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Home My WebLink About1776 FALMOUTH ROAD/RTE 28 - Health '776 Falmouth Road (route 28) Centerville p A = 189 034 I /7//7/Iell(G UPC 10259 No.H�R �►, HASTINGS. YN 0 - _ pd c l�- k-V u NSU Commonwealth of Massachusetts c Title 5 Official Inspection Form 5U�) osal System Form -Not for Voluntary Assessments Subsurface Sewage Disp '( 1776 Falmouth Road, Centerville MA 02632 /M Property Address Ocwen Asset Services CIO Jac reaven Remax Real Estate k C 5 2008 Owner's Name 02648 May Owner M_A -�— Date of Inspection information is 167 Lovell's Lane, Marstons Mills State Zip Code required for Citylrown in any every page. not be altered Inspection results must be submitted on this form.Inspection forms may way. Important: A. General Information When filling out forms on the computer,use 1, Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return Septic Ins ection Services Co. key. Company Name r� 189 Cammett Road 02648 Company Address MA Zip Code Marstons Mills State City/Town SI 12855 508-428-1779 License Number Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the ection information reported below is true, accurate and cn epin the proper fulete as of the lnction and maintenance me of the inspection.The insp Inf ning and experience of on 40 of see a DEP approved system inspector pursuant to Section 15.340 was performed based on my trai sewage disposal systems. I am 9 The system: Title 5(310 CMR 15.000). ® ❑ Conditionally Passes ❑ Fails Passes ❑ Needs Further Evaluation by the Local Approving Authority l May 5, 2008 Date Inspector's Signature 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 inspector and thection. Iftsystem owner shall submhe system is a shared it the tem orer has a design flow of 10,000 gpd or greater, t report to the appropriate regional office of the DEP. The ovi original be sent to the system own and copies sent to the buyer, if applicable, and the approving of inspection and under the conditions of use ****This report only describes conditions at the time 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 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 15 08-142 Ocwen.doc•08/06 r z� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 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: ® 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: Tank is not in need of pumping at this time, leaching system shows no signs of surcharge. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 08-142 Ocwen.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. I 08-142 Ocwen.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is Y required for 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow El ® 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. 08-142 Ocwen.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5 2008 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 ❑ El Area 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. I 08-142 Ocwen.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5 2008 required for City/Town State Zip Code Date of Inspection every page. 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 El ® this inspection? ® El available 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? ® El information 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)) I Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 08-142 Ocwen.doc-08106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5 2008 required for State Zip Code Date of Inspection every page. City/town D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 0 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 116,000 gal. _ Water meter readings, if available(last 2 years usage (gpd)): 158 gpd. Sump pump? ❑ Yes ® No 60-90 days prior Last date of occupancy: to inspection. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease.trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 08-142 Ocwen.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: None 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 7/8/98 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-142 Ocwen.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 required for every page. City(Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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 -------------------------------------------------------------------------------------------------------------------------- 10.5' long x 5.8'wide- 1500 gal Dimensions: 3„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 30" 1„ Scum thickness 6„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" - How were dimensions determined? Measured 08-142 Ocwen.