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HomeMy WebLinkAbout0020 FARM HILL ROAD - Health 20 Farm Hill Road, Centerville A=247-082 a No. 42101/3 ORA ESSE -rE 101YO iO ® O O .,...:.... .. _..�:.� .-.:.n,s....:..,..a:�u�wa.:a...��w.:;.�,�.�,,.�._.�..,..,. ..:.:,._..m...... _ .,,,......�...e.:.�.�._;.rs�.r�s.._.:...: � -� w`ar;.;�.u�..�..�.nma..�.wme..._.�n::a,uau• e....____..,...............Win= - Commonwealth of Massachus6fti` -I ea Tootle .5. Offic ­.1! J0 e io Form Subsurface Sewa a Dlspmsal system 1`arm 'Not far Voluntary Assessments k, <�� f 20 Farm:Hill Rd. . Property Address Bernice Smedber Owner . O.Wners game 'information is required for every Centervil.l.e Ma,, 02632 712212fl13 a e. Cit !Yawn _ p 9 y State Zip QOde Dafe of Inspection lnspectian results must be stib¢vaitted on this form, inspecticir'I f srs � may no be:altereci an aeiy vvay..please sod"cmm letenass c �ckli$t t tl�e`end e>f the•,f tm. Impoitant.When, a � e , [.1 ndQ1 ation fillingout forms_ _ on:the computer, use only the tab ^ 1. Inspector �\ key to move your cursor do not d SeanM Jones 9 use the return .... - = — key, Marne of Inspector Capewide Enterprises rs Company Maine - - — 153:Commercial Mash pee ..._��_ iU1a 02649 —. _ Cityrrown _,, State zip Code 548=477-$877. $I 4522 Telephone Number W License Number :; 6 ficIi certify,that I have per onallyInspected the sewage dlspQsai,system at.,,this address and that the information reported below Is true, accurate and,cornolote as of the time of'the,ins,pec.ipn. . e Inspection was performed based on my training and"experience n the proper functon,a�d;;maintenance:of on;site sewage.disposal systems,I arrt a [�Ep,approued system;:}nspeetor pti cant to 3e tiorl 15 344�f Tine 6¢3' 0 CiR ISO The system. _ . Passes Q Conditionally Passes Q Falls ❑ Needs Further:Evaluation by.the;Locai Approving Authority C> *9 r 2 ° � r "' 712 /2013 Inspector's Si4na#ure: — €)ate m y tV The systeMl inspector shall submit a copy, thi Inspection report`to`'the.AO',©wing Authc rlty(3oard� of Health or DE,P}.within 3:Q days;of completing this inspection If the;systerr isa s ared systmorcva has a design flow cif ID 000.,gpd or greater the:insp'ect and the system oinrner s 91 submit i to �. report to the appropriate reglonai'offlce'of the DEP. Tt O original should-be sent to he systelrbov n an__ pies sent to the buyer; if.a}?plrcab.le, and the:approving authority. *This reportbr.1ly tdescri. a cc>'rs atlons:at"the,ti a cat inspectics� alad'ij d� ;the cpr itaor�s of use . at that time.This;i tespet+. ion,doe's,'not address how the system;will perfprm' tt the f ture`' nde the same or different cOnditio s of use.. f5tns%3l13 Title 5 Q f cial Inspescit Farm;S tbsur,'ace sewago€iisposa!Sys a n .Pale:i of 57 Commonwealth of Massachusetts W Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 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 dwelling located at 22 Farm Hill Rd Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 4 Infiltrators. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 .7/22/2013 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced- ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Farm Hill Rd. M Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. .System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow (Sins•3113 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 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 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. El ® 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. (Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 20 Farm Hill Rd. M Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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: 2011 = 20,000 total = 55 gpd 2012 = 18,000 total =49 gpd Sump pump? ❑ Yes ® No Last date of occupancy: vacant Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title t e 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 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: system installed 9/25/1996 per town records 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: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok,-no leaks, vented through the roof Septic Tank (locate on site plan): Depth below grade: 15"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 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 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 3" Scum thickness 3 11 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 10" How were dimensions determined? opened covers, took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Inlet cover is on a riser 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 Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Farm Hill Rd. M Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators ❑ 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.): Soil and stone surrounding s.a.s. was probed and found to be dry with no sign of past hydraulic overloading. 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 page. CitylTown 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 r - Commonwealth of assachuse (473 Subsurface Sewaoe P€spcaaal System Pc►rrn -plot for Voluntary Assessments 20 Farm mil[Rd PropertyAddress - ---- — . Bernice Smedberg Owner ..... Owner s;Name information is C.eriteruille Ma 02632 7i22/2013 required for every page: City/Town State Ztp Gt cie C}ate;of'nsPection q system:Infer , a �n {cant } _ Sketch Of Sewage`Dispo$al System: Provide a`view.of the sewege::disposal system, iricltacl in ties,to at least two permanent reference landmmarks or benchmarks.:Locate a!1 wails virithiii l OQ feet. Locate where public water'suppI enters the.building -Check one of the boxes below: hand-sketch in#lie area be(or E].drawing:attach;ed separately I f .. 