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Home My WebLink About0062 FIVE CORNERS ROAD - Health 62 Five Corners Road Centerville P A = 168 039 a i Y I a P f t Y f YECYQED uu qr$a UPC 12534 ' No.2_ 1_53LOR �, HASTINO8.YN TOWN OF,BARNSTABLE S .�� . �� 15 X-� SEWAGE # 2 0 U - LOCATION II 5r VILLAGE Ct✓ ��rl ASSESSOR'S MAP & LOT It t-03 J INSTALLER'S NAME&PHONE N0. %�- tf"-Acg*,b%-P't- _ SEPTIC TANK CAPACITY l00 LEACHING FACILITY: (type) y L t- l¢ ��`�+ ��r s (size) K� NO..OF BEDROOMS ` BUILDER OR OWNER SL S PERMITDATE: COMPLIANCE DATE: 3 2-ih Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Witer 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 Fu ished by 0 `C4 �Aq m Q /68 r os Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments FD M 62 Five Corners t Property Address David Still 's Owner Owner's Name Wc+ information is ; required for every Centerville Ma. 02632 12-04-2017 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. General Information on the computer, oZ use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 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 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 LbyockiVS T 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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: This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding 4 Ic 6 chambers. At the time of the inspection the leacging was dry and there were no visible signs of past hydraulic failure. 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 i i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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 cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 T Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G ,M 62 Five Corners Property Address P Y David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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.6/16 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 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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 CM 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 Plus GPD t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 page. City/Town 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: Sump pump? ❑ Yes ® No Last date of occupancy: Fall 2017 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.doc•rev.6/16 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 I °M 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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.6116 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 62 Five Corners �M Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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 was installed in 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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: 12"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 Standard H-10 1.000 gallon septic Dimensions: tank Sludge depth: 1" t5ins.doc-rev.6/16 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 wM 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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 36" Scum thickness 1" 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 12 How were dimensions determined? Sludge 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.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. 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 �M 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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 L W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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.): The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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.): At the time of the inspection the leaching was dry and there were no visible signs of past hydraulic failure. 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM z 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 l fTOWN,OFBARNSTABLE LOCATION_ •:i u CL Cctu ar5 R-- SEWAGE# 10 " /1� + r VILLAGE L44 oI(� v_ ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. F k&*� (o SEPTIC TANK CAPACITY (OQ 0 LEACHING j;ACILITY:-(type) L�`. la a 6% S (size). NO,OF BEDROOMS BUILDER OR OWNER S� �1 PERMPI'DATE: D COMPLIANCE DATE; 3 z U Separation Distance'Between the: Maximum Adjusted Groundwater T le 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 facibry) Feet Edge of Wetland and Leaching Facility(If any wetlands exist withia 300 feet of leaching facility) Feet Furnished by �L tZ S I e Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 62 Five Corners Property Address David Still Owner Owner's Name information is required for every Centerville Ma. 02632 12-04-2017 page. Cityfrown 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 plus feet 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: I augered a hole to 12 feet to show four feet of seperation. 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 °M 62 Five Corners Property Address David Still Owner Owner's Name information is Centerville Ma. 02632 12-04-2017 required for every page. Citylfown 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 PHONE .CA.L U, FOR DATE TIME A. M V� PHONED' OF PHONE 22 } YQUR CALL: AREA CODE NUMBER EXTENSION a MESSAGE PLEASE CALL' WILL GALL,;'. AGAI3�1 GAME,TC SEE YOU WANTS TOj,; SEE YOU SIGNED MniverSal 48003 NOTES COMPLETE • COMPLETE ■ Complete items 1,2,and 3.Also complete A. Signature Aaedressee item4 if Restricted Delivery is desired. nt ■ Print your name and address on the reverse X so that we can return the card to you. B. ece ed by(Pdnr Name) C. D to of):)elivery ■ Attach this card to the back of the mailpiece, C or on the front if space permits. 