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 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.): Liquid level was found at bottom of outlet invert tees are intact and clear. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet-invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 08-142 Ocwen.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth & Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes. ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-142 Ocwen.doc•08M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts up Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 Maximizers. ❑ 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.): Interior of SAS was video inspected, found no standing water or evidence of backup. 08-142 Ocwen.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 08-142 Ocwen.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r( 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5 2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 41 39 39 26 Water Service Falmouth Road (Route 28) Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments y 1776 Falmouth Road, Centerville MA 02632 Property Address Ocwen Asset Services C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 May 5, 2008 required for State Zip Code Date of Inspection every page. Citylrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20 Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: USGS to o map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el 25 and topo map shows property at el. 50. 08-142 Ocwen.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable Cf THE Tp� Regulatory Services Thomas F. Geiler,Director p,Eo ,�a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC. INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIODisclaimer Private Septic Inspections.DOC i ' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FO.R VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address: 1776 Fa em o ut�ad en e�U.i.Q.Qe Owner:%ete2 Shea Date of Inspection: 5 5 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water50 feet z Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: u e.3 Observed site(abutting property/observatign hole within 150 feet of SAS) u e Checked with local Board of Health-explain:a A � n o . Checked with local excavators,installers-(attach documentation) Accessed USGSdatabase-explainAtt/2:I-own. gaanzta9ie.,ma.,u.s �—.. You must describe how you established the high ground water elevation: llsed : Cape Cod Comm.izzon Natea 7aafie Cohtouaz And l ug-2.ie /datea SuI212hy N*. Oeii head /22oteet.ion aaeas map , Sept 1995 {` Watea aezouacez o,ePice cape cod comm.c.5.con Top of Oroml Leaching Pit ;eet Groundwater Feet Below Bottom,of Pit 8 f High Groundwater Ad'ustment 1. t g per Frtmpter Method Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is 3`� feet: 11 n•rnnrn r+s+•rvr:�'.-•tmramensn.s^nr*atrfreran:•rrrteerrt�rt+'++en tfti�•+tw*wa'emvnss ' �,.�.,.••�-.,�„--;;ram.-.r-••Y A0 'TOWN OF BAi2NS74BLE BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D • CERTIFICATION -x•tr.+n,+r.m,enn---e+.:+aas.�'+an^�n+�eer' san :,�,•r,•-•rr•-„••...� •••rrt-r:•::T--++r.•:Ts*+mr.+n•mm�'*+t*rnee"''^''^'^ -TYPE OA PRINT cl.EARLY- PROPERTY INSPECTED STREET ADDRESS 1776. Falmouth Road ASSESSORS MAP , BLQ.CK AND PARCEL # 189-034 letea Shea OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR Rotend Pa.oi�lnc r • COMPANY NAME ose/�h !•' (7acom .Son Inc Box 66 Cen;eav i g ee (lass' 02632 COMPANY ADDRESS Street Town or City. state LIP COMPANY TELEPHONE ( 508 ) 77.5 ' 3338 FAX ( 508 1790 - 1578 R CERThFICATION STATEMENT I certify that I have personally inspected .the sewage dieposi system at this address and that t}i.e information reported is true ,. a.acUrate, and omplete as of the tilne o.f +inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repa_ir .are consistent with my trainii,,g and experience in the proper function and maintenance of on-- site sewage disposal systems . Check one: XXXXSystem PASSED The inspection which I have conducted has ,not found any information which indicates that the system fails to adequately protect public health or 4.the environment as defined in 310 CMR. 16, 303 , Any failure criteria riot evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have 'con L ' ted has found that the system fails to protect the jiublic )iealth and the environment in accordance with Title 5 , 310 CMR 15 + 303, and as specifically noted on PART C - . FAILURE C[tITERIA