. 3" 9" = = = O o00 = = O ; UNLESS A 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND 4 PVC IN FROM " o coo THE TOP OF THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. c EXIST. TANK 4 PVC OUT TO oo �o o o i 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 19^ O LEACHING FACILITY o00 0 37.6 ' �- 37.4 ± 2. 2' o 0 00 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. (EXIST.) (EXIST.) 37.17' MIN. 6" 37.00' oo 7. A o 0 0 0 0 0 0 o 0 0 o LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK LIQUID LEVEL 6"CRUSHED STONE o FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS PROVIDE GAS BAFFLE OVER MECHANICALLY 4.0' 3.0' I 4.0' 4.0' 4.0' I NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH COMPACTED BASE 8.5' ,- AND DESIGN ENGINEER. CONTRACTOR SHALL VERIFY ' 51.0' 4•9� CONDITION OF EXISTING TEES i CONTRACTOR SHALL VERIFY 5 OUTLET DISTRIBUTION BOX ***27.57' in (TYP.) 8. ELEVATIONS BASED ON APPROXIMATE MEAN SEA LEVEL DATUM. ELEVATION OF AND REPLACE AS NECESSARY ( EXISTING TANK TO BE H-20 AND SEASONAL HIGH GROUND WATER ELEV.= _ _ - _ _ _ - - - 12.9' 47.79' ESTABLISHED ON A NAIL SET IN TREE AS SHOWN ON PLAN. TO BE INSTALLED ON A LEVEL STABLE 1992 CONTOURS MAP GROUND WATER ELEV.= 25 _ 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION REPLACE IT, IF NECESSARY, I ** '+ - - WITH A 2,500 GAL. H-20 TANK BASE. FIRST TWO FEET OF OUTLET ADJUSTED GROUND WATER ELEV.= *24.17' (O.W.##1) *;*BASED ON THE ADJUSTED G.W.EL.PREVIOUSLY USED FOR BLDGs A&FIN 2006 PIPES TO BE LAID LEVEL. 4- _ THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT BASED ON THE TOWN OF BARNSTABLE 1992 GROUNDWATER CONTOURS MAP f 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES EXISTING 2,500 GALLON SEPTIC TANK CROSS SECTION VIEW OBSERVED GROUND WATER ELEV.= 17.97' (O.W.#1) *BASED ON THE CAPE COD COMMISSION METHOD(SEE BELOW) TO THE DESIGN ENGINEER. SEPTIC TANK PROFILE H-20 DISTRIBUTION BOX DETAIL 4 - 500 GAL. MB CHAMBERS H-20 CHAMBER DETAILS 10• ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE STRUCTURES SHALL BE MADE NOT TO SCALE NOT TO SCALE TYPICAL CHAMBER PROFILE CHAMBER END VIEW NOT TO SCALE WATERTIGHT. SWING-TIESSCALE: 1" =20' SPECIAL NOTES: FALMOUTH ROAD(RTE 28) + • I reel TEST PIT DATA 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING Pt STATE HIGHWAY-80'WIDE) • ♦ •• REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM DESCRIPTION BC-1 BC-2 O.W. ( • ' '•, AGENT: Donald Desmarais, R.S. APPROPRIATE AUTHORITY. 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF N86°30'25"E ., • !. « ' CORNER OF STONE (1) 50.6' 72.9' 26.1' EACH SEPTIC SYSTEM COMPONENT. 238.14' • " EVALUATOR: Michael Pimentel, EIT 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS MAP 209 �� w » • r• *+• 0 DATE: July 6, 2012 LOCATED UNDER FAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE CORNER OF STONE (2) 47.5' 60.4' 35.8' 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF �8`'Q PARCEL 86 • wi + w• • THEY SHALL WITHSTAND H-20 LOADING. THE PROPOSED LEACHING FACILITY DOWN TO EL. =29.90'TO ENSURE _'� 9z 1.68 Ac. • : � + • TEST PIT#: 1 CORNER OF STONE(3) 98.3' 67.9' 43.0' CONSISTENCY WITH TEST PIT DATA SHOWN ON THIS PLAN (i.e. SOIL LAYER • ' p • • 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. MAP 209 r• • . ELEV TOP= 45.80 "C"). REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH IF SOILS ARE ti%`' BLDG G PARCEL 85 :+ • +' � CORNER OF STONE(4) 99.9' 79.2' 35.3' NOT CONSISTENT WITH TEST PIT DATA. BLDG A • • Q ELEV WATER= ,24.17' (O.W.#1) 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE - - - -- • • � • + ® •+ , MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. 1645 3 ) PROPERTY IS LOCATED WITHIN THE ESTUARINE WATERSHEDS ZONE. "�° • , , ; /i+ ••+• +• PERC RATE _ <2 Min/In REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, . EXISTING As s • + . • oQ, ' �, *• . •r ?Q LOCUS, •• FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). COMMERCIAL F,, �y BLDG F �% ass, • ' • • • i J' �+ DEPTH OF PERC = 42"-60" 4.) CONTRACTOR TO CONTACT DAN WIGGINS AT WIGGINS PRECAST 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN BUILDING "E" CORPORATION, 1138 POCASSET, MA PH: 508-564-6776 FOR SPECIAL A • ' • • TOF =46.8'± ( ) MAP 209 •• • • r �� + TEXTURAL CLASS: 1 SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. BC-2 ORDERING THE H-20 LEACHING CHAMBERS AND DISTRIBUTION BOX AS PARCEL 87-1 BLDG B •• Q SHOWN ON THIS PLAN. 1C BLDG E goo .