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HomeMy WebLinkAbout0072 FIVE CORNERS ROAD - Health 72 FIVE CORNERS RD., CENTERVILLE A=1G8-038 i �J�0.ECVCtFp�0 /N s UPC 12543 No 5. � ��Sf.CON`'JJ HASTINGS. MN - � � a TOWT'OF BARNSTABLE LOCATION �oZ T 1 CG f SEWAGE# 26 ZO VILLAGE ASSESSOR'S MAP.&PARCEL &.6 p3A INSTALLER'S NAME&PHONE N01' ErL.ic SEPTIC TANK CAPACITY 2000 QA1- . ff7^ ' LEACHING FACILITY:(type) �P. 1 �� T (size) X/3 NO.OF BEDROOMS OWNER tJf PERMIT DATE: COMPLIANCE DATE: Separation Distance Be een e: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 23 Y AZf t�� oD Q Zr.3 , z T+D'INt O B4J�NST LE. � a " 5�'SSEW�iGIE a `crs ----�-.-:---= VILLA rd WSTA.UxR NAME 'MOM NO. - $"G TAX&CAIPACM o LEACIwo PAC1➢LYTY (rdze� a X. �° " 190..,CDk�� . �6JILttFIZ OR 0 IWNER41 Sipptu�tso��9is�nnaa Bstviesn the; � ,,. :: M xiuni m Adjusti d Grau�dw�ter'Csble�o tl�G Bottom Off .ac4MO ,,I I.Y." rely a lfttor upply Wilt aad eaa6�ing paaitet any wells exist atxset ce uvitWn?,Op'fecit a 1 acitipg taeft). we!{aflds exist Es c�t.�let9and and LoHcblac Iicy _ fee wlitasSflO"fee ag P tplleacbfus�uilityy 1C�urni3hed blPl �rv,,,,+ � , , 0 P r t .A i o o pr o � 5 �''" SEWAGE V y rE e e rO INS'TP . M S.NAME&PHON NO SEPTEC TALK imq icrry LEAC�IIrTG FACB.�'l'� tom) No.OP-70FDROOMS ,. BUTMOER os ()W a FERR ITDATE. CC31V€PL ►NCfi MA. Separation Distance getwesn:�e Feet tviaxiatum Act ustesl Groundwater Table to t5e$ottom o.fLeaching Fac l;ty 7 Private Watar Supply well andLeae3 ng Facliuy f�Y v�elb exist' Feet as sacs or unth�n 20p feet a Iesstimtg fac �y) Edge of Wetland and Leachfg#%aa'tity{If any wetlands exist Feet withtst 3©0`feet aleactung facttity) r 1 Furashed by__ /' f' �raG� t la 1 Q � ! r o a ' j I � d� s /� � No. 9 0—.5 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWWO.F BARNSTABLE, MASSACHUSETTS 0(pplication for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �a w��'prt,�pg (Z�, Owner's Name,Address,and Tel.No.W►411,t+y-- '►'ar C£1�9ig-I�v►�\ i W119 '72Z fv-t v`� Cer -5 �y' ��^�tr�rV� 'W�►o-� Assessor's Map/Parcel , (T 03 L Installer's Name,Address and Tel.No. G%a1�51�11"us Designer's Name,Address,and Tel.No. � lop, P� .X 1 t wi r W1f ,- k2.5ls. �-�c 9 ► s�4n ,c� VhWsg 3Fs0— �1 Type of Building: Dwelling No.of Bedrooms 77 Lot Size 301 sq.ft. Garbage Grinder( ) Other Type of Building eC5 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '776 gpd Design flow provided ��( �(' gpd Plan Date l`I�d 1 2® Number of sheets Revision Date Title Size of Septic Tank q,4 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ZQ w Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. — Date Issued J 'v o No g Fee / CJ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I/"`'rn PUBLIC HEALTH DIVISION - TOWI�.OF BARNSTABLE, MASSACHUSETTS Yam_ +. Rpplication for �i8tl08aY.�pBteln Construction 3permit Application for a Permit to Construct Repair Upgrade Abandon pp ( ) p ( ) pgr ( ) ( ) ❑Complete System ❑Individual Components 3 Location Address or Lot No.-7;� cot h%� %A_ Owner's Name,Address,and Tel.No. P VV\CQf rt- Ell Assessor's Map/Parcel , 6 TO 3 8" Installefrr's Name,Address,and Tel:No. (j�7p_jL 51UIJ15 Designer's Name,Address,and Tel.No. � �?O, �3axll 4 Y5�b.. (�14�S h'►��5, 1jkA 9 6E G. w IL Type of Building: Dwelling No.of Bedrooms "7 Lot Size ,�01 sq.ft. Garbage Grinder( ) Other Type of Building eGS No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 70 gpd Designn flow provided W6,77 6 gpd Plan Date !j1_�o 12 en Number of sheets Revision Date Title tt Size of Septic Tank 2000 Cep Type of S.A.S.a 9_150 4 �,i.,�,yd- ►y'� �(„� Description of Soil Nature of Repairs or Alterations(Answer when applicable) QfaAk e Date last inspected: '?QZ_C:) Agreement: d The undersigned agrees to ensure the"c'nsti uc rion and maintenance of the afore described on-site sewage disposal system in *' accordance with the provisions of Title 5 of heew onmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Health. / ! ' Signed Date Application Approved by ti, / Date A..", 31 r=*) Z) Applicat on Disapproved by Date 4 for the following reasons Permit No. --46 1� Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS >• Certificate of Compliance ^ THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by EP-Nc 5V&jr_A)_s at 7 Vr je-, Cor vw y-% f% has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Np;Z dated Installer Z>Q.1 G. ST-SOLpa-'4. Designer Mf_W6?_ #bedrooms w Approved design flow ��t . gpd The issuance of this permit shall not be construed`as a guarantee that the system +will funs'n,aass less g ed Date % 4Inspector \ �•_,_ �...