of this ins t ' m ur � 4� Inspector Signature Date 2:�L. bar . . -•---- 0 ne copy of this certtficat,ion must -be provided ,to the .QWNER, the. BUYER where appli.aable ) and th±a BOARD OF HEALTH. . * If the inspection FAILED, the owner .or operator ahall upgr:ade_' the system. within o'ne year of the date of the inspection, unless. allowed or requ.i;red otherwise as provided in 310 CMR 16 305 . . par..td.,doc _ TOWN O BARNSTABLE LOCATION m(o �et6�h 2i SEWAGE# h5� VILLAGE('AMJrUA ASSESSOR'S MAP&PARCEL II��NAME&PHONE NOr'►GIC� ,dnIJ 1. SEPTIC TANK CAPACITY I LEACHING FACILITY:(type) ake,+ &a&� (size) NO.OF BEDROOMS OWNER 3CW&#^ i,A5S&50C-S, PERMIT DATE: CAA4AL"=E DATE: SP_ S�S� )Z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY w r T 41 39 39 26 t Water Service Falmouth Road(Route 28) Commonwealth of Massachusetts Executive Office of Environmental Affairs V11t, 1.;. i Department of ti 4 - , Environmental. Protection William F.Weld 40, o9�s 1� Governor Trudy Coxe Fit 'g& dt r Secretory,EOEA David B. Struhs commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM \ $ MAP# PART A PAR#�f CERTIFICATION r►+o u 4,N R�. 'f2 r t'r (P� .uD�o�{I.y r�cn r•SO t'� r Property Address: i177(p �1 Address of Owner: Date of Inspection: JD-23`355 (If different) Name.of Inspector: ?AtneS S�M►'S € Company Name, Address and Telephone Number: , A,& .B Canco 350 Main Street West Yarmouth MA 02673 (508) 775-2800 CERTIFICATION STATEMENT rt 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 tl _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority. ` j Fails "'ra t .r Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 systen, ov,ner anci copwe x'r'ri io tiu• biyu:, if applicable and tl-w ap;xo,in� auihOri'y. INSPECTION SUMMARY: Check A, B, C, or D. Aj SYSTEM PASSES: 5, , 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. B) SYSTEM CONDITIONALLY PASSES: # One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, Fey passes inspection. t 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, cracked, structurally unsound, shows substantial infiltration or ex(iltration, or tank 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. (revised 8/15/95) 1 ; 5 One Winter Street o" Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone (617)292-5500 1 Printed on Recycled Paper �,,' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) .J. Property Address: 1774o FH it ncc,,4� Rd. Owner: �CiCtoTw� ferso�Date of Inspection: I p a3_q q, "p B]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 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 ,i. C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: st: 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER . c: 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 fAll 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 SAFETY AND THE ENVIRONMENT: _ The wstem nas a septic tank and suii abbutptiun *,stein and i� within 103 flee, t0 a sur .acE water supply or tritJtltar)' t0 c 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 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corr.>ct 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 of cesspool. 2 (revised 8/15/95) Y SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION (continued) ' Gal r•.o o l I, f2� . L'en r Property Address: Owner: �o�6-rN y P2¢erso r, Date of Inspection: I Q _aay.c(5 D) SYSTEM FAILS(continued): 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. AL Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). r` . Number of times pumped t A/ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. r AL Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Al Any portion of a cesspool or privy is within a Zone I of a public well. AL 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 s coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information, (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST F'i✓ y. ' .,. Property Address: �771e �A�' 1O��h (Zd• Cgs�r�r ((� Owner: 7o ro`4 h� Pe f ce-sc r� ,J, Date of Inspection: IC)-��_ q$ s Check if the following have been done: 'r .... Pro Peeryy e011°+1( Pumping information was requested of the owner, occupant, and Board of Health. Wei- ghee T1}r), 1495 V None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates r.. during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. !TzN As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ The system does not receive non-sanitary or industrial waste flow ' :z;: ✓The site.was inspected for signs of breakout. .;L: All system components, excluding the Soil Absorption System, have been located on the site. 