• • �w Ow 16. PROPOSED PROJECT IS LOCATED WITHIN: MAP 209 ' w �� # • t 0" 45.80' ASSESSORS MAP 209 PARCEL 86 BUILDINGS D05 - - ,yA BLDG C BLDG D PARCEL 83 • « Fill OWNER OF RECORD: BAYBERRY SQUARE CONDOMINIUMS ID .. • • w 18" 44.30' o � . � � ADDRESS: 1645 FALMOUTH ROAD #1645 ,P9 + e�chw CENTERVILLE, MA 02632 EXISTING ?� -w • • °- LL FEMA FLOOD ZONE C sss°3a2s COMMERCIAL A MAP 209 247.TT • + ,+' w• B Loamy Sand BUILDING AS SHOWN ON COMMUNITY PANEL# 250001 0005 C D' « �y + TOF =47.8'± PARCEL 87-2 MAP 209 r'�y '�; �' "'lI • 10Yr 5/6 • 17. DEED REFERENCE: PARCEL 91 • �,..' � •+• .�/ • --- - -- - - 5 - --- - - --- -- _-_ - - ..-." � . : �• • // • �"" • ( BK. 3517, PG. 1 42.30 �2 INDEX PLAN an rry + • 18. PLAN REFERENCES: 3) • • l A Perc 1.)PL. BK. 363, PG. 36 2) SCALE: 1" =80' '� * • �`w * 60" 40.80' 2.)PL. BK. 365, PG.40 BC-1 °3 _ rya • * t+• • 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. O O . • • N O 4) . • Med. to Coarse Sand 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY ' ,p•" ♦ O • C 2.5Y 6/6 a . !, / „ ° FOR SEPTIC SYSTEM UPGRADE. PESCE ENGINEERING WILL NOT ASSUME ANY LIABILITY 1.0 (20/o gravel) FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. (1 21. THE FOLLOWING VARIANCES ARE REQUESTED FROM 310 CMR 15.221(7): j LOCUS PLAN p g (1.) A 5.50'VARIANCE (3.00-8.50') FOR THE MAXIMUM COVER OVER THE LEACHING FACILITY. O.W. \ No Standin Wee in 2. A 4.93'VARIANCE 3.00-7.93' FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX. i or Mottling Observed SCALE: 1"= 1000' 128" 35.13 ! 22. THE FOLLOWING VARIANCE IS REQUESTED FROM 310 CMR 15.223(1)(b): �sr (1.) A VARIANCE FROM PROVIDING A SECOND TANK IN SERIES WITH A MINIMUM Water reading of on-site observation well#1 EFFECTIVE LIQUID CAPACITY OF 100% OF THE DESIGN FLOW OF 619.6 GPD(I.E. NO \ (O.W.#1)taken on August 30,2012;EL.=17.97' XIST. CBN f ` DESIGN DATA SECOND TANK PROVIDED). i RIM =43.96 �,� ° 1 23. A LOCAL VARIANCE IS REQUESTED FROM THE TOWN OF BARNSTABLE'S INNOVATIVE& \ TEST PIT DATA ALTERNATIVE SYSTEMS REGULATION (SECTIONS 360-36 THROUGH 360-42) (i.e. 1,650 gpd rule): EXISTING vCO\ �,� 2�S BUILDING "F" \ \ COMMERCIAL OFFICE CONDOMINIUM BUILDINGS'C', 'D' &'E' I � �. 6'j Sy \ \ AGENT: Donald Desmarais, R.S. DESIGN FLOW 75 GAUDAY/1,000 S.F. LEGEND OFFICE SPACE AREA 8,261 S.F. EVALUATOR: Michael Pimentel, EIT TOTAL DESIGN FLOW (8,261 S.F./ 1,000 S.F.)x 75 GPD =619.6 GPD DATE: July 6, 2012 50x0' EXISTING SPOT GRADES EXISTING \ \ \� �\ \ `��"'��' TOTAL DESIGN FLOW x 200 % = 1,239.2 GAUDAY TEST PIT#: 2 - 50 - - EXISTING CONTOUR BUILDING "B" #1645 ` �q0 "'d' \ '7 USE EXISTING 2,500-GAL. SEPTIC TANK, WHICH IS GREATER THAN 1,239.2 GPD / G EXISTING MAP 209 \qz \ \ ELEV TOP = - 45.80' Q COMMERCIAL 50 PROPOSED SPOT GRADES � \\ \ (o NO 2nd TANK IN SERIES PROVIDED(SEE GENERAL NOTE 22 FOR VARIANCE REQUEST) ELEV WATER- "24.17' (O.W.#1) BUILDING "f° 1.68 Ac.PARCEL 86 \4� \ \\ a 50 PROPOSED CONTOUR (Total Floor \ C9 PERC RATE_ J� 39 Area-2,897 s ) \ \ E/T/C EXISTING UNDERGROUND UTILITIES TOF =46.8'± ,; EXIST. CBN ` \ \\ CD I INSTALL 4 - 500 GALLON H-20 LEACHING CHAMBERS DEPTH OF PERC RIM =44.43 = \ \ \ #1645 cBN m I TEXTURAL CLASS: 1 W W EXISTING WATER LINE EXISTING Benchmark J SIDEWALL CAPACITY #1645 Nail Set in Tree \ \ \\ a TEST PIT LOCATION Elev. =47.79 COMMERCIAL �• `� , EXISTING `'' \ (LENGTH +WIDTH) (2) (2 HIGH) (0.74 GPD/S.F.) = GAUDAY 0 45.80 BUILDING "C" � � \ 39.6 COMMERCIAL _ \ MAP 209 BUILDING "D' (51.0'+ 12.9') (2)(2') (0.74 GPD/S.F.) = 189.1 GAL/DAY (Total Floor 'py �� Approx. M.S.L. \ \ Fill O EXISTING 2,500 GALLON SEPTIC TANK ?y � � ` Area=2,867 sf) \ PARCEL 85 18" 44.30' � TOF =47.7'± (Total Floor L �c Area=2,497 sf) x44.8 \ BOTTOM CAPACITY PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE TOF = 47.8'± a� cn Q PROP. . PROPOSED 4" PVC VENT \ i (LENGTH x WIDTH) (0.74 GPD/S.F.) D� \ \ \ (51.0'x 12.9') (0.74 GPD/S.F.) = 486.8 GAUDAY Loamy Sand E3 PROPOSED H-20 DISTRIBUTION BOX H-20 l � EXACT LOCATION PER OWNER \ \ B I 0"D-BOX" V PROPOSED 500 GALLON H-20 LEACHING CHAMBER f `\ \� / \ \ �- Ado ` P`� �� 27.6 EXIST. CBN \ 10Yr 5/6 \ TOTALS: \ i ,� 1 10-8-12 MCP JLC ADDED 1,650 GPD LOCAL VARIANCE REQUEST f \ \ - WOOD GUARD RAIL-� 45.4 RIM =44.57 \ i TOTAL NUMBER OF CHAMBERS: 4 42 42.30 ' \ / \ REV. DATE BY APP D. DESCRIPTION \ TOTAL LEACHING AREA: 913.3 SQ.FT. - -_- -53- \ ' OB �w '__� ° o ° ° 1 ` TA LEACHING CAPACITY: ALJDAY PROPOSED SEPTIC SYSTEM UPGRADE -X -X-X-X \ \� x44.5 / '� x46.4 f. _ OBSERVATION TOTAL C G C C G PREPARE O.W. # 675.9 _X-X CB/DH 1 TOP EL.