1. Article Addressed to- D. Is delivery address different from Rem 1? El Yes If YES,enter delivery address below: ❑No rd � 3. Service Type 01-Certified Mail 0 Express Mail 6 7,Z ❑Registered B Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) `❑Yes 2. Article Number 7006 0810 0000 3525 0373 I t(� (Transfer from service labeo PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-15410 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 I • Sender:Please print your name,address,and ZIP+4 in this box• ac Health Division own of Bamsta6ie 200 Main St Hyannis,Massouseffs 02601 I I I I Certified Mail#7006 0810 0000 3525 0373 ayti Town of Barnstable o� Regulatory Services BARNSMS �• Thomas F. Geiler,Director � sa�9. bum Public Health Division Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 { February 2, 2007 David &Linda Still C . t4,- 411 Scudder Avenue �. Hyannisport, MA 02672 0 Il (> NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION, THE STATE ENVIRONMENTAL CODE, TITLE 5 AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property.owned by you located at 62 Five Corners, Centerville, MA was inspected on February 2, 2007 by Timothy O'Connell,Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. T e following violations of the State Sanitary Code were observed: 105 CMR 410.300 and 310 CMR 15.00: There were a total of five (5) bedrooms observed in this dwelling; three were.observed on the first floor, two were observed within the basement. However, the existing septic system was not designed for five bedrooms. Permit#2004-115 issued on 3-19-04 is for three (3)bedrooms. 105 CMR 410.450: One sleeping area with a bed was observed within the basement wi out adequate emergency egress (second means of egress). 105 CMR 410.401: Observed both rooms in basement with ceiling height of 6'5". 105 CMR 410.482: Observed that there were no working smoke detectors within home. QAOrder letters\Housing violatious\Rental ordinance\62 five comers.doc I The following violation(s) of the Town of Barnstable Code were observed: 170-10—Maintenance of Smoke Detectors and Carbon Monoxide Alarms—No CO detectors observed on main floor of home as required by Town of Barnstable Code §170- 10. 1§ 70-7- Provision of names addresses and telephone numbers-Owner\Property Manager's name, address and telephone number were not posted inside the dwelling.* *Note: Once all the other violations have been corrected, you will be issued a certificate of registration for the rental property. The certificate of registration will have all the necessary information to satisfy the requirements of § 170-7 of the Town of Barnstable Code. You are directed to correct the violations listed below within twenty four (24) hours of your receipt of this notice by installing smoke detectors in home in accordance with local fire department regulations and installing CO detectors on main floor also in accordance with local fire regulations. You are ordered to remove the bedrooms from the basement by removing entrance doors, by removing the beds, and by opening all door-way entrances to each room in the basement to minimum of five feet wide openings within (30) ten days of your receipt of this letter. Note: COMM Fire Department has been notified of violation on smoke detectors and CO detectors. You may request a hearing before the Board of Health if written petition requesting same is received within ten.(10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. �&as DER OF BOARD OF HEALTH .McK an, R.S., CH Director of Public Health Town of Barnstable Cc: Timothy O'Connell,Health Inspector QA0rder letters\Housing violations\Rental ordinance\62 five comers.doc �oe#) 9 COS A c (f� �D (-�v �ii.d�Pg ��, CRC � �� 3�r � �c z Parcel Detail Page 1 of 3 x�rSA5�i, s _ Logged in As: Parcel Detail Friday, Octob Parcel Lookup ........... .. .....---- --- Parcel Info Parcel ID 168-039 _ Developer,LOT 2 Lot Location 62 FIVE CORNERS ROAD _ Pri Frontage 1100—�-- _ — Sec Road I Sec Frontage I Village CENTERVILLE Fire District!C-O-MM — � sewer Acct — Road Index Interactive _ Map =;,i-P Owner Info Owner 1STILL, DAVID B & LINDA C Co-Owner _ Streets I P 0 B 323 .� � Street2 City HW YANNISPORT State 1MA zip02672 Country SUS Land Info _ Acres 0.35 use Single Fam MDL-01 zoning IRC Nghbd 0106 Topography Level �m�� Road Paved -- --. --------- .......... ........... Utilities Septic,Gas,Public Water Location Construction Info Building 1 of 1 Year 1974 � Roof IGable/Hip ____� Ext:Woo lery Built, Struct: Wall i g Effect'"-------1427 _ ._� Roof Asph/F-GIs/Cmp � AC None ____-_-� Area 1 _ Cover Type Style Raised Ranch Inti Drywall ' Bed�Bedrooms Wallll` Rooms Model;Residential Int Bath 1 Full Floor- ! Rooms Grade lAver a Heat!Hot Water Tot e Ho al 6 Rooms g Type Rooms-- http://issql/intranet/propdata/ParcelDetail.aspx?ID=10950 10/13/2006 Parcel Detail Page 2 of 3 n Stories 1 Story Heat"Gas _ Found- T yP ical Fuel ation ° _..._ Permit History Issue Date Purpose Permit# Amount Insp Date comments (� Visit History Date Who Purpose 8/17/1999 12:00:00 AM Donna Dacey Meas/Listed Sales History Line Sale Date Owner Book/Page Sale P 1 3/23/2004 STILL, DAVID B & LINDA C C172439 2 9/15/1986 SCRUFUTIS, WILLIAM C& LOIS C107929 ; 3 CLARK, JOSEPHINE C79735 4 CLARK, PAUL W DTH CTF C79735 5 SCRUFUTIS, VASILIOS M792 C107292 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parce 1 2006 $118,100 $6,000 $0 $170,200 2 2005 $110,600 $6,000 $0 $135,700 3 2004 $89,800 $6,000 $0 $101,800 4 2003 $86,200 $6,000 $0 $44,900 5 2002 $86,200 $6,000 $0 $44,900 6 2001 $86,200 $6,000 $0 $44,900 7 2000 $68,200 $5,900 $0 $34,000 8 1999 $66,700 $5,400 $0 $34,000 9 1998 $66,700 $6,200 $0 $34,000 10 1997 $73,700 $0 $0 $30,600 11 1996 $73,700 $0 $0 $30,600 12 1995 $73,700 $0 $0 $30,600 13 1994 $70,800 $0 $0 $21,400 14 1993 $70,800 $0 $0 $21,400 http://issgl/intranet/propdata/ParcelDetail.aspx?ID=10950 10/13/2006 r • Parcel Detail Page 3 of 3 15 1992 $80,500 $0 $0 $23,800 16 1991 $82,800 $0 $0 $54,300 17 1990 $82,800 $0 $0 $54,300 18 1989 $82,800 $0 $0 $54,300 19 1988 $61,500 $0 $0 $23,700 20 1987 $61,500 $0 $0 $23,700 21 1986 $61,500 $0 $0 $23,700 Photos http://issql/in.tranet/propdata/ParcelDetail.aspx?ID=10950 10/13/2006 FORM 30 HOBBS&WARREN'" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE TH CIT�TOWN s w o F - PARTMENT o;L6 D ESS t4 O Ll(9:iq M 0a a TELEPHONE ° Address --- — ------Occupant Floor Apartment No. No. of Occupants_No.of Habitable Rooms .7 No.Sleeping Rooms 5__-- �� No. dwelling or rooming units— o.Storie Name and address of owner_ + _ _ Iti� � t 6RemaZl Reg. Vio. YARD Out Bld s.: Fences: 2— Garba e and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains.- Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: 410, Li htin ,� STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows.- HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusin ,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors I Floors Locks Kitchen Bathroom —Pantry Den —Living Room 1 Bedroom 1 ° Bedroom 2 F ' Bedroom 3 R Bedroom 4 n Hot Water Facil. Su en.,Gas,Oil, lect.: Stg4s, Flues,Vent feties: Kitchen Facilities in Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." r INSPECTOR TITLE DATE s TIME ! I P.M. THE NEXT SCHEDULED REINSPECTION A M P.M. .. ... .. ti..++ti3 , •s�,�,....+wr;....n;.a�."4+... .�'s.n......�mL,-" :_�`�, +. .-} �{ . j , _ M - k.. ' .�.� _ii�. r � � S p�F`. fit 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201. or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. D Failure to provide the electrical facilities required b 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) or any defect which renders them inoperable. (3) Any defect inthe electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not.create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. O Y An other violation of 105 CMR 410.000 not enumerated in 105_CMR 410.750(A)through(0)shall be deemed to be a con- dition which may endanger er or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. ,r "N�.��C.m.,d,. r ..-rn.••� w. r..'•�!•-•try".^?...�r-...-rv.-, . y...,h��ran v.n-r•e.r4.,`.�:.�, .—� . „ra....: + FoRM30 CIInW�cHOeeSaV�ARREN`" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH CIT /TOWN W ' D PARTMENT ADDOESS 1 TELEPHONE Address - __^� Y Occupant Floor _Apartment No. No.of Occupants No. of Habitable Rooms "7 No.Sleeping Rooms }7, No. dwelling or rooming units _ o.Stories Name and address of owner___ H it &111 -- Remarks Reg. Vio. YARD Out Bld s.: Fences: 1 / 467 j Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: , `I, Chimney: BASEMENT #,,Gen. Sanitation:- Dampness: Stairs: 10 4 0- 00 • T7 ' ��. Li htin : • 44 3.... STRUCTURE INT. Hall,Stairway: ` _ �, f , ts,_ Obst'n.: Ow r Hall, Floor,Wall, Ceiling: Hall Lighting: I ' Hall Windows: I HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: ,Stacks, Flues,Vents:- PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 t 10 Bedroom 2 q .. Bedroom 3 C, Bedroom 4 ) Hot Water Facil. Su en.,Gas, Oil, ect. N4 Sta- s, Flues,Vents Safeties: Kitchen Facilities 6in r Q Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted '' Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF,THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR TITLE Ao M DATE •- — TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. L Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, ( ) p g 9 9 9 gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. Town of Barnstable Regulatory Services o� EM"STABM Thomas F. Geiler,Director MASS t639. � Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Febuary 5, 2007 Attn: COMM Fire Health Inspector Timothy B. O'Connell conducted a rental inspection in accordance with Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector (and\or CO detector) violation(s): 62 Five Corners,Assessors Map-Parcel: (168-039): -No Smoke detector working within home. CO Detector not working on first floor. Y- Timothy B. 4Connell-Health Inspector Q:\Order letterMousing violations\Rental ordinance\\Fire ViolationsTfRE TEMPLATE.doc i J, L .� No. � /v i p Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZlppYtcatton for r3t5pont 6pgtern Construction Vermtt Application for a Permit to Construct( . )Repair(,,,()Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ;7tL#Q, Co fktVf66r^ ,a Owner's Name,Addres§and Tel.No. (GoS) 4 a®—SS 61 Assessor's Map/Parcel — `IJ9 Cal Installer's Name,Address,and Tel.No. 7)75 333 Designer's Name,Address and Tel.No. NDO 2D 16 O�T� -5— P1"PMbQr aya 5.n Y-ne- J.G.crtbulke/l b?uric. 6t,x to rip i� aSSL1 (San6elrrul}l" Type of Building: Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building u.re,l No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 331 gallons per day. Calculated daily flow 3SL gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank C)1,1,f-;& 8 oGn Type of S.A.S. L1 - C, Description of Soil, Nature of Repairs or Alterations(Answer wppen applicable) l�SM -0 144QyLbn I ok q I-C- 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 anbL,$I18IRjRG t tl rya r I �Eertifi- cate of Compliance has been ' by s Board of Health. INSTALLATION AND C--'-rlrV 'N' RI I IG Signe 4-!O �X Application Approved by ® p i Application Disapproved or the following re o Permit No. v Date Issued No. •-•• Fee �— THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: V Yes, L/ -. PUBLIC,HEALTH DIVISION -TOWN'OF BARNSTABLE,MASSACHUSETTS 2ppYication for Miopool bpztem Congtruction Permit 3 Application for a Permit to Construct( . )Repair( :)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. (pp, 1paJe, CP WW f-->Ir�,' Owner's Name,Address and Tel.No. (so Z) a®—SS 64 q� lX/'A`t�ti(l�ii-/i��-N1VVI f� Assessor's Map/Parcel - 39 (�l f 8�U1 t..MA Installer's Name,Address,and Tel.No. (5"C�') 775 1 Designer's Name,Address and Tel.No.LravO 27)3 - 0377 _ -5-',04(,Dmbz'o.