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 existing information or approximated by non-intrusive methods. The facilityy uv nr: Wnd uccupar,tb, if d*.ffe,,c;-: from, 3v,ner; •,,:ere provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: grl--r A'741�cu-kh Ed. Cch4er✓, IleOwner: H 7 PQ4ersdn Date of Inspection: f o-,q 3_ q5 j FLOW CONDITIONS ` RESIDENTIAL: Design flow: ,330 rtallons Number of bedrooms:L Number of current residents: 0 Garbage grinder (yes or no): 0 Laundry'connected to system (yes or no): VA Seasonal use (yes or no):A16 Water meter readings, if available: /995-.2, //on 5 /991/- /(o, Ono 4941 o n s /923 f...: I Last date of occupancy:J&n 99 COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ '.Water meter readings, if,available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: NV ke C o rcl o` Pum p i V ro /19 5 l i ie r.S System pumped as part of inspection: (yes or no) V2S If yes, volume pumped. All gallons T Reason for pumping: rr 45 SDecTivn ^., TYPE OF SYSTEM Septic tank/distribution box/soil absorption system -77- Single cesspool Overflow cesspool. Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: U h icn0W h Sewage odors detected when arriving at the site: (yes or no) 1�0 (revised 8/15/95) 5 ..-rav SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 179G 64Lm av7"H 2 c. C2LPrer'v1 11' Owner: PIC,ro4-h� �ferSorN Date of Inspection: 1p_ag_ �� SEPTIC TANK: NG (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Sludge depth: Distance.from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.) GREASE TRAP: NO (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from.top of scum to too of outlet tee or baffle: Distance.from bottom n� <rorr fn hnttnm of outlet tee or baffle Commenis: (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 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) } Property Address: rA+•mavrH IPoO• Cw�Fe+'�i lle Owner: DOrOTMy &krcon Date of Inspection: i� TIGHT OR HOLDING TANK: ' (locate on site plan) Depth,below grade: Material of construction: _concrete _metal _FRP_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: fia (locate on site plan) Depth of liquid level above outlet invert: -' Comments (note if level and dist:ibu::C- i, e:; ;:', e.idcnce of so!id> ca• v(,.er, evidence of leakage into or out of box, etc.) PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /T1(o r�Alr~o�+ Rd. Cen-tervdJe_ Owner: �oroT}+y a4ers n Date of Inspection: /0-.21 s t SOIL ABSORPTION SYSTEM (SAS):21_0 i (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) i.~ CESSPOOLS: 2S (locate on site plan) Number and configuration: Depth-top,of liquid to inlet invert: .3 Depth of solids layer: IV Depth of scum layer: 'Dimensions of cesspool: Materials of construction: �L1ksK Indication of groundwater: ND inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, sign_ of hydraulic failure, level of ponding, condition of vegetation, etc.) >Pac I is t+r w air tt:rng level `fli,ere- A-re, pin s r9n5 0-P Qe)tvG FULL. Or- over 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.) (revised 8/15/95) 8 Y I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 177w rpI o j4-J, Ce^ie4-v'�l Owner: AP-4ersor, Date of Inspection: 10—23 i; 1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' r, yk 6' �esr _moo DEPTH TO GROUNDWATER Depth to groundwater: 10 feet p method of determination or approximation: 7Du6 —re-s-r 146le *0 10'0" AlD q rDy-0 �¢ST I�IdIe ►JeTe� nn o Iron rAmove (revised 9/15/95) 9 350 MAIN STREET TEL: (508)775-2800 WEST YARMOUTH MA 02673 (800)698-3993 FAX:(508)778-9628 Septic Service Mechanical Services Pumping & Heating & Plumbing Installation �� Fire Sprinklers Since 1930 June 23, 1998 Town of Barnstable Department of Health PO Box 534 Hyannis, MA 02601 Attn: Jerome Dunning RE: 1776 Falmouth Road, Centerville A & B Canco filed a Septic System Inspection Report for the property at 1776 Falmouth road, Centerville on November 9, 1995. The report passed the existing requirements of the State of Massachusetts Department of Environment Protection Format at that time. The basement has two plumbing fixtures which are not plumbed into the septic system. The home made shower and sink drain onto the opening in the basement floor. A & B Canco re-submits the original Septic System Inspection Report for your records. Please note that the system has had full usage for the past three yea rs. Respectfully submitted, Richard K. Cannon RKC:akb I t Af TA r FIHEr, Town of Barnstable Department of Health, Safety, and Environmental Services BARNSPABLE, 