=45.37' WELL (TYP. OF 7) D FOR: FND/DIST \� - H2O EL.=17.97' 1 �Mpsr 4\ BAYBERRY ( ) +� \ i-� TP 1� ADJ. EL.=24.17' x FR Med.to Coarse Sand SQUARE CONDOMINIUMS i li %45x8 __ 145.2 ,"� -- -- - � C 2.5Y 6/6 - IE7T7C% -_ MAP 209 (20%gravel) LOCATED AT +�+\\ qs� x46.2 x46.3 x463 °�-�� J T5 8'*L.P. �+TRE r- -44 -X - `X --- II (Ty _ PARCELS3 1645 FALMOUTH ROAD �+� - 247.77 _-- - BUILDINGS 'C' 'D' 'E' - ' ' N86°30'25"E +\+ oor Mottling Obmrved CENTERVILLE, MA 02632 MAP 209 �� - - - - f PROPOSED 4 - 500 GAL, _ - - ----- - '- XISTING "D-BOX" MAP 209 128" 35.13' --- -f'� •�- FENCE (TYP) EXISTING LEACHIN�� H-20 LEACHING CHAMBERS SCALE: 1 INCH - 20 FT. DATE: SEPTEMBER 4 2012 TO BE-ABANDONED PARCEL 87-2 Water reading of on-site obsevation well#1 ���/ 0 10 20 ao so FEET PIT TO BE PUMPED, PARCEL 91 !�'� -- L( (O.W.#1)taken on August 30,2012;EL.=17.97' " EXISTING LEACHING PIT TO REMOVED OFFSITE �f:'" s EXISTING 2,500 GALLON ---- -- --- - BE PUMPED AND FILLED AND VOID FILLED w/ `� PREPARED BY: SEPTIC TANK TO BE *BASED ON THE CAPE COD COUIMISSIONMETHOD ' �` CHu I. m JC ENGINEERING, INC. WITH CLEAN SAND CLEAN SAND INDEX WELL: MIW-29 = ,C ILL JR. UTILIZED IN THIS DESIGN WATER-LEVEL RANGE ZONED 2854 CRANBERRY HIGHWAY WATER DEPTH READING: 932' '" NO' 80 WATER DEPTH READING DATE: 8-29 12 EAST WAREHAM MA 02538 WATER-LEVEL ADJUSTMENT FACTOR: 6.20' "6`'�so, sT SITE PLAN ADJUSTED WATER-LEVEL: EL.=24.17' 508.273.0377 (i.e.17.97'+6.20'=24.1T) _ - Drawn B MCP Designed B MCP Checked B JLC JOB No.2255 SCALE: 1" =20' y 9 Y• -�_ Y Tagr (6 Lc r TMA A26A 4600 SF p-1-514 4*10% Fl, :SS i44ex,, LOAM UeAo tooO dl'w%AL. �- Zo -r-Alie- STo a pl> M TOTAL L -rVTA L- VA L,f FLMI G, 600 L- 'Lilt f:�IPT V" -F twl -jox� EATr+ Lam,4;XA�T L4e� TJ,o Per. ALL Sol's S 3 +Vow P=t 4 Fr oF PwxFIL-Cl ALM& Ftapc!SSL�� � � t lx' y Ube t-I��r� l7vr� r-�aw,,�, �• f /S rLT/4 =0 r4 e, (,7r-, 1; LA4t> 5CZVellcrl-e, l(LLG MA14�, T\ A :-X K-TI 114 AS4 AMA C-A TC44 �3A ♦ Y IST, 14.*1 k r 1 4 , r { ..�. ,4' X ,x t.-.. .«.. '.�.,.. �,.; _+w t1:.:6�^�*��,�� K-�:cw-.y';'S•�: C - r -.!:.�- .r;-. •;yy.� .,,n.. .e.s' �tY '� - -ry*Y" ,.. _ t., � .. ..,.,._._.^.—,w...e.... .... ... .::�.w,�,r.,::'J.r- .� ,aw.- _ .._ .. � ,. -. 1x•... k _ .y.,,.tiwS+u _ .i�S� + M �i I � � f _-_..__ .,... --. i I ...✓!�a '.;��r' �g% •,�7',''f' G-�.$:d.t 1" •%,.•�r.A.r'r.,s, r,,,f `t� <'..^�-'+F.. : ! � i •"` +� �`^rxa�.{r � •- .�.�..,,;„x' an,c�g�.!�- '°'� ate,yb. �'x'1s!ry, W« { 1' f`-- .::. iii_..::iw,..--. .,._.i`3__. +w, :ro -:_.e.:... '^ �.:'..-: ...._'14 .":. - _S.7i: ... .y'M'• rt�.y •'ate b rr'?M! rl 4 4 TM r •wc.xa „ r d. w'h' ., '� r- fir,-�y- ..-- �,• — - -�:_.-. ..,� .1�;+�F�wi��,�.;-`� �`';��, �ssr J�.:`.:[.t ��� � »-'".+ ..1.; ,:e , �`i'..'_F'.,'Iax`�:"''_ .:""�.q'a _ 7����`�j4���_a'x,`++. �-.q, �� ✓": - - i y , i FI 1 tr , '1�♦F♦.�Y.wiiR u.w:usurw..+�s..++wnw...ewe...._..._.+wwa�M�,.Wwww..Yw._w+�... ...�.._»+`M —_ - +._— TOP OF FOUNDATION = 47.2'± EXISTING EXTENSION RISER WITH FINISH GRADE OVER D-BOX= 45.3''� GENERAL NOTE S MANHOLE COVER TO EXISTING FINISH GRADE OVER CHAMBERS = 45j.3 - 45.4 PROPOSED VENT WITH CHARCOAL FILTER TO ABOVE GRADE - GRADE (INLET AND OUTLET) H-20 CONCRETE RISER AND CI SLOPE @ 2% MIN. OVER SYSTEM FINISHED GRADE o 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE FINISH GRADE FRAME &COVER TO FINISHED 4' SCHEDULE 40 PVC MIN SLOPE 1 /0 3/4 TO 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE @ FOUNDATION = 46.0 ± OVER TANK EL.= 45.4�±-� OVER"D-BOX" EL.= 45.2'±� GRADE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL __._____.__ 5" DIA. OUTLET(S) 2"OF 1/8"TO 1/2" DOUBLE WASHED STONE CODE AND ANY APPLICABLE LOCAL RULES. EXISTING -..- - 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE EXTENSION RISER-may TOP OF SAS = 37.80' CAST IRON DESIGN ENGINEER. " 9" MIN. RING & COVER 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL EXIST. 4 SEWER PIPE 36.80 36 MAX. BREAKOUT EL = 37.30 PLACE RISERS ON ALL SYSTEM UNLESS OTHERWISE NOTED. 