-J �5-nT-nc J.C.C-ftbmft"?YnC• ,. P x co�P , a.�stl (sw16oTul Ja Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building -bwe tiftA No.of Persons —Showers( ) Cafeteria( ) Other Fixtures Design Flow 1*11D gallons per day. Calculated daily flow V',2 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank C11C4cn.c' 10DO'r,.\G" Type of S.A.S. U 1 C_-�., Ko gkj�," J Description of Soil, Natur(er of Repairs or Alterations(Answer when applicable) L11Yi��f(r 1 (ynw6us. .on'J XC�a�U1(. �P(\(tl1Y1c ( C.IAl��_7p1� J 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- caie of Compliance has been issued by this Board o-f�Health. Signed : /%(` l` Date In, . Application Approved by Date Application Disapproved for the following rea. on Permit No.' v Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired O Upgraded( ) Abandoned( )by .� 1)1Q �� ,c�� 0.X1 '--n11 .. i in . at tad` F+ v p. Ca +•to f fr S r-8 C'Q 1 iV Y b 1 H o t ll tt • has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer _Designer--, The issuance oT-) s pet shall not be construed as a guarantee that the ate_ wi nction as d signeJd. Date � l)L) Inspector �l --------/��————————————————————— / No. � � -----Fee /I r pJn�� THE COMMONWEALTH OF MASSACHUSETTS i6 l/ PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mi,5pozar bpeum Con.5truction Permit Permission is hereby granted to Construct( )Repair O Upgrade( )Abandon( ) System located at (n F u o C�c 1r1P 1 `j r C'�k1� s 1 i+1�t 0 l c, - i 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: Cons Lion ust be ompleted within three years of the date of this p{erfnit. Date: Approved b Al Towne of Bamstsible Regulatory Semeeg 1 Thomas F.Ceder,Director Pubiae Heolth Division Thom"McKeen,Director 200 Man st r"t,Hyanz&j Mi!02601 7sx., 501-790.6904 office. soa.�-aft Date: 3 d y j?atglaen A ,IyL c. Installers Adds.: ►a�tw� Address: p U Box �� j� was issued a permit to install a on to a J septic system at e de (Orricv.s 6entc,VI e based on a.design drawn by s tCri�1 'Lc,: _ dated_�ra<c X I cettif�that the sap0ie syat= referenced above ch as I installed bateral�locstion of the y according to the de� which may include minor approv ed changes disadbuflon box=Woe septic tank. I cc that the scpsic s�yyssttem referenced above was Mulled with mjer changes (i.e, com than 10' lateral zetocataon of the SAS or MY vertical reloc tioa�ot� awnt n' revia��on or of the sue) but is we with State di Local Iteula. c eed as bush by doei6W to follow. CISJ r nfii 0 bmmc AND Nu 4'i}v P Q•Ha�e��as��asdas poem Z9 'd L9£0 £LZ R0S `_1NI:A33NION30f Wd TS: Z0 b00Z-0£-80w TOWN-OF BARNSTABLE LOCATION C-CC A k r3 SEWAGE # 20 — /I VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Acow,to SEPTIC TANK CAPACITY 1000 LEACHING>iACILITY: (type) y LC— (size) . NO,OF BEDROOMS BUILDER OR OWNER 5C- PERMITDATE: COMPLIANCE`DATE: 3h U Separation Distance`Between the: Maximum Adjusted Groundwater T le 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 ram. �. i 0 �� a 0 Q . r UAT E: , 10/7/96 PROPERTY ADDRESS: 62 Five Corners Road Centerville ,Mass . 02632 On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1-000 gallon septic tank. . 2. 1 -Distribution box. 3 . 2-1000 gallon leaching pits . based on my InR:kectlon, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code ) 2. The septic tyshem: iat-in proper working order at the present time. 51GNATUR�: IVan1e:_J_P . Macomber Jr..___ __.__ Vt Company: J• P,Maconiber &— Son_Inc . �f Address:_-8-e,x—bb------ --- --- OCT CentervilleLAfass__02632 Phone 0 , THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tank&-Ces&pool&-Leachflelds . Pumped & InsUII&d Town Sewer Connections P.O. Box 66 ' Centerville, MA 02632.0066 7?5-3338 775-6412 Executive Office of Environmental Affairs ®epartment of Environmental Protection William F.Weld ao»rrwr Trudy Cox* Arpeo Paul Celluoci 8--tag' u.comrnor David B. Struhs Ccmntfailorwr • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 62 Five Corners Road Centerville Address of Owner. Date of Inspection: 10/7/96 (If different) NameofInspector: Joseph P.Macomber Jr. Company Name,Address and Telephone Number. J. P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338 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: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails i/(/*a6" /j Inspector's Signature: Al �" Date: /D 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 system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: S 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 used to be replaced or repaired The system, upon completion of the replacement or repair,passes inspection. p 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 guile is metal, cra:ked,structurally unsound, shows substantial infiltration or exfiltretion,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Winter Street a Boston, Massachusetts 02108 • FAX(617) 556-1049 • Telephone(617)292-SSW Printed on R"Ied Paper J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Add resar 62 Five Corners Road Centerville,Mass . 02632 Owner. Lois Scrufutis Date of Inspeotions 10/.7/9 6 B)SYSTEM CONDITIONALLY PASSES(continued) . �[D Sewage backup or breakout or h0h static water level observed in the dLtribution boa Is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution boa. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution boai Is levelled or replaced Nd 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 pipes)are replaced obstruction is removed Cl FURTHER EVALUA TION IS REQUIRED BY THE BOARD OF HEALTH: .JD Conditions cdst which require fiuther evaluation by the Board of Health in order to determine if the system is failing to protect the J — 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: A Cesspool or privy is within 50 feet of a surface water AP 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) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system bat 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. 