- r' K. No. Crht i ( ._. Fee / t _Y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstrin Construction 'ermit _ Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at "7a �-`tfp Cr and as described in the above Application for Disposal System Construction Permit. The`applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must,be completed within three years of the date of this permit. '' Date Approved by � Town of Barnstable Regulatory Services Richard V. Scali, Interim Director K Public Health Division 1639. �, � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 I Installer&Designer Certification Form Date: Aikq1z16Sewage Permit# Assessor's Map\ParcejLSL'3 9 Designer: f�/ ( /L� C., Installer: r--STy&AS C&x sTr UCTI&ryA -U• Address: Iro Address: On Z '+ -CRi c, was issued a permit to install a (date) nstaller) septic system at L Y L based on a design drawn by (address) r � dated ( (designer) MLA ,e,rS I certify that the sdptic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA approval letters (if applicable) of DARREN Ins igna (Designer's Signature) (Affix ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH D rONCERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certificarion Form Rev 8-14-13.doc I �►1 �1111��■ I� ��7��JILJIuu—� 72 5 Corners Road, Centerville, Massachusetts. _ 0 Site Location List of Symbols Drawing List so Architectural 5 Smoke Detector Sheet Number Sheet Name Sheet Number Sheet Name sDco Smoke/CO Detector Aaoo Cover Page A300 WlntlawaDoarceWila �` ��. 9} A100 Existing L—Level Mn 11100 P.M.n Types A101 Propoxtl Laxer Level Plan A500 Typ cal Sfa r Details J' A102 Existllg F rst Floor Pk. A600 Typ cal Roo/DeWih I f }' Bathroom Exhaust Fan A103 Propaxtl First Fr PWn Afi10 Typical Roof Details II ®nsran weed'` '^° Fbo Al0 Exrstirg SecorN Fbor PWn ,r euma'4'A A105 Propoxtl Sewntl r Plan A200 E[is South EWvet'an t A201 PropoxE South Ekvatwn Structural A202 EAWhg West EWvahan A203 Proposetl West Elevat on Sheet Number Sheet Name a A20a E%Isgng North Elevators ® �.r A205 Propoxtl NOM1h ElevVn 5100 First Floor framing Skuavaiea A206 Evism East El—Wn 5101 Semntl Fbar Framing Pover N1ltllik -Y-' A207 Proposetl Eesl Ekv-Wn I S102 Rool Frammg .w�s.mea a g avb. No. Description Date 72 5 Corners Road, Cover Page Project number Project Number Centerville, MA. Date 11/06/2)20 A000 Drawn by Author Checked by Checker I Scale 31 A205 1 17'-9" 8'-0" 10'-2" O 0 ® Finished Battment N —— �� r A203 1 ® e= srorase 1 A207 0 U 20'-1 1/2" 3'-1 1/2" 14'-0" 1 A201 No. Description Date II 72 5 Corners Road, Proposed Lower Level Plan Centerville, MA. Project number project Number Date 11/06/2020 A 1 0 1 Drawn by Author Checked by Checker Scale 1/8"=1'-0" D -A205 1 DN Deck DN I 17'-31/2" '-0"3'-0" 18'-6" 5'-6" 14'-0" M,rer C oB� Bedroom DN M -Ck- Laundry — _ 0 A203 1 BD ® Oioing 1 A207 Bedroom N —u— 2 UP 17'-10 1/2" o umng or Room f0 Porch DN 23,-0" 1 A201 No. Description Date Proposed First Floor Plan 72 5 CornersRoad, Centerville, " A. Project number Project Number / Date 11/06/2020 A103 Drawn by Author Checked by Checker Scale 1/8"=1'-0" A2os 1 19'-11/2" 3'-6" 19'-01/2" 5'-0.' 14'-0" I I - v CL O Fatuity ® �' Bedroom V Bedroom Room I N — N o DS a FOE]1 ---� " cc 1-4 A203 1 ® wa.c. m 1 A207 as I ee Bedroom v 24'-5" 14'-0" ao nu��er Bedroom v 23'-0" 1 A201 No. Description Date Proposed Second Floor Plan 72 5 Corners Road, Centerville, MA. Project number project Number Date 11/06/2020 A105 Drawn by Author Checked by . Checker Scale 1/8"=V-O" _ Roof 24'-2" ®® ®® ®® ®® ®®® ®®® _ Second Floor 9-6" ®® MON MON ® ®®® ®®® El I ( - -� -1 —III —I � —� III— - -- 0 0 -� I —I �—III—L i r 11 I—I 11 1 I 1—I I I—I I I-1 I M I I-1 I —I 1 —1 III I —1 — —_ _ _ Lower Level � H-f—�H�-1 I1--H1 H�--F-��� I —= I I—�-O .III1 I I_III=1 I I1 I I=1 I I1 I I-1 I I1 I I1 I I-1 I I1 I I1 I I=1 I I1 I I1 I I=1 I I1 I IIII=1 I I1 I I1 I I=1 I I=1 I I1 I I1 I I-1 I I-1 I No. Description Date Proposed South Elevation 72 5 Corners/Road, Date „/os/2o2o Centerville, " A. project number project NumberA201 Drawn by Author Checked by Checker Scale 1/8"=1'-0" — Roof 24'-2" Second Floor 9'_6" FFM First FIoQr =III=III=III=III=III=1 1=III=1 1=III=III=III=1 i 1=III=III=III=III=III=III=III=III=III=III=III=II 'El II1��ME Gr e _I III III III III III III III III I I I III I I I I I I I I I I I I I I I I I I I I I I I I I I I o'-o" -IIIIII=III—III=IIIIII=IIIIII—III=IIIIIIIII—IIIIIIIIIIII—IIIIII—III—IIIIIIIII—IIIIIIIIILower Level =H l � I�-�H=H � _ _T_3" � No. Description Date 72 5 Corners Road, Proposed West Elevation Centerville, MA. project number project Number Date 11/06/2020 A203 Drawn by Author