2" DROP MIN. 3„ 9„ EXIST.4"PIPE EXISTING CHAMBERS TO 6" 3" 3" DROP MAX. _ 4"PIPE PROVIDE WATERTIGHT FINISHED GRADE 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN b ® JOINTS (TYP.) ELEVATION =37.30' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. T 14" 37.74' 37.6'+ 4" PVC IN FROM �o ��� O UNLESS A 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND EXIST. D-BOX 4 PVC OUT TO o0o THE TOP OF THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. �� �� O LEACHING FACILITY T ac) 00 0EXISTING D-BOX 0 0 0 0 0 00 0 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 38.31' 48" 38.07' 37.17' MIN. 37.0Q' 2' oo oo o0 0 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. o 0 0 0 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK 6'CRUSHED STONE 0 0 o 00 0 0 o FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS tw M�3 OVER MECHANICALLY oo - NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH COMPACTED BASE 4.0' 8 5� 4.9'4.0' I 4.0' 4.0' 4.0' AND DESIGN ENGINEER. 10.2' 5OUTLET DISTRIBUTION BOX 29 0, (TYP.) 8. ELEVATIONS BASED ON APPROXIMATE USGS DATUM OF 47.00'OBTAINED TO BE INSTALLED ON A LEVEL STABLE 27.57' FROM A NAIL SET IN UP 88 AS SHOWN ON PLAN. BASE. FIRST TWO FEET OF OUTLET SEASONAL HIGH GROUND WATER ELEV.= - - - - - - - 12.9' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION PIPES TO BE LAID LEVEL. 34.80� OBSERVED GROUND WATER ELEV.(MW)_ *23.27' THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT EXISTING 1 ,000 GALLON SEPTIC TANK *see TP data 5' MIN. 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES ' CROSS SECTION VIEW 2 - 500 GAL. H-20 CHAMBERS 7.23' PROVIDED) TO THE DESIGN ENGINEER. SEPTIC TANK PROFILE H-20 DISTRIBUTION BOX DETAIL TYPICAL CHAMBER PROFILE H-20 CHAMBER DETAILS CHAMBER END VIEW 10. NOT TO SCALE NOT TO SCALE NOT TO SCALE ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE -- STRUCTURES SHALL BE MADE WATERTIGHT. MAP 209 « •s• ` ,� +� •a TEST PIT DATA 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING PARCEL91 9 ; + + • r+r REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM N/F ROBERTS + • • • AGENT: Donald Desmarais $ . + * • APPROPRIATE AUTHORITY. EVALUATOR: Ed Pesce, P.E. • . • 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS ° . • + t� ! DATE: September 19, 2005 LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE • .• • ( .•• s TEST PIT#: 1 THEY SHALL WITHSTAND H-20 LOADING. MAP 209 • '�•� • •' CO r " • • °� • • ' ¢�• 'r• ELEV TOP= 45.40' 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. M PARCEL 87-2 • �' • `. �y N/F LYNCH • • • ` ' ELEV WATER= *29.00' �L ► L • • q r 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE cli MAP 209 • • • • * /j+� PERC RATE - <2 Min/In MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, °j PARCEL83r8 >E • • • r •+• • llllJ _ FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). N/F MSPCA MAP 209 • • •• i' �+ • DEPTH OF PERC - 51"-69" PARCEL 86 • • « I 4 BUILDING A01 • . ' ++~ !� " • • ! TEXTURAL CLASS: 1 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN . ' • • a • - SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. *• • •" • • + ` r f• � # 0" 45.40' 16. PROPOSED PROJECT IS LOCATED WITHIN: • • • • • 5U Fill Asphalt& ASSESSORS MAP 209 PARCEL 86 BUILDING A01 ° f ,: r Gravel MAP 209 •f •••'•~• �: r 18" 43.90' OWNER OF RECORD: KATHLEEN S. VENDOLA TRUSTEE OF VEO TRUST VARIANCE REQUIRED PARCEL87-1 • ` *• • • r r •• • '• ty+ ADDRESS: 38 RAINBOW DRIVE B Loamy Sand N/F DACEY •r • • SM I0 « • R •/� ^ CENTERVILLE, MA 02632 • � 310 CMR 15.221(7) MORE THAN 36" DEPTH TO TOP OF "D-BOX"AND LEACHING MAP 209 • ' �'� 10YR 5/6 CHAMBERS (7.6' DEPTH PROVIDED TO MATCH EXISTING STRUCTURES) PARCEL85 BUILDING A ' • � � FEMA FLOOD ZONE C �• e N/F GARRETT %� •• • + AS SHOWN ON COMMUNITY PANEL# 250001 0005 C` • eechw ' ' �� +•• r_ + a- C'- 51" '' 41.15' 17. DEED REFERENCE: • ► r �. Perc r= 1.) BK. 11262, PG. 131 •; J o ' �'; .r 41 69 Medium Sand &Gravel 39.65' 18. PLAN REFERENCE: +r + ••• �! • ~ C-1 2.5Y 6/4 PL. BK. 363, PG. 36 l - `` - _ • •• •' ; ! (10-20% Gravel) 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. lil. ++ an rfy� ' • « • - 80" 38.73' 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY RTE 28) Q , ' • 1 _ FALMOUTH ROAD ( .. • ' "'-"- � FOR SEPTIC SYSTEM UPGRADE. PESCE ENGINEERING WILL NOT ASSUME ANY LIABILITY • I FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. (STATE HIGHWAY 80'WIDE)) + x - ��l E'% t'� C-2 M-C Sand 2.5Y 2/3 INDEX PLAN LOCUS PLAN 132" No GW 34.40' #1645 SCALE: 1"=60' SCALE: 1"= 1000' BLDG. "F" \ EXISTING MAP 209 *water elev. of on-site monitoring well =23.27'EXISTING � BUILDING "B° PARCEL86 � MAP 209 PARCEL 87-1 TEST PIT DATA LEGEND COMMERCIAL BUILDING A01 N/F DACEY DESIGN DATA BUILDING S� AGENT: Donald Desmarais x 50.0 EXISTING SPOT GRADES � TOF =47.90' ROPOSED PVC VENT PIPE (LOCATION TO BE CONFIRMED BY OWNER) EVALUATOR: Ed Pesce, P.E. -- - 50 EXISTING CONTOUR \ W DATE: September 19, 2005 XISTING 1,000 GALLON SEPTIC TANK 50 PROPOSED SPOT GRADES TEST PIT#: 2 COMMERCIAL OFFICE CONDOMINIUM BUILDING i EXISTING "D-BOX"TO BE UTILIZED AS PART OF THIS DESIGN DESIGN FLOW 75 GAUDAY/1,000 S.F. ELEV TOP = 45.30' 50 PROPOSED CONTOUR 1 J #1645 \ OFFICE SPACE AREA 3,702 S.F. --- EXISTING UNDERGROUND UTILITIES% \ BLDG. A XISTING LEACHING PIT TO BE PUMPED AND FILLED WITH CLEAN SAND TOTAL DESIGN FLOW k ELEV WATER= *29.00' EXISTING (3,702 S.F. / 1,000 S.F.)x 75 GPD =277.65 GPD COMMERCIAL ` \ TOTAL DESIGN FLOW x 200 % = 555.3 GAUDAY i PERC RATE _ < 2 Min/In W - EXISTING WATER LINE BUILDING J ROPOSED H-20 D BOX" EXISTING \ USE EXISTING 1,000-GALLON SEPTIC TANK DEPTH OF PERC = 48"-66" GAS - EXISTING GAS LINE (3,702 S.F. -TOTAL) ROPOSED 2-500 GALLON H-20 LEACHING CHAMBERS BUILDING"G", TOF =47.2'± i' TEXTURAL CLASS: 1 TEST PIT LOCATION r. /EXIST, MONITORING , o� P2 INSTALL 2-500 GALLON H-20 LEACHING CHAMBERS WELL (TYP.) / 45x,V 0" 45.30' O EXISTING 1,000 GALLON SEPTIC TANK TOP ELEV. =45.60' / 9 Asphalt& WATER ELEV. - 23.27' O SIDEWALL CAPACITY Fill \ Gravel (LENGTH +WIDTH)(2)(2' HIGH) (.74 GPD/S.F.) = GAUDAY 20" 43.63' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE / O '_ ., �, (29' + 12.9') (2)(2') (.74 GPD/S.F.) = 124.0 GAL/DAY 4__ o B Loamy Sand Q PROPOSED H-20 DISTRIBUTION BOX � 45x4 \\ BOTTOM CAPACITY 10YR 5/6 O (LENGTH x WIDTH O PROPOSED 500 GALLON H-20 LEACHING CHAMBER (.74 GPD/S.F.) " (29'x 12.9') (.74 GPD/S.F.) = 276.8 GAUDAY 48' Y 41.30 :.;� 41.30' Perc 61 Medium Sand &Gravel TOTALS: C-1 2.5Y 6/4 1 3-22-06 MCP ELP NORTH ARROW C X.LT' J TOTAL NUMBER OF CHAMBERS: 2 REV. DATE BY APP'D. DESCRIPTION n � ® \ TOTAL LEACHING AREA: 541.E SQ.FT. 72" 39.30' �5� I CB TOTAL LEACHING CAPACITY: 400.8 GAL./DAY PROPOSED SEPTIC SYSTEM UPGRADE PREPARED FOR: CB > £ v --� S\ \ 1 9 ., USGS SEASONAL HIGN GROUNDWATER ADJUSTMENT BAYBERRY SQUARE CONDOMINIUMS �, � _ C_2 M-C Sand \ INDEX WELL: MIW-29, ZONE D, SEPTEMBER 05 GW ADJUSTMENT=4.3' 2.5Y 6/4 --------------- - ----- 5"E _- --- LOCATED AT SIDE WALK BUILDING "A" - 1645 FALMOUTH ROAD -- __- 156" No GW 32.30' 88\ SIDE WALK _ - -UP-- *water elev. of on-site monitoring well =23.23.27' ' A 02632 \, -46- '� ---- RESERVED FOR BOARD OF HEALTH USE SCALE: 1 INCH = 20 FT. DATE: JANUARY 25, 2006 UP 87.5 EDGE OF PAVEMENT _ CURB (TYP.) T.B.M. ���P�SNOFMgss90 0 10 20 40 8i FEET 'y G - - - - -Nail in U.P. 88 '�-- -_ �o EDWgRD RTE 28) Elev. =47.00' o PESCE PESCE ENGINEERING FALMOUTH ROAD,( Approx. U.S.G.S. No 2,00i AND ASSOCIATES `. (STATE HIGHWAY 80 WIDE)) 9pc9FQ STEREO "{r EDWARD L. PESCE P.E. FS ENGINEERING SERVICES 451 RAYMOND ROAD O SITE PLAN �: SEPTIC SYSTEM DESIGN PLYMOUT0 60 � SITE SURVEYS 02360 PHONE/FAX:508-743-9206 Drawn B MCP Designed B EP Checked B EP JOB No.932 SCALE: 1" =20' �i Y 9 Y Y EXISTING EXTENSION RISER WITH TOP OF FOUNDATION = 47.2 ± MANHOLE COVER TO EXISTING FINISH GRADE OVER D-BOX= 45.3 ± FINISH GRADE OVER CHAMBERS = 45.3' - 45.5' PROPOSED VENT WITH CHARCOAL FILTER TO ABOVE GRADE GENERAL NOTE S GRADE (INLET AND OUTLET) H-20 CONCRETE RISER AND Cl SLOPE @ 2% MIN. OVER SYSTEM FINISHED GRADE FRAME& COVER TO FINISHED 4" SCHEDULE 40 PVC MIN SLOPE 1% 3/4"TO 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE 1 UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION @ FOUNDATION = 46.01± FINISH GRADE OVER TANK EL, 45•4'±-� GRADE 5" DIA. OUTLET(S) METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL - - - - - 2"OF 1/8"TO 1/2" DOUBLE WASHED STONE CODE AND ANY APPLICABLE LOCAL RULES. EXISTING - - - -- - ------EXTENSION RISER 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE TOP OF SAS = 42.50� CAST IRON RING& DESIGN ENGINEER. COVER TO GRADE (TYP.) 9" MIN. 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL EXIST. 4"SEWER PIPE 41 .50 36" MAX. BREAKOUT EL = 42.00 PLACE RISERS ON ALL 6" 3" 2" DROP MIN. „ CHAMBERS TO SYSTEM UNLESS OTHERWISE NOTED. 3" DROP MAX. 3,. 9 PROVIDE WATERTIGHT FINISHED GRADE 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN o JOINTS (TYP.) o 0 0 0 0 0 0 oc:6 ELEVATION =42.00' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. 