2The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system bas a septic tank and soil I.absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unlew 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 6 ppm. 3) O�,THHEjt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (Continued) PropertyAddreas; 62 Five Corners Road Centerville ,Mass . 02632 Owner. Lois Scrufutis Date of Inspection: 10/7/9 6 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 correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or Cesspool. 1,0 Discharge or ponding of effluent to the surface c,fibs 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. AV Liquid depth in•esspea}is less than 6"below invert or available volume is less than 1/2 day flow. &6) Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped V Q[f'? 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 a surface water supply or tributary to a surface water supply. AS Any portion of a cesspool or privy is within a Zone I of a public well. Nd Any portion of a Cesspool or privy is within 50 feet of a private water supply well. ti Any portion of a cesspool or privy is less than 100 feet but greater than 60 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 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: the system is within 400 feat of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinldng 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 fluther information.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 62 Five Corners Road Centerville ,Mass . 02632 Owner: Lois Scrufutis Date of Inspection:10 7/9 6 s Check if the following have been done: ` 4_44ping 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 slow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ,,,14s 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 The site was inspected for signs of breakout. ZAll system components,aieluding 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 baMes or /tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Y 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. facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. `5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddrans: 62 Five Corners Road Centerville ,Mass . 02632 Owner. Lois Serufutis Date of Iuspootiut:: 10/7/96 FLOW CONDITIONS RE9I D F,NTIAIy �1.�, Deeign flow:,6Rr`aW Number of bedrooms: Number of current residents: 1�9 Garbage grinder(yea or no): Laundry connected to system (yea or no):ye; Seasonal use (yea or no):�'� > Water meter readings, if available: Last date of occupancy: Jp-7 I COMMERCIAL N`DUSTRIAL- Type of establishment: 4,14 _ Design flow: �L_A- gallons/day Grease trap present: (yea or no)A/4 Industrial Waste Holding Tank present: (yes or no)-,&�'# Non-aanitary wasto discharged to the Title 5 gystern: Ives or no),/4'g Water meter readinb , if available: 4 Last date of occupancy: OTHER. (Describe) 14-14 Last date of occupancy:_ - — GENERAL INFORMATION PUMPING RECQRDS and so f inforiraticn System pumped as part of inspection: (yes or no)�^ ) If yes, volume pumpedi�al.lu:w y l Reason for pumping s41)v _Cii'�iui TYPE OF SYSTEM Septic tauk/distribution box/soil absorption w)stem Overflow co"pool Privy J(J Shared system (yes or no) (if yes, attach pm;v;ous inspection records, if any) Other (ezpl:.in) Z RO MA AGE of all components, date ir:.aalled (if known) d source of information:ai^d=iiD/rJi�� /.:ilJ Sowa¢o Od_o detecte , ,. ., \�7 .when xrri vino nt thou � i��..� � ..� A )al "VBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM PART C. • SYSTEM INFOfL4A1TION (continued) Property Address: 62 Five Corners Road Centerville ,Mass . 02632 Owner: Lois Scrufutis Date of Inspection: 10/7/96 SEPTIC TANK: /WVV" 14,c, 1'Ati4 ' (locate on site plan) ,r Depth below grade:a� Material of construction: concrete —metal —FRP —other(explain) Dimensions:_ 4 / 5 _ Sludge depth: ' ^ Distance from top of e to bottom of outlet tee or baffle: 0 _ Scum thickness: U hh Distance from top of scum to top of outlet tee or baffle: y _ Distance from bonom of scum to bonom of outlet tee or baffle. a Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle depth of liquid level in relation to outlet invert, structural �rity, evidence of leakage, etc.) Pump tank .every_.2-� yearS . in placetSeptic tank is t ct l� eakage-.- No rPnair_ nP ; mQ GREASE TRAP /Uepf Depth below grade:,/,,i4 Material of conslrlwiion;,�.oncrete metal FRP Dimensions.,—, . 444 _------_--- Scum thickness: ----"" Distance from top ui scum to top of outlet tee or battle:AW Distance from bottom nt Srunn t,, bottom of ou!!t•! t(,t Ur _omments: recommendation for pumping, cond!rj of inlet and uutict tccs or uanlvs, depth of liquid level in relation to outlet invert, structural ntegrity, evi ence of leakage, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 Five Corners Road Centerville ,Mass . 02632 Owner. Lois Scrufutis Date of Inspeotlon: 1 0/7/9 6 TIGHT OR HOLDING TANK:Z,1-�� (locate on site plan) s Depth below grade:, Material of Construction:&( Concrete_metal_FRP—other(explain) Dimensions: A/4 Capacity:_ A,4 gallons Detign flow: V--gallons/day Alarm level: 1CW Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX- (locate on site plan) Depth of liquid level above outlet invert: ,,Cjd Comments: note it level and distri�tion is equal eviden of soli over, vile ce of leakage into or ut of bq:,etc.) istribution box is not level: hou�d have speed Veveler ins a . No evidence of solids carry over: No evidence Or leakage in or ou o thp istribution bo _ PUMP CHAMBER:�.L>� (locate on site plan) Pumps in working order:(yes or no) iC'D Comments: (note conditio f pump chamber, condition of pumps and appurtenances, etc.) SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART C SYSTEM INFORMATION (oontinued) Pcvi;irty ..... ... .. 