1 4 r ,L)C� . t5ins•3113 Title5,Offi6d inspectian Form Subsurface Sevaega Disposal System•Page of)7 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Farm Hill Rd. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 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: 12'+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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 2 F Hill R 0 Farm a d. Property Address Bernice Smedberg Owner Owner's Name information is required for every Centerville Ma 02632 7/22/2013 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 A&SMORS MAP N No. / 7 PARCELS Z Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Mtgw5ai *pgte7)an n.5tructton Permit _ Application is hereby made for a Permit to Cddonst�rucrt( )or Repair( n site Sewage Disposal System at: Location Address or Lot No. 4 � / aZ. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 Type of Building: Dwelling No.of Bedrooms Garbage Grinder(^I) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) V 2.4,p j' 7 7 �Xe // 4�X / J CIO S r D (30A /o✓0:-/jz^/ZA702S Sze)-W /ere " &, r"-,z Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by thl*& oard He Signed .100 Date S_ 3/ 5 Application Approved by Application Disapproved for the following reasons Permit No. 3� Date Issued ` ! � ——————————————————————————————————————— No. / �^ 'C3 ` �+ Fee t THE COMMONWEALTH OF MASSACHUSETTS i PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS t i ,application forigaarpgterrt. �C r��tructiottern�it Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: - Location Address or Lot No. ,4 cs' 9 Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. A Q e,u /o risT C e NYA�i✓� S 7 7 .3�9'.2- Type of Building: Dwelling No.of Bedrooms Garbage Grinder(iU) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow gallons per day. Calculated daily flow gallons. j Plan Date Number of sheets Revision Date i Title n Description of Soil 5•���+ f' G �9 c. Nature of Repairs or Alterations(Answer when applicable) V G �= /i a-�'e (/ � C x��Xo� / S,-o S r L3 Sox7Z ..✓. ,/r'2rtto2s r 7 O.W 6 ice " U .,. �OZ i Date last inspected: ' i Agreement: i The-undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by this 131.oard He/ h s Signed �t�/ _ / Date S� 3 Application Approved by i Application Disapproved for the following reasons �Permit No. 71 � Date Issued ;9 A- THE COMMONWEALTH OF MASSACHUSETTS PUBLI HEALTH DIVISION , BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )o�,repaired/replaced( )on by 2 C f/ ri 3 T for /2 <<A,94-d .5�t=,1; e E le C- al- 49 !` /Z 11, r12 zV c wT. has been constructed in accordance with the—rovisions of Title 5 and t�for Disposal System Construction Permit No. dated -15;7 f=� U of this system is conditioned on compliance with the provisions set f rth below: ----- No. �G�� ,�---=_____—___ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Xigpogal *pgtem Construction 'Permit Permission is hereby granted to A/L e- ,,� to construct( )repair(-,-ran On-site Sewage System loo-at d at Z O Fp/L r.+ f/ // ,Q and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/h r duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: t J /"' Approved b 1� c j HM ] 01 H E A L T H M A S T E R ] HELP [ ] R E C O R D ] ACTION Cl For Parcel Number 2471 0821 ] ] Rental Property(Y/N) [ ] Owner Name SMEDBERG, RICHARD N TR & ] Zone of Contrib (Y/N) [ ] Location 20 FARM HILL RD W HYPT ] Contaminant Rel (Y/N) [ ] Business Name [ ] Area Number Contact Person [ ] Phone (000] [ ] Fuel Storage Tank Permit [ ] Card on File [ ] Perc Test Well Septic File/Permit No. [ ] [ ] [96-236 ] Issuance Date [ ] [0531961 Completion Date [ ] [092596] Last Communications [ ] (MMDDYY) Comments [UPGRADE ] Cancel [ ] NEXT SCREEN [HM ] ACTION [ ] PARCEL NBR [ ] [ ] [ ] TANK NBR [ ] ] [ ] TOWN OF BARNSTABLE LOCATION 112 ���'''��i�/� R �� SEWAGE VILLAGE C 9 N r�= 2" i / ASSESSOR'S MAP & LOT,;? 7, � INSTALLER'S NAME&PHONE NO. /L 2 2 SEPTIC TANK CAPACITY I s,00 GA LEACHING FACELrrY: (type) �' "' •/; iO ro.tl (size). 6 NO.OF BEDROOMS -3 / �1 BUILDER OR OWNER /? 1 G PERMTTDATE:---1 '—.:�:- / 914 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le dity) Feet Furnished by a r2 s 3s 7 d,✓� GA2IQGE ° TOWN OF BARNSTABLE BOARD OF HEALTH �7 ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date T 2� i Time: In Out 1 Owner. v0 Tenant _ pp ' ,2 3 4—a-�1�--� Address ( 7 Address 01 Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities ' 6. Heating Facilities -�= 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal I" v 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE LOCATION �o �i7�''h/�/��`� SEWAGE# VILLAGE 64EFI&ESSOR'S MAP&LOT ,OfZ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J 00 LEACHING FACILITY: (type) ^'`•l% i° "�' (size) NO.OF BEDROOMS 3 n BUILDER OR OWNER Ar J L"e G / PERMTTDATE:,--' -'"3/"1,-,'- COMPLIANCE DATE:�-Z,r-s 57S 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 le chi a 'lity) Feet Furnished by t � �/.�/r r�T'Q�70�.S ��%d.✓c� T I r p L3 �. 9 gar-,4 h 0