6Ass. i63q• Public Health Division �0 P.O. Box 534, Hyannis MA 02601 Office: 508-8624644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health April 30, 1998 Mr.James Sears A&B Canco 350 Main Street W.Yarmouth,MA 02673 RE: 1776 Falmouth Road,Centerville Dear Mr. Sears: According to your septic system inspection report regarding 1776 Falmouth Road, Centerville. The system"passed"and one cesspool was found. However, on April 29, 1998, Health Inspector Jerome Dunning observed more than one sewer line exiting the dwelling in the basement. For example, a basement shower was located at the opposite side of the dwelling and did not appear to be tied-into the cesspool which you identified in your report. It is the duty of the certified septic system inspector to identify all wastewater disposal systems on the property. Although you are licensed by the State of Massachusetts,the MA DEP informs tts that the local Board of Health oversees and ensures compliance in regards to the septic system reports. Thus, you are hereby ordered to amend your septic system inspection report to meet the State Environmental Code, Title V, within fifteen (15) days of your receipt of this order. The amended report shall be submitted to the Board of Health at the office of the Public Health Division,367 Main Street,Hyannis, MA. You may request a hearing if written petition requesting same is received within seven (7)days. PER ORDER OF THE BOARD OF HEALTH omas icean Director of Public Health cc: Mary Nicholson DEP.Lakeville Office Jeff Cannon,A.B. Canco �- f_ ill III �-- -- - - A_ _ - lit � i{� r ��i I, _ -. ; t o -- � .`., z i �3� +�� r F •j" � ,j� �(� �E. � , i�� #� ,,, � , ,�{ 'a ' � � - i, • � � ,+. t� j ��; 3�r fl 1� �r� 1 � ..�.� _ �ti1 ii: v �f' ril �'� !i� i _ � t ��. ' _ F - ` t { - , t !�� 1 . . �� t �'� v ,+,� y � � n �{� t � � � ,� _ r �1�1 - - • - � - , �}111 1+�f — � , ��i ., `��II .` r - ` ' t r ` 'F � ��I r { � . � ' 4 �. � w e- r 1 s ti � � � i —. �� t c III. AtA el 279) '74 LIZ III � III d � III IIl III I1 11 Ill I Ill II �� ca Ir • I't it, !!'I I;+ 3 �1 . jai P ' 339 578 888 it-o ' US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not se for International Mail See revers Sent to St �Obe P Office,Stet ZI C Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee u') rn Retum Receipt Showing to Whom&Date Delivered n Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ M Postmark or DateLL _ € �� CL Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1.If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service m window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,slick the gummed stub to the right of the Q) return address of the article,date,detach,and retain the receipt,and mail the article. u� 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. 4. If you want delivery restricted to the addressee, or to an authorized agent of the O O addressee,endorse RESTRICTED DELIVERY on the front of the article. co 5. Enter fees for the services requested in the appropriate spaces on the front of this f receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. li 6. Save this receipt and present it if you make an inquiry. a 3;o SENDER:■Complete items(and/or 2 for additional services. I also Wish to receive the rn ■Complete items 3,4a,and 4b. following services(for an ■Print your name and address on the reverse of this forth so that we can return this extra fee)' .card to you. ai ■Attach this form to the front of the mailpieos,or on the badcif space does not 1. ❑ Addressee's Address v permit. d 4t ■Write'Retum Receipt Requested'on the mailpiece below the article number. Q, ❑ Restricted Delivery N t ■The Return Receipt will show to whom the article was delivered and the date a c delivered. Consult postmaster for fee. 3.A ' Is Addressed to: 4a.7Number c. cc E 4b.Service Type Be u oz ❑ Registered ( Certified IE tNn / ❑ Express Mail' ❑ InsuredLU 5 Sd y ❑ Retum Receipt for Merchandise ❑ COD a7.Date of r/y, ZM91 0. °C 5. c y:(Priftlit NamWf 8.Addre e s d ress(Only if requested c W . and fee is paid) r W t— g 6.Sig ature:(Adds hee or Agent) �°. .X, m PS Form 3811, December 1994 102595-97-e-0179 Domestic Return Receipt 4 irs- Iass-Mail UNITED STATES POSTAL SERVICE) ' "' 'P`OSffge&-Fees Paid r`" 'Pe�mifNo:G40 ^ >• Print your'nameodd ess, and ZIPYCode in thrs tzox!