14" 4'E PVC XISTI D-FROM OX 4" PVC OUT TO 0 0 � O 0 0 0 � L� 0 000 �� O � � UNLESS A 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND o THE TOP OF THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. 42.80'± LEACHING FACILITY poo �o o 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 48" 42.55'± 42.00' MI'N. 41 ,80' 2' o0 0 0 oo o0 0 o0 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. CONTRACTOR SHALL VERIFY CONDITION OF l i o 0 0 0 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK EXISTING TEES OVER MECHANIC6" CRUSHED ALLY o0 0 0 0 0 0 0 0 0 _ 0 0 0 o FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS AND REPLACE AS NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH COMPACTED BASE 4.0' I 2.0' I 4.0' 4.0' 4.0' AND DESIGN ENGINEER. NECESSARY 5 8.5' T 4 9, OUTLET DISTRIBUTION BOX 37 5' (TYP,) 8. ELEVATIONS BASED ON APPROXIMATE USGS DATUM OF 45.00'OBTAINED TO BE INSTALLED ON A LEVEL STABLE 27.57' FROM A MAG NAIL SET IN PAVEMENT AS SHOWN ON PLAN. BASE. FIRST TWO FEET OF OUTLET SEASONAL HIGH GROUND WATER ELEV= _ _ _ _ _ _ _ _ 12.9' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION PIPES TO BE LAID LEVEL. OBSERVED GROUND WATER ELEV= *23.27' THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT N. EXISTING 1 ,000 GALLON SEPTIC TANK CROSS SECTION VIEW .5 3 - 500 GAL. H-20 CHAMBERS *see TP data (11 913' PROVIDED) 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES SEPTIC TANK PROFILE H-20 DISTRIBUTION BOX DETAIL TYPICAL CHAMBER PROFILE H-20 CHAMBER DETAILS CHAMBER END VIEW TO THE DESIGN ENGINEER. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE - - -- ---- - STRUCTURES SHALL BE MADE WATERTIGHT. __ - - - - MAP 209 b • ,�•• '� * � � a *'� *� � TEST PIT DATA 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING �' ` ' • • • •• ' REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM PARCEL 91 " " • e • •N/F ROBERTS bo AGENT: Donald Desmarais APPROPRIATE AUTHORITY. • + • , ' • EVALUATOR: Ed Pesce, P.E. i 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS co • • • • - • DATE: September 19, 2005 .` LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE � MAP 209 co w (' THEY SHALL WITHSTAND H-20 LOADING. • `-', • TEST PIT#: 1 M PARCEL 87-2 ;• • e ' • • % • • "` �'� I•' • ELEV TOP = 45.40' 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. " N/F LYNCHco « LO �f • • '" �► ! ti ' ELEV WATER= *29.00' 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE t' a • . ' • • ,¢ C� i PERC RATE - <2 Min/In MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. MAP 209 MAP 209r8 �!� REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, . ' •, s* • •• • ' DEPTH OF PERC = 51"-69" FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). PARCEL 83 PARCEL 86 •` • N/F MSPCA •• " ' • • + ©la TEXTURAL CLASS: 1 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN BUILDING A01 * • • + • � ,�. • * � 4 _ SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. ' • * • 0• * • • law �"� �� • 0" 45.40' 16. PROPOSED PROJECT IS LOCATED WITHIN: • O Fill Asphalt& ASSESSORS MAP 209 PARCEL 86 BUILDING A01 F o MAP 209 'f� i% `•';• • • $ 18" Gravel 43.90' OWNER OF RECORD: KATHLEEN S. VENDOLA TRUSTEE OF VEO TRUST PARCEL 87-1 •, • • •• • . •• • ADDRESS: 38 RAINBOW DRIVE N/F DACEY . ,. Bid 60 `�., • • B Loamy Sand CENTERVILLE, MA 02632 A • V` 10YR 5/6 FEMA FLOOD ZONE C MAP 209 f' •• D �-- .. • . p� AS SHOWN ON COMMUNITY PANEL# 250001 0005 C PARCEL 85 eech 48" 41.40' 17. DEED REFERENCE: N/F GARRETT `'" � *�* - ,p • - Perc 1„ -{, 41.15' 1.)BK. 11262, PG. 131 ♦ H { # • • f ' p , y 69° -Mediu 39.65' 18. PLAN REFERENCE: • • ,. �,, • ' •+• �� • * C 1 2SY 6/4 Gravel PL. BK. 363, PG. 36 fi B.M. ,� �.r" "• - _ • . • /I (10-20% Gravel) 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. Mag Nail Set � . 