62 Five Corners Road Centerville ,Mass . 02632 Owner. Lois Scrufutis Date oflnoj:.,;u::" 10/7/96 SOIL ABSORPTION SYSTEM (SAS):A-1000 CY}��Osc� 4CIACh >>c.!'l' (locate on site plan, if passible; excavation not regtured, 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: p leaching fields, number, dime ions — overflow cesspool, number: 90mmants: (note condition of soil signs of hydraulic failure, level of ponding,condition of vegetation,etc.) Loamy sand to medium sand;No signs of hydraulic fail,,-re or A i i Veg—et Vio n is normal No repairs needed at the Don -- nrP4Pnt }i mP CESSPOOLS: "t'tll . (locate on site plan) Number and configuration: dJA Depth-top of liquid to inlet invert:—A-�- Depth of solidi layer: AA Depth of scum layer: AM Dimensions of ccsfpaoL•_ Materials of couctruct.on:_ ,U14 Indication of TouadwuUr:_ inflow(ooaspool must be pumped as part of inspection)_ /P/D Comments: (nqte condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRrvy: &ji jie_ ! (locate on site plan) Materials of construction: iyr9 Dimensions: A)�z Depth of solids: Comments: (nee condition of soil, signs of h fail ydraulic ure, level of ponding, condition of vegetation,etc.) J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L'SPOSAL SYSTEM: include ties to at least two permanent references landmarks. or benchmarks locate all wells within 100 ' Centerville 'Osterville Marstons Mills Water Company 428-6691 DEPTH TO GROUNDWATER -,Oct c-Za depth to grou wader �`\ m4thod of determinaLtion or approximation: Tnnt„� 7 „ ram•.• 000 gal on leaching pit, in o wa• r encounzered -- a t 1 G ' ��_ .•c��-. SIC _ V S�iY �71 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ' ' ion of Water Pollution Control r 6 .l '1'0HPI OF Barnstable WARD OF HEALTH 9011S1JUFAU SFHAGE WS1USAL SYST1 ,,M INSPECTION FORM - PART D - CEIITIFI CAT ION cr�r.—r.•.r.rrr r._. ._.. -TYPE OR PRINT CI.EARL)'- PROPERTY INSPECTED STREET ADDRESS 62 Five Corners Road Centerville ,Mass . 02632 ASSESSORS MAP , BLOCK AND PARCEL #i OWNER ' S NAME Lois Scrufutis PART D - CERTIFICAT-ION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J•P•Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or Clty Stat• LIP COMPANY TELEPHONE—( 508- ) - 775 ` 3338 FAX ( 508 1 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : :XXXXXXXXX System PASSED The inspection wflich I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date 10/8/96 One copy of t' 11ia nnf ( • . 140 � � ! �` l Fims....#.... .:.3.....'00 No............�.._....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '�t' TOWN OF BARNSTABLE Appliration for Disposal Works Toustrnrtann randt Application is hereby made for a Permit-to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: 62 Five .Connors Road Centerville -------------------------------------------- ......................--......--•-------------•-•----........._.................---•-•--•-----•-- Location-Address or Lot No. ....Wi11iam Scrufugis.--•-•............................................. ..........--...................................................................................... W J.P.Macomber JrOwner Address Installer Address P Type of Building Size Lot............................Sq. feet Dwelling-X No. of Bedrooms................3_........................Expansion Attic ( ) Garbage Grinder ( ) 'k Other—T e of Building No. of persons----------------_-----.--- Showers — Cafeteria Q' Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity...........gallons Length---------------- Width................ Diameter................ Depth................ 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........................ �rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix ----------------------------------------------------------------------------------------------------......................................................... 0 Description of Soil...............................................................................-------------------------------------------------------...------------------------------ v .--------------------------------------------Sand---&- Gravel W UNature of Repairs or Alterations—Answer w13en a livable---------------------------------------------- --------------------------------------------------------------------------- .............. 1-1000 gallon pit. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE S of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia e has be, n i ued by the boa d of ealth. Signed ... . Date Application Approved By .................. ..---- . -- . ..... ---- .- -------- --- / Date / Application Disapproved for the following reasons- ...............................................................................- --------- ---------------------------------------- -------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- -------------------------- Date PermitNo. // ................. ............................................... .. / f ------------------------------ Issued Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _X0 N OF BARNSTABLE Appliratinn for Disposal Warks Taustrn.rtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: 62 Five Connors Road Centerville .............. -- ---•••--••-----•-----------------...................._.....-------------- --•--•-------•----•----•----------•-•-•-•-•----------••--•-------.............------------.....--- Location-Address or Lot No. Will1am SC, c ru 'uis ......... ..........._ ... --------•---------..----------------•-------- •--------•---- ---- ---- ------ -------- •---------------------- ----------------------------------- •........... . caner Address �i J.P.Macomber JrQ. Installer Address d Type of Building Size Lot.....:......................Sq. feet Dwelling—X No. of Bedrooms.................3........