��' Pablt Health Dlvtsioa Town of BaMSMIS P0.Box 534 Hyannis,Massachusetts 02601 a No. / ' ` FEE ��t COMMONWEALTH OF MASSAC14USETTS Board of Health, `IC.C-Cs Q , MA. V APPLICATION FOP, DID ®SAS. SYST M CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) -Xcomplete System ❑Individual Components Location G m L Owner's Name v� ��rso Map/Parcel# l —. Address Lot# Telephone# Installer's Name O C-N (C i. _ Designer's Name Address &(��`� `� (Address Telephone# W Telephone# Type of Building Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder,(C Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS C, Ce 6a L The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to lace t operation until a Certificate�Co Rlianre 4as been issued by the Board of Health. Signed / Date // �t"�✓✓JJ [t//V r �rfy'Y 4"vw�.r�r+�'1•r q.f�'r►�I�-^.-� ^'a.r•N...+.-•"�'i+Y-"' .-r. ...7 - . .� :,`t'.v 'V..^.. rq��'.rr{�;,li..y�+.i.�.�..-.......r'.'4'r`r .lr rq^' o. %U 'L GY. 42. FEE -5-0 t--' (� x. N, Board of Health, "�d..�pSU MA. f APPLICATION FOP, DISPOSAL SYSTEM STEM CONSTRUCTIONPERMIT r krV pplication for a Permit to Construct( Repair Upgrade OAbandon O -Complete System ❑Individual Components Location Rd Owner's Name (C U f s a n Map/Parcel# O 3 QC�� / Address Lot# Telephone# -1 Installer's Name � C"� � r Designer's Name Address �� U Address Telephone# Telephone# Type of Building Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinderko Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd {� Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation - •t F DESCRIPTION OF REPAIRS OR ALTERATIONS < < .S OO 1u 6e4 L- { The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to lace a to m operation until a Certificate of Co li 7�Y been issued by the Board of Health. Signed Date 0 No. C NW¶-'ALT14 OF C USETTS FEE J `� • �'/ Board of Health, t� -��. , MA. CERTIFICATE Of COMPLIANCE Description of Work: ❑Individual Component(s) AcompleteSystem The undersigned hereby►certify that the Sewage Disposal System; Constructed ( ),Repaired ('4 pgraded ( ),Abandoned ( ) by: Sy/ - t� at N Syt "has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and th�approved design plans/as-built plans relating to application No��`yt`1i dated O2- Approved Design Flow (gpd) Installer �4;)`hL rn 1�:Cca"Lx, c� Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee th t the system will function as designed. No. FEE C COMMONWEALTH OF MASSACHUSETTS Board of Health, 1�.\G�(�Sy MA. DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(Vil"Upgrade( ) Abandon( ) an individual sewage disposal system at /b l-{. �M 0 V� �,Q��Ciry1`, l � as described in the application for Disposal System Construction Permit No. 901�;"_7�.� dated -Z- Provided: Construction shall be completed within three years of the date of this permit. All local conditions must bemet. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date / Z O Board of Health ` 'Q. 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, ® C� .hereby certify that the application for disposal works construction permit signed by me dated , concerning the property locatedfat meets all of the following criteria: There are no, wetlands located within 100 feet of the proposed leaching facility /There are no private wells within 150 feet of the proposed septic system f /There is no increase in flow and/or change in use proposed I There are no variances requested or needed. "• If the proposed leaching facility will be located within 250 fee�of any wetlands,the bottom of the P P g tY proposed leaching facility will not be located less than fourteen_(.14)feet above the maximum adjusted groundwater table elevation. . Please complete the following: M A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) _ SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. i q:health folder:cert 11. TOWN OF BARNST LE ✓ LOCATION 1-7 —Z (V e-,�M(YU r "t`= SEWAGE # �1 VILLAGE -e 1� -�U� 1 _ASSESSOR'S MAP & LOT -03 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �5� v G- LEACHING FACILITY: (type) T( 6 (size) NO.OF BEDROOMS BUILDER OR OWNER_ � A t "o"S CS n PERMITDATE: � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility IS Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist ,t t�) , within 300 feet of leaching facility) ! y Feet Furnished by d 0 4o � � S Ate, a�x; TOWN OF BARNST LE ✓ LOCATION 1 7 C� ��.�MCSU " SEWAGE # /V VILLAGE �.��I '��_ ASSESSOR'S MAP & LOT /95.03 INSTALLER'S NAME&PHONE NO.�cc a SEPTIC TANK CAPACITY V LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER 6,rV IlJ r:c�Izsd ^ w PERMIT DATE COMPLIANCE DATE: 2l k/7 0 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; q� 0 on site or within 200 feet of leaching facility) /' �`'ti Feet Edge of Wetland and Leaching Facility(If any wetlands exist ^ I within 300 feet of leaching facility) ! y Feet Furnished by F;v tiLK Ao a�x yI y