8t1 er � ,` � • '• • * 80" 38.73' 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY Elev. =45.00' RTE 28) • ' • ' . �, `' FOR SEPTIC SYSTEM UPGRADE. PESCE ENGINEERING WILL NOT ASSUME ANY LIABILITY Approx. u.s.G.s. FALMOUTH ROAD (WIDE ) • (STATE HIGHWAY 80 ) _� FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. _ C-2 M-C Sand / 2.5Y 2/3 / INDEX PLAN LOCUS PLAN EXISTING SEPTIC TANK .. _ 132" No GW 34.40' / SCALE: 1 -60 SCALE: 1"= 1000' EXISTING "D-BOX" / *water elev. of on-site monitoring well =23.27' TO BE ABANDONED / TEST PIT DATA LEGEND EXISTING LEACHING PIT TO DESIGN DATA BE PUMPED AND FILLED ' AGENT: Donald Desmarais x 50.0 EXISTING SPOT GRADES 10 WITH CLEAN SAND 10, EVALUATOR: Ed Pesce. P.E. - -- 50 - - EXISTING CONTOUR DATE: September 19, 2005 50 PROPOSED SPOT GRADES 4S. S x44.4 COMMERCIAL OFFICE CONDOMINIUM BUILDING I TEST PIT#� 2 � 50 PROPOSED CONTOUR srQo I DESIGN FLOW 75 GAUDAY/1,000 S.F. ELEV TOP- 45.30' OFFICE SPACE AREA 6,525 S.F. ELEV WATER= *29.00' E/T/C EXISTING UNDERGROUND UTILITIES TOTAL DESIGN FLOW (6,525 S.F. / 1,000 S.F.)x 75 GPD=489.4 GPD �- TOTAL DESIGN FLOW x 200 % = 978.8 GAUDAY PERC RATE _ <2 Min/In W -_ EXISTING WATER LINE /x x44.3 USE EXISTING 1,000-GALLON SEPTIC TANK DEPTH OF PERC = 48"-66" GAS - EXISTING GAS LINE LP~ B DG#1645F" EXISTING MAP 209 I TEXTURAL CLASS:- 1 }� BUILDING "B" TEST PIT LOCATION EXISTING PARCEL 86 INSTALL 3-500 GALLON H-20 LEACHING CHAMBERS COMMERCIAL BUILDING A01 , EXISTING CATCH BASIN BUILDING r 0 45.30 EXISTING 1,000 GALLON SEPTIC TANK ° TOF=47.90' SIDEWALL CAPACITY Fill Asphalt& (LENGTH +WIDTH)(2)(2' HIGH) (.74 GPD/S.F.) = GAUDAY 20„ Gravel 43.63' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE EXISTING LEACHING PIT TO '� W - BE PUMPED AND FILLED LP J,: ..; TP 2 (37.5' + 12.9') (2)(2') (.74 GPD/S.F.) = 149.2 GAL/DAY WITH CLEAN SAND 45x3 B Loamy Sand Q PROPOSED H-20 DISTRIBUTION BOX 41 BOTTOM CAPACITY 10YR 5/6 PROPOSED 500 GALLON H-20 LEACHING CHAMBER O PROPOSED 3-500 GAL. 5 '� //��/ kr (LENGTH x WIDTH H- LEACHING CHAMBERS O j ) (.74 GPD/S.F.) 44" 41.63' 0' (37.5'x 12.9') (.74 GPD/S.F.) = 358.0 GAUDAY 48" =t-, 41.30' 20 C O EXISTING Perc �, �, S ��C BUILDING A / 66" 39.80' PROPOSED "D-BOX" / Medium Sand &Gravel MAP 209 �, EXISTING TOTALS: C-1 2.5Y 6/�4 1 3-22-06 MCP ELP NORTH ARROW, WATER LINE, TP LOCATIONS PARCEL 85 EXIST. MONITORING O T�1 BUILDING "G" TOTAL NUMBER OF CHAMBERS: 3 REV. DATE BY APP'D. DESCRIPTION N/F GARRETT WELL (TYP.) ►�`�' 45x4 � TOTAL LEACHING AREA: 685.4 SQ.FT. 72" 39.30' TOP ELEV. =45.60' F_ �� TOTAL LEACHING CAPACITY: 507.2 GAL./DAY PROPOSED SEPTIC SYSTEM UPGRADE WATER ELEV. = 23.27' / �1� / PREPARED FOR: CONTRACTOR TO CUT& EXISTING / ° M-C Sand BAYBERRY SQUARE CONDOMINIUMS RESET MW TO SURFACE USGS SEASONAL HIGN GROUNDWATER ADJUSTMENT C-2 PARKING y INDEX WELL: MIW-29, ZONE D, SEPTEMBER 05 GW ADJUSTMENT=4.3' 2.5Y 6/4 - -- - - PROPOSED LOT / v' LOCATED AT VENT ` C 1645 FALMOUTH ROAD <` / " No Gw BUILDING "F" 156 32.30*water elev. of on-site monitoring well =23.27' CENTERVILLE, MA 02632 -- SCALE: 1 INCH = 20 FT. DATE: JANUARY 25, 2006 jT / I}1 OF Mgssq� 0 10 20 40 80 FEET C. �o EDWARD L. tiG -_._.---.--.---_.__------- ._..._ _ j o PESCE PESCE ENGINEERING CIVIL No.32001 AND ASSOCIATES 0 9F p e EDWARD L. PESCE P.E. ENGINEERING SERVICES 451 RAYMOND ROAD SITE PLAN SS/ NAL SEPTIC SYSTEM DESIGN PLYMOUT0 60 S SITE SURVEYS 02360 PHONE/FAX:508-743-9206 JOB No.933 SCALE: 1' =20' � - Drawn By: MCP Designed By:EP I Checked By: EP Falmou-�-h Joao 17/ ao9- 08� No...- ---•----- Fimic .0Z �...J....... THE COMMONWEALTH OF MASSACHUSETTS ���� ��try►r ►'► ���-Pr Z� BOAR® O HEA T ............. ......... .. .... . ... ...... . ------�................. Appliratinn for Roposat Workii Tonstrnrtiun Pprutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System C - � �'- ocat n-Address _ or Lot No. Owner Address W � Installer Address Q Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms..-_ _. ._. -Expansion 4tticy ) Garbage Grinder ( ) aOther Type of Building—�� �.___ No. of persons........................... Showers ( ) Cafeteria ( ) Q Other fixtures .....----- --- Design Flow ..........2-1 I..__��-gallons per person per day. Total daily flow._......._....._...._____ ..._.... ...__.gallons. WSeptic Tank Liquid capacityl�l�gallons ' Length________________ Width................ Diameter---------------- Depth____________.... x Disposal Trench— o. .................... Widtl ---- ---- -- a gt .. Total leaching area sq. ft. p d� Total leaching area.Seepage..Pit No_____ ___________ Diameter__ Dosing to_-e e ow , let----.-¢ -f--d �1. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by..............................................�_�...__.......... Date------------------------------------.--- ,-1 Test Pit No. 1_____________•_-minutes per inch Depth of Test Pit.................... Depth to ground water---­------------------- 44 Test Pit No. 2................minutes per inc Depth of Test Pit.................... Depth to ground water........................ --------•- -------•-------• --- ODescription of Soil........... - - ----• '�------------------------------------------------------------------------ x W UNature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b b the oard of heal i Sign e .. ----•-- __ - •----•--- DZ7-2 Application Approved By------- rJA- � is Application Disapproved for the following reasons:.............................. •-•----•••---••-----•----•--------•----••------...--•------•••-----•--•----•-•--•-------------•-•-••-•----•----•--•------•---------------------------_•---------------------------•-•---•-•------------- Date 6/e Permit No. Issued ------------ PW .....�........ No..... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEA T _._ ....�`t ✓ .............OF..,......:. ... -............ Appfiratinn for Rspoiial 18orks Tomitrnrtinn Primit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System w + -------------------- ac..., ocaAon �dress + or Lot No. /17 ner Address W nstaller Address Type of Building Size Lot__-. Sq. feet ------------------------ Dwelling—No. of Bedrooms-' ..:. ......•--_-__---_•__--____••_--_-Expansion ,ttic� ) Garbage Grinder ( ) aOther Type of Building- ...... No. of persons......... ______._.__. Showers ( ) — Cafeteria ( ) dOther fixtures ;;----------•---------------------------------------•---•----------------•-•---•-•-•---•-------•------------------------•---- ------- WDesign Flow..........................,.J._._...._..gallons per person.per day. Total daily flow..................... `" _.gallons. W Septic Tank�Liquid capacity_gallons Length................ Width---------------- Diameter---------.------ Depth.-_-_____-_.__. ---------------- Disposal Trench—No_-------------------- Width............ Total leaching area____-_-_--.---•---sq. ft. Seepage Pit No------.............. Diameter.. �� De e ow��n°l"et_..___ _ ":. Total leaching area_ ._... ._ q. ft. Other Distribution box ( ) Dosing tank ( ) ��r Percolation Test Results Performed by------------------------ .................... ����� . Date - Test Pit No. I.................minutes per inch Depth of Test Pit.................... Depth to ground water--------:________::____. 41 Test Pit No. 2................minutes per in h Depth of Test Pit.................... Depth to.ground water---------------------- O Description of Soil........... �., .....: . tit ------------------------ ----------------.----- x W 1 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been-issued by thrye, oar of heal Signed� __ r /��g --• heal ........ --••••---•--•-----------•• •-•-•--••--•-•••--••-••--•_---•. i 9 / — , DatQF Application Approved By..... ------ 1!: � '- -7 ate Application Disapproved for the following reasons------------------------------- -----------------------------------•------... --------------------------- . ••••-•----•--•-------••-•----•••••--••----•-------•••••••--•- ---------------------------------------------- Date Permit No......................................................... Issued...... 2._. 3-------- Dat THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :�...�C:r 'h od ..........OF........ t` % a .. ........... TWrtifiratr of Tontphaurr 000 THIS IS TO CERTIFY, That the I�T_ Dispo 1 System constructed ( ) or Repaired ( ) by ,= - �C et.. -••---•--•--•-•--•----------- --------------- /j star •3 14 _ b has been irlled itI accordance with.the provisions of Article XI of The State Sanitary Code as descr' ed in the application for Disposal Works Construction Permit No_................... �.......... dated..-.; �:_g .... _....ZZ..... :.• THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FU CTIO SATISFACTORY. �/ C DATE ----------• Inspector •.lam - THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALT 0 .......... .....�� No. `X :�..........OF......!i0_(....... ._..... ------------...... FEE---•----_.................... . a- , ,�rnrtinat' rrntit Permission is hereby granted •----.....--- • ............................................. to Construct (6`) r Rep "r ( ). an Individu 1 Sewage Di' o �iI Sy tem 14 at No.-"-'----------- . 'f ' ���a�t°. I�,_ p � ----- .�'�"- Street (� as shown on the appl' at' n for isposal Works Construction. P r it N .� __. :Dated-___ _�__ _���+�" s' - ---y------•-•---•-•---. Board of Healt DATE......� - - ---�'--------------------------- - 1255 FORM 08 S & WARREN, INC., PUBLISHERS