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther 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 ( ) aPercolation Test Results Performed by........ •-•••---•---------------------------------------•--•-•--6........ 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---___---..-____--_.___. a ---•-----------------------------------------------------------•-------•••......•-•-------------.-- -.----------------------------- ----------- ------•--------- 0 Description of Soil....................................... Sand &..Grave 1...... -------------------------------------------------------------------•-....-------•••---•--••. W ---------------•----------------------------------_------------------------------•------------------------------------.------ U Nature of Repairs or Alterations—Answgr whin ap licable-------.......................d..__............................................................ ' ....1-10 0 allon it. y, ........................................................................... -,•-••-�------••-•--••. ..------------•-------••---•---•-•.............-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in.operation until a Certificate of Compliance has been i iss ssued by the board of health. Signed ..--,�i �R ... - ..... 1/1J/91.. Date Application Approved By.................. _ �.. -e...-a -._-„s��.------...------------........------...------. n -�'� ,,� � J - ------ Date Application Disapproved for, fo lowing reasons- -------------............................................- ---- -----------------........--------------------------------------------- ---------------------------------------------------------- ------- -- -------.............................-----------------------------------------.................................................... ------------ --------------I..------ Date PermitNo. ....------- X .0-------_----_------------ Issued .................................................................. Date THE COMMONWEALTH OF MASSACHUSE77S BOARD OF HEALTH TOWN OF BARNSTABLE (g.er#ifirate of OUTLImpliance PHIS S TO C RTIF . That the Individual Sewage Disposal System constructed ( ) or Repaired ( XX� J.V. tacomoer ��. by ....................................................... -- ----...--------------------.-----........-------- Installer at -...-62--.Five--..Connp- '; -.-.RQa d.....CEn.tP.r�vJ 11e............................................................................. .... .............-..........------ -- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................... Z.-..../..6...... dated ........---................................ .---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... ✓ � or , t � �." s -------------------------------------------------------- THE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No......- .`../ FEEb--�---30,00 .� Dish oal Works Tunstrnrtion 'prrntit Permission is hereby granted_....s�_._P Ma c Omh ... Jr.-_ ..--•..•-•-•---••--------------- .---•----•................................................ to Construct ( ) or Repair (KX� an Individual Sewage Disposal System at No..... r:ive...Connors...Road Centear....i..11e.••------------•-••-•-------•... ...........................•-----•---------....---•--.-•--•- • .. . - Street a as shown on the application for Disposal Works Construction Permit No./.,/: ��.. Dated.......................................... ........................................ .!. .....___........_.._..._............----....„ - /B'�ard of Health DATE .-.. . ...:... 1------•--------------- LJ FORM 36508 HOBBS h WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION 62 k eve L'.e,-rnP�1S )7C/ SEWAGE VILLAGE Ce�Te�,�,`//� ASSESSOR'S MAP & LOT�t�g•^ f) 3 INSTALLER'S NAME & PHONE NO. 'SEPTIC TANK CAPACITY Y LEACHING FACILITY:(type) '7" (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BVINMR OR OWNER , � ,Se-Yca is 1S DATE PERMIT ISSUED: !" ® �` DATE COMPLIANCE ISSUED: �'"��`� / VARIANCE GRANTED: Yes No {/ l r Q i 0 r Od � C3 CONTRACTOR SHALL VERIFY SIZE AND FINISH GRADE OVER D-BOX= 20,0' FINISH GRADE OVER CHAMBERS = 195 - 20,8' GENERAL NOTES CONDITION OF EXISTING SEPTIC TANK REMOVABLE CONCRETE COVER SLOPE @ 2% MIN. OVER SYSTEM TO WITHIN 6"OF FINISHED GRADE 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 @ FND. EL.= 20.0' - 21.0' FINISH GRADE OVER TANK EL.= 19.0 5" DIA. OUTLET(S) 2"OF 1/8"TO 1/2"DOUBLE WASHED STONE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE N \ ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES. 20"MIN. ACCESS COVER 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD (TYPICAL FOR 3) TOP OF SAS = 17.83' PLACE RISERS ON ALL CHAMBERS OF HEALTH AND THE DESIGN ENGINEER. 36"MAX. TO 6"OF FINISHED GRADE 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL EXISTING 4 9 MIN. PVC PIPE 17.00 36"MAX. BREAKOUT EL = 17.50' BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED. 6"+ 3" 3" 9" PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN 3" DROP MIN. rl JOINTS (TYP.) ELEVATION = 17.50' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS 10" E PVC IN FROM �\ " O pop O op OF THE LINER A 40 MIL MIS NOT LESS ESS THAN THE BRENE LINER IS D AT KO TAST FIVE LE ELEVATION. FROM S.A.S.AND THE TOP T 14 17.56 SEPTIC TANK ( ) 4 PVC OUT TO o f �-/ LEACHING FACILITY 1.01 o00 � � � � � � � � � o op 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 12" o0 0o D o 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. 48�� CONTRACTOR SHALL OUTLET TEE 17.37' MIN. 17,2Q' S po po op po po po po pCD po po po po po po po po po po po po po p 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO po po 0o po po po po po po po po po po po po po po po po po 00 0o BACK FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR VERIFY CONDITION OF � _ EXISTING TEES 6"CRUSHED STONE INSPECTION. SYSTEM IS NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING OVER MECHANICALLY 2.8 6.1' (TYP-) 2.8' APPROVAL FROM BOARD OF HEALTH AND DESIGN ENGINEER. AND REPLACE AS COMPACTED BASE 4.0' 3.0'(TYP.) 4.0' NECESSARY 8. ELEVATIONS BASED ON ASSUMED DATUM OF 20.00' OBTAINED rj DISTRIBUTIONOUTLET 30.0' 11.0' FROM A NAIL IN A UTILITY POLE AS SHOWN ON PLAN. TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV.- Adjusted t0 10.33' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION EXISTING 1000 GALLON CONCRETE SEPTIC TANK BASE. FIRST TWO FEET OF OUTLET THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE �� „ ,� PIPES TO BE LAID LEVEL. /15.5' 5 MIN. AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY LENGTH 8 -6 WIDTH 4�-10 DEPTH _5,-74 - LC-6 CHAMBERS DISCREPANCIES TO THE DESIGN ENGINEER. CROSS SECTION VIEW 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL TYPICAL CHAMBER PROFILE CHAMBER DETAILS CHAMBER END VIEW STRUCTURES SHALL BE MADE WATERTIGHT. NOT TO SCALE NOT TO SCALE NOT TO SCALE 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH - �• DETERMINATION FROM APPROPRIATE AUTHORITY. t �r TEST PIT DATA s,z, . � 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE OVERHANG ' IF �, _} AGENT: Unwitnessed THEY SHALL WITHSTAND H-20 LOADING. HC 1 ran r EVALUATOR: Bradley M. Bertolo 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND_ - DATE: February 28, 2004 FINES. R► '� °' A TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND f a' UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF 1 ELEV TOP= 19.50' 4 LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN ! ) ( ) '� .. ' •• '""� � � � ELEV WATER= Adjusted to 10.33' COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). PERC RATE _ < 2 Min/In 1 .� �� 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN HC 2 _. . ~ DEPTH OF PERC -_ 70"-88" SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. 9 `} '� • • �, 16. PROPOSED PROJECT IS LOCATED WITHIN: {4 � � TEXTURAL CLASS: 1 ASSESSORS MAP 168 PARCEL 39 (3) gobefty // , 0 19.50' OWNER OF RECORD: WILLIAM & LOIS SCRUFUTIS (2) �� '` ADDRESS: 62 FIVE CORNERS ROAD CENTERVILLE, MA 02632 4 FsII FEMA FLOOD ZONE C DESCRIPTION HC 1 HC 2 EXISTING LEACHING PIT TO � ` +, i AS SHOWN ON COMMUNITY PANEL# 250001 0016 D BE PUMPED AND FILLED N LEACHING CORNER(1) 35.0' 17.2' WITH CLEAN SAND MAP 168 ,/ j � •�, ;�"` 7r�-� � � ,+ 17. PLAN REFERENCE: LEACHING CORNER(2) 64.3' 21.4' 50" 15.33' 1. LAND COURT PLAN 31043-A PARCEL 34 Loam Sand EXISTING "'D"-BOX TO BE N/F PAN ITZ :�/ fl 8 B 10 YR 5/6 18. DEED REFERENCE: LEACHING CORNER(3) 67.0' 29.0' REMOVED MAP 168 t( * 1 - � 65" 14-08' 1. LAND COURT CERTIFICATE 107929 70" 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. LEACHING CORNER(4) 39.8' 26.1' r`i 13.6T PARCEL 38 � . ,1�` �` ,r-' e EXISTING 1000 GALLON N/F WAUGH I • 1►II Q * Perc 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY Z SEPTIC TANK I MZc[xh I . �+ O\ `� .; 88" Medium Sand 12.17' FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERINC WILL NOT ASSUME ANY LIABILITY SWING TIES w 1 Pow ,',f l� �" ** • • Jf *�, , Y C-1 2.5Y 6/4 FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. SCALE: 1"=20' > EXISTING PLUMBING EXITS STK.TK./FND �t Q �� • ., Adjusted a- BASEMENT BELOW SLAB _ 110 10.33' Groundwater 0 w LOCUS PLAN w 1 N84'57'40"E 132 8.50' \ 151.54' Medium Sand I n = REMOVE AND REPLACE UNSUITABLE _ SCALE: 1" 1000' C-2 2.5Y 611� MATERIAL TO ELEVATION 14.08' WITH CLEAN COARSE SAND G GAS 22 DESIGN DATA 162" 6.00' LEGEND f �AS EXISTING CONTOUR < EXISTING - NUMBER OF BEDROOMS (ASSESSORS) 3 DRIVE / NUMBER OF BEDROOMS (DESIGN) 3 50 PROPOSED SPOT GRADES � MAP 168 ir i= _ I DESIGN FLOW 110 GAUDAY/BEDROOM L � #62 MAP 168 �5o PROPOSED CONTOUR PARCEL 33 TOTAL DESIGN FLOW 330 GAUDAY GROUNDWATER ADJUSTMENT N to W J I EXISTING PARCEL 39 � � N/F BRESKI DESIGN FLOW X 200 % = 660 GAUDAY EXISTING OVERHEAD UTILITIES GALLON SEPTIC TANK FRIMPTER METHOD Z w - �, 3-BEDROOM 15,252 S.F. ± rn USE EXISTING 1000 ( ) ir 9 o `n DWELLING �� n EXISTING WATERLINE O 3 ' rn -' DEPTH TO WATER OBSERVED: 162" U o TR = INSTALL FOUR "LC-6" INFILTRATION CHAMBERS INDEX WELL: MIW-29 GAS - -- EXISTING GASLINE r TOF=26.13' j � n 19x50 = �,,r � SLAB = 19.13' SIDEWALL CAPACITY ZDONEH TO WATER: 8.31'(PLEB. 200D4) TEST PIT LOCATION - ' DECK LENGTHx2 +WIDTHx2 DEPTH 74 GPD/S.F. - GAUDAY ADJUSTMENT: 4.3'(52") ( )(DEPTH)( )- DEPTH TO SEASONAL p p EXISTING 1000 GALLON SEPTIC TANK �10.5' 10.0� (30'x 2 + 11'x 2)(1.5')(.74 GPD/S.F.)= 91.0 GAL/DAY HIGH GROUNDWATER: 110" 18"OAK ^8'3. BOTTOM CAPACITY 4"SOLID SCHEDULE 40 PVC PIPE (LENGTH x WIDTH) (.74 GPD/S.F.) = GAUDAY ❑ DISTRIBUTION BOX 00 (30 x 11 ) (.74 GPD/S.F.) 244.2 GAUDAY �� 500 GAL. LEACHING CHAMBER uF J I TOTALS�2-10" •sr o 0"E / TREES N87 020 152.23' � STK.TK./FND TOTAL LEACHING AREA 453 SQ.FT. SYSTEM CAPACITY 335.2 GPD PROPOSED "D"-BOX B.M. Nail in Utility Pole W Elev. =20.00' SSE REV. DATE BY APP'D. DESCRIPTION � PROPOSED 4-"LC-6" LEACHING CHAMBERS PARCEL 32 1 .5j��\N � PROPOSED SEPTIC SYSTEM UPGRADE Assumed MAP 68 }p�R� 0 EXISTING LEACHING PIT AND SPOILED MAP 168 N/F QUEENEY ��` _ !f ��S�R\G PREPARED FOR: Uj 1 SOIL TO BE PUMPED, REMOVED AND PARCEL 40 SCRUFUTIS W FILLED WITH CLEAN SAND N/F SMITH O��P�GE / LOIS _��'' LOCATED AT EXISTING WATERLINE TO BE RELOCATED"` ., __ __ _ � 62 FIVE CORNERS ROAD CENTERVILLE, MA 02632 RESERVED FOR BOARD OF HEALTH USE SCALE: 1 INCH = 20 FT. DATE: MARCH 10, 2004 0 10 20 40 80 FEET OF�{cS s� JOHN L. y PREPARED BY: *THIS PROPERTY NOT LOCATED WITHIN A DEP APPROVED ZONE II. o CHUR JfR.HILL JC ENGINEERING, INC. CML 4 No 181F3G7 2854 CRANBERRY HIGHWAY x� EAST WAREHAM, MA 02538 SITE PLAN '� � .� � 508.273.0377 SCALE: 1"=20' Drawn By: MLP Designed By:MLP Checked By:AC JOB No.623