Checked by Checker Scale 1/8"=1'-0" Roof 24'-2" Second Floor 9'-6" RFirst Floor _ _ _ _ _— T IIE111 Grp e III—III LEI I I—I I I I I I—I I I I I I I I I I I I—I I I I I M I I—I I I I I I I I I—I I I-0. I°'- — —� I - -� —II —III—I I I—II —� —I -1 I I_=I I El I 1_1 I 1_1 - -II — =I I MII111=III= Lower —owI erIeye1 -ylI H_= I F' 1 I� _ 1_I I I I II 1 1 1 1=I I I I I No. Description Date 72 5 Corners Road, Proposed North Elevation Centerville, MA. Project number project Number Date „/os/Zozo A205 Drawn by Author Checked by Checker Scale 1/8"=1'-0" Roof 24 -2" Second Floor 9'-6" First Floor 0' —i— � No. Description Date 72 5 Corners Road, Proposed East Elevation Centerville, " A. Project number project Number / Date 11106/2020 A207 Drawn by Author Checked by Checker Scale 1/9'=1'-O" A2oa 1 17'_9" 8'-0" 10'-2" up Baen.00m to 0 N r A2�2 1 CL Beamom o 1 A206 17'_9„ _p., 17'_6" 1 A200 No. Description Date 72 5 Corners Road, Existing Lower Level Centerville, MA. project number project Number Date „/o6/Zo2o A100 Drawn by Author Checked by Checker Scale 1/8"=1'-0" A204 1 3'-0" 18'-6" 6'-0" 13'-6" UP CI. Bathroom o Bed—rn o rooster Bath— Kitchen 3'-0" 16'-6" br aeeroom o cl. ct DN a ct a. V3 Dining O A202 1 Master BWKJIauM ap' Bathroom Room N (D 1 A206 Be4rOOm Bedroom Llvin9 IT-1"- _ 10'-3" 10'-8" 7 Room &D 23'-0" 1 A200 No. Description Date 72 5 Corners Road, Existing First Floor Plan Centerville, MA. Project number Project Number Date 11/06/2020 Al 02 Drawn by Author Checked by Checker Scale 1/8"=1'-0" A204 5'-6" 14'-0" 12'-0" 11'-41/2" 14'-11" H CL cL a'-0 1 A206 16'-31/2" T-0" 14'-0" u N CJ � Bedroom t` 14'-0" 1 A200 No. Description Date 72 5 Corners Road, Existing Second Floor Plan Centerville, MA. Project number project Number Date 11/06/2020 Al 04 Drawn by Author Checked by Checker Scale 1/8"=1'-0" -.s Roof— - - - 20'-5 7/32" /1 Second Floor — - - - 9'-6„ -710 First Floor III- III-IIIIIIIII-IIII -__ ___ _ _ Gr e 1=III=IIIIIIIII-IIIIII-I I I-I I I-I I II I I-I I II I - _- 0' 0" IIIIII-III-III-IIIIII-III-III=IIIIII-IIIIIIIII-IIIIII-IIIIII-III = - -_ _ W0 , wer Leve 1 _2 3/4" =1 I I1 I I=1 I I-1 I I1 I I=1 I I1 11=1 I I=1 I I=1 I I1 I I=1 I I=1 I I1 I I=1 I I=1 I I_III=1 I I=1 I I=1 I I1 I I1 I I=1 I I1 I I1 I I1 I I=1 i i-i i i1 No. Description Date 72 5 Corners Road, Existing South Elevation Centerville, "/A. Project number Project Number A200 Drawn by Author Checked by Checker Scale 1/8"=1'-O" _ Roof 20'-57/3 Second Floor — — — — — — — — — — — 9,-s — First Floor III=III=III=III=III=III=III=III=III=III—IIII—III—III—I I— IIIIII—III—I .I—I IIII—IIIIII—I.I I—I I—III Gr e III=III—IIIIII—IIIIII—III—III—III—III—III—IIIIII—IIIIIIIII—IIIIII—III—IIIIIIIIIIII—III=1 I II I o -o III=I I Eli I I=I I I—I I I—I I I I I—III I I M I I—III III—III I I I—I I I I I I—I I I I I I—I I I—I I I-1 I I—I I I I I I—I I I III—I ILower Level =1+I=1-� H H H=�I+-+I H f-1=I 1=1 H +I H H=�I H H� I I H={F+�-�I H N=�11 1 -7'-2 3/4" � [=Mil_I I I=I I I I I I I=� �_� �_� �_� �_� �_� �_� 1 I_� �_I I I=T l_� 11_f �_� 1 I=III=III=III=I I ' I I=III=111- No. Description Date 72 5 Corners Road, Existing West Elevation Centerville, MA. Project number Project Number Date „/06/202o A202 Drawn by Author Checked by Checker Scale 1/9'=1'-0" Roof n — — — 20'-57/32" Second Floor 9'-6" First Floor — — T — IIIIIIIIIIII—III—Gr 1711711 I—I I =I I I I I I_I I I—I I I _I I I I I I—I I I—I I I I I I_I I G I I—I I I—I I MI I I I I I-0 O"= =III=III=III=III=III III=III 1 =III=III=1 I I=I I I=I I I—I I I=I I I=I I I—I I I=I I I=I I I I I I—I I I=I I =I 10 I =I I I=I I E 1 1 I 1 I I �er Level HI1 +H II 2 i4 1-1 -+ " No. Description Date 72 5 Corners Road, Existing North Elevation Centerville, " A. project number project Number / Date 11/O6/2020 A204 Drawn by Author Checked by Checker Scale 1/8"=1'-0" _ Roof 20'-5 7/32" Second Floor 9' 6„ First Floor ® — Gr e —0'-0' � I � � ��-Lower_ _ Level . _ _ _ _ _ _ _T-12 3/ No. Description Date 72 5 Corners Road, Existing East Elevation Centerville, MA. Project number Project Number Date 11/06/2020 A206 Drawn by Author Checked by Checker Scale 1/8"=1'-0" f �L Fee$50 .00 No. t/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for Miopool *pgtem Con5truction Vermit Application for a Permit to Construct( )Repair(x4 Upgrade( )Abandon( ) []Complete System ❑Individual Components Location Address or Lot No. 72 Five Corners Rd Owner's Name,Address and Tel.No. 4 2 8—8 0 9 0 Assessor'sMap/Parcel Centerville, MA Chris Bartlett . ) 72 Five Corners Rd, Centerville, - PA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service PO Box 1089, Centerville, MA 0263 Type of Building: Dwelling No.of Bedrooms 4 5 Lot Size sq.ft. Garbage Grinder(no) 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 Size of Septic Tank Type of S.A.S. Description of Soil Gan Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic Repair con— .sisting of 1500g tank, D—box, and five stonepacked maximizers. 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 issue by th' Bo d of Healt Signed Date Application Approved by Date ®" , Application Disapproved for the following reasons Permit No. Date Issued �� --------------------------------------- No. / Fee$5 0.0 0 S THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer ✓ t Yes PUBLIC HEALTH DIVISION - TOWN OF_BARNSTABLE., MASSACHUSETTS 2pplication for Mie;paal *p$tem Congtruction Permit Application for a Permit to Construct( )Repair(XN Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7\2 Five Corners Rd Owner's Name,Address and Tel.No. 4 2 8—8 0 9 0 Assessor'sMap/Parcel Centerville, MA Chris Bartlett c2rAr 72 Five Corners Rd, Carterville, MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. ; W E Robinson Septic Service PO Btbx 1089, Centerville, MA 0263 Type of Building: Dwelling No.of Bedrooms 4/5 Lot Size sq.ft. Garbage Grinder(no) 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 Size of Septic Tank Type of S.A.S. ` Description of Soil sand t Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic Repair con— sisting;�of 1500g tank, D-box, and five' stonepacked maximizers. 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's of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has beewis by th' Bo d of Healt Signed- sue Date Application Approved by Date " Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS Bartlett BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired(XXXUpgraded( ) Abandoned( )by at 72 Five COrnbes Rd Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. g?- ,? dated ;r 7- J �. Installer W E Robinson Sept SrV Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 'y Inspector S, 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Bartlett lwigozaf *potem Conotructton Permit Permission is hereby granted to Construct( )Repair(XX)Upgrade( )Abandon( ) System located at 72 Five Corners Road Centerville, MA Installer: W E Robinson Septic Service 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. I Provided'Construction must be completed within three years of the date of this rmit. Date: Approved b �' J NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated a v2�7 2 C� concerning the property located at 72 Five Corners Road, Centerville, MA, meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in flow and/or change in use proposed. * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) 7 B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: 14_11 DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). 0`6 GA�' TOWN OF BARNSTABLE /,f �U LOCATION '�; t-l�'Yr: (`;c�l%y�h'.S- �l SEWAGE # ZZ VILLAGE ASSESSOR'S MAP &LOT . b- . INSTALLER'S NAME&PHONE.NO. ,.a ael 6Nsa�r/ 77S - ff 77 C SEPTIC`TANK CAPACITY LEACHING FACILITY: (type) .�S' �/ X S (size) NO.OF,BEDROOMS a9 r S7 BUILDER OR'OWNER PERMTTDATE: � 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 leaching facility) Feet Furnished by i 6)(x S f Sfiok � /w/d FO W✓� (J //�J Commonwealth of Massachusetts �/ ,w Title 5 Official Inspection Form i�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments igbf�Gn1 �� z; .�._� 72 Five Corners Rd (System 1 of 2 Back) Property Address en. Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) .r Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 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. A. Inspector Information 64 1L1,* - Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth , MA 02536 City/Town State . Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000);1 have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11-13-19 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 1 f c Commonwealth of Massachusetts Title 5 Official Inspection Form r� p c�li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � !oI 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 ears old is available. p 9 Y ❑ Y ❑N ❑ ND (Explain below): t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts r� ;w Title 5 Official Inspection Form rai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form C�,4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. []The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) stem S Failure Criteria Applicable to All S Y pp stems:Y You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form i-Il Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Z 1 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632_ 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ; ,µ Title 5 Official Inspection Form C-► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of El ® 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form i;i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville - MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 L c Commonwealth of Massachusetts Title 5 Official Inspection Form -M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 lie- Commonwealth of Massachusetts Title 5 Official Inspection Form ? i;l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4-5 Number of bedrooms (actual): 7 Total for house DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail' Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 'C�'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Centerville MA 02632 11-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ail Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. 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.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form wa ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VI> ' 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form 1o1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C•__ ,r: 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 r Commonwealth of Massachusetts s r� 4 Title 5 Official Inspection Form ► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page.e. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): Good condition with water at working level and no sign of back-up. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5-MXH's 11'x50' ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts r, ,w Title 5 Official Inspection Form !'I ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition and empty at inspection with no sign of back-up into d-box or surrounding stone. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form wa ! r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . . 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' -ll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) J" Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately .......... "g ," a 3 _ 01 ycito ej 5 6 -3 - A a. 67 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 'I s Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 1 of 2 Back) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included . t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Ln .m� o CE) OFFICIAL- USE cI3 Certified Mail Fee Extra Services&Fees(check box,add fee as appropriate) ❑Return Receipt(hardcopy) $ 0 ❑Return Receipt(electronic) $ -n2j�S 'pcostmark .❑Certified Mail Restricted Delivery $ i G09Z�Here 3 ❑Adult Signature Required $ 77 i r-I&Adt Rinnaturn Ra4rlcted Delivery$. 6 O" _ rti r 5 WAUGH, EDWARD J ESTATE OF C/O CALIBER HOME LOANS INC"$�Ln I r-1 L 13801 WIRELESS WAYZ b` OKLAHOMA CITY, OK 73134 N V PS Form 3800,April 2015 PSN 7530-02-000-9047 See Reverse for Instructions Certified Mail service provides the following benefits: •A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate •Electronic verification of delivery or attempted return receipt for no additional fee,present this , delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. _ signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent Important Reminders: Adult signature service,which requires the - ■You may purchase Certified Mail service with signee to be at least 21 years of age(not =,.. First-Class MailO,first-Class Package Service®, available at retail). T- or Priority Mail®service. Adult signature restricted delivery service,which I ■Certified Mail service Is notavailable for requires the signee to be at least 21 years of age international mail, and provides delivery to the addressee specified ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent" with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a- certain Priority Mail items. USPS postmark.If you would like a postmark on ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the maiiplece,you may request Certified Mail item at a Post Office'for p:.. the following services: postmarking.If you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply _ You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Retum Receipt•attach PS Form 3811 to your'mailpiece; IMPONTANT.Save this receipt for your records. Ps Form 3800,April 2015(Reverse)PSN 7530-02-000.9047 SENbER-'COMPLETE THIS SECTION C• PLETE THIS SECTION ON DELIVERY n complete.iferri'at''"and 3. A. Signature 0 Agent N Print your in - address on the reverse MR x ❑ 0 Addressee so that we can�eiui'�Fihe card to you. 0 Attach this card to the back of the mailplece, B. Received by(Printed Name) C. Date of Delivery or on the front if space permits. I 'iddress different from item 1? OYes it delivery address below: ❑No li WAUGH, EDWARD J ESTATQW- C/O CALIBER HOME LOANSING 5 13801 WIRELESS WAY DEC 0 2019 _17-CKLAHOMA CITY, OK 73134 3. Service Type 0 Priority Mail&press@ 0 Adult Signature 0 Registered MajlTM 0 Adult Signature Restricted Delivery 0 Registered Mall Restricted 0 Certified Mail® Delivery 9590 9402 5357 9189 1974 93 0 Certified Mai Daivairy .Restricted Return Receipt for 0 Collect on Delivery Merchandise y 11 Signature ConfirmationTM 2—Artil.-Num r-?Ransfer from service label) 0 Collect an Delivery Restricted Deliver 7be _ _Insured Mail El Signature Confirmation 015 1730 0001estriceevery Restricted 4988 3 11 Restricted Delivery Delivery PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Ret -Receipt 4 Ll T -. First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9402 5357 9189 1974 93 United States •Sender:Please print your name,address,and ZIP+4®in this box* Postal Service Town of Barnstable d Health Division � 200 Main Street i Hyannis,MA 02601 j d.idi ldl'r I d . i li Id , i i ,dlidldl dlll►i d i I 1 i'�l 11!Jill i I �IIIJ� l�ll I t11aJ l�1.1li � it _ - Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name / information is required for every Centerville J MA 02632 11-13-19 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. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails 11-13-19 In ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwrealth'& Massachusetts ,w Title 5 Official Inspection Form il Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rr' 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes.: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 s Commonwealth of Massachusetts 3 Title 5 Official Inspection Form i�li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,�� �•'n 9 p Y rY 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy cLD Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 7 Total for house DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 L Commonwealth of Massachusetts ' r� Title 5 Official Inspection Form w: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . . 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts 1 � Title 5 Official Inspection Form I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �._ 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Centerville MA 02632 11-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): Precast pit with leach line Approximate age of all components, date installed (if known) and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 36"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.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form F�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 24"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: 6x6 precast pit Sludge depth: 0 Distance from top 9 of sludge to bottom of outlet tee or baffle N/A Scum thickness 0 Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Precast pit acting as main tank shows signs of being filled beyond capacity and into riser. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts ;w Title 5 Official Inspection Form I�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r e ': •T ;>rJ 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy cLD Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of i nspecti on)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I� w:• Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 C ` Commonwealth of Massachusetts M. ,'. Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �G•;_ jr 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-10'x2'x2' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 T s Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form i.I. I� ws ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Q-4 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach line shows signs of being filled beyond capacity and backing into holding tank. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�._� 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts 3� Title 5 Official Inspection Form in► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 2 of 2 Side Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5insp.doc+rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form �I�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V ; 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form "l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Five Corners Rd (System 2 of 2 Side) Property Address Hudson Homes Management LLC (Contact Maiza Eloy @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 11-13-19 page_ City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: P rY 1, 2, 3, or 5 completed as appropriate 4 (Failure,Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Town of Barnstable Inspectional Services Department HOW STAOM 6'9 ,� Public Health Division rf° s 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 1357 December 2, 2019 WAUGH, EDWARD J ESTATE OF C/O CALIBER HOME LOANS INC 13801 WIRELESS WAY OKLAHOMA CITY, OK 73134 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The second septic system, located on the side of the house, at 72 Five Corners Road, Centerville, MA, was inspected on 11/13/2019 by Shawn McElroy, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. P ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\72 Five Corners Road System 2 of 2 Centerville.doc Town of Barnstable + ,WMNSPABLE + �, a 3,639 Inspectional Services Department . 1em AT fD MA'S A Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool { ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) (Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER c / � ❑ MU� �U�e- �'�"'S � S C� SyS��^'� -� 2-� D� Si02 o� �o�S2 Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc ,per COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 72 Five Conners Rd. Centerville Owner's Name: Edward Waugh Owner's Address: same Date of Inspection: Name of Inspector: (please print) W i 1 1_jam E_ . Robi_nson Sr. Company Name: William E. Robinson -Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: ( 5 0 8) 7 7 5—8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Sec ion 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _ Date: 7 i-/ —O Z The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l r. r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 Five Conners Rd. Centerviiie Owner: Waugh Date of Inspection: O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy;tem Passes: t//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. mments: B. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repa' ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please exp in. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally sound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the e 'sting 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 ind Gating that the tank is less than 20 years old is available. ND xplain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with app val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 trm a year due to broken or obstructed pipe(s).The system will p inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND xplain: Paga 3 of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 Five Conners Rd. Centerville Owner: Waucrh Date of Inspection: - - 6 .1 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 fa ing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. ystem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the Sys em 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 front a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 K - a Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 Five Conners Rd. Centerville Owner: Wau h Date of Inspection: D System Failure Criteria applicable to all systems: Yo 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 _ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. L rge Systems: To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You in st indicate either"yes"or"no"to each of the following: (The fo lowing criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ e system is within 200 feet of a tributary to a sm f=drinking water supply he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped one II of a public water supply well . If you ha'e answered"yes"to any question in Scr nn E the system is considered a significant threat,or answered "yes"in e, n D above the large system has failed.The owner or operator of any large system considered a significa t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. he system owner should contact the appropriate regional office of the Department. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address72 Five Conners Rd. Centerville Owner: aug Date of Inspection: 7 3-Q 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 c/ _ 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? V _ 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: Yes /_ Existing information.For example,a plan at the Board of Health. �1/ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 1 5 Page6ofll . l4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 Five Conners Rd. Centerville Owner: Waugh Date of Inspection: v 1-5-0 / FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_f-rNumber of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): L C G Number of current residents: w1a Does residence have a garbage grinder(yes or no):,44 Is laundry on a separate sewage system(yes or no).Wzd_ [if yes separate inspection required] Laundry system inspected(yes or no): A,0 Seasonal use:(yes or no):�i 6 Water meter readings, if available(last 2 years usage(gpd)): 2n o n 1 h 7 ,0 0 gal. Sump pump(yes or no): At O 1999 205,000 gal. Last date of occupancy: C MMERCIAL/INDUSTRIAL T e of establishment: De 'gn flow(based on 310 CMR 15.203): gpd Bas of design flow(seats/persons/sqft,etc.): Gre a trap present(yes or no): Indu trial waste holding tank present(yes or no):_ Non sanitary waste discharged to the Title 5 system(yes or no):_ Wat r meter readings,if available: Las date of occupancy/use: O HER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as padof the inspection(yes or no):A,p If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP,&OF SYSTEM _ eptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): v 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Five Conners Rd. Centerville Owner: Waugh Date of Inspection: 1'3--O / BU DING SEWER(locate on site plan) Depth elow grade: Materi is of construction:_cast iron _40 PVC_other(explain): Distan a from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:zoocate on site plan) 1 " Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 0 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: !—3 ' r , ti Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 'Z ' How were dimensions determined: 0 )� .+✓ T� � l Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): V GR SE TRAP:_(locate on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_fiberglass_polyethylene_other (expla ): Dime sions: Scu thickness: Dis nce from top of scum to top of outlet tee or baffle: ' Di nce from bottom of scum to bottom of outlet tee or baffle: of last pumping: Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as re ated to outlet invert,evidence of leakage,etc.): 7 Page 8 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Five Conners Rd. en ervi e Owner: Waugh Date of Inspection: TI HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dept below grade: Mate al of construction: concrete metal fiberglass_polyethylene other(explain): Dime sions: Capa ty: Rallons Desi Flow: gallons/day Alarh present(yes or no): Al level: Alarm in working order(yes or no): D e of last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Z(ifresent must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 _ evidence of solids carryover, ver an evidence of level and distribution to outlets equal,an e � y (note if box is lee ITY Comments( o Q Y leakage into or out of box,etc.): g K PU P CHAMBER: (locate on site plan) Pu s in working order(yes or no): Al s in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 I Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Five Conners Rd. Centerville Owner: Waugh Date of Inspection: 1-13—® 1 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type aching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): S S D LC �ab L CE POOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Numb r and configuration: Depth top of liquid to inlet invert: Depth f solids layer: Depth scum layer: Dimens ons of cesspool: Material of construction: Indicati of groundwater inflow(yes or no): Comme s(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensi ns: Depth o solids: Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): r 9 Page 10 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Five Conners Rd. Centerville Owner: Wauah Date of Inspection:2fZ�3 —o !' SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. �n `t a � r.J 10 r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address 2 Five Conners Rd. Centerville Owner: Waugh Date of Inspection: 7"b� b 7 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: !Obtained from system design plans on record-If checked,date of design plan reviewed: VO�Observed site(abutting property/observation hole within 150 feet of SAS) ✓Decked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describ how ou established the high ground water elevation: o f 11 TOWN OF BARNSTABLE LOCATION �� (�c� /Y�/I'.S- SEWAGE# Z �T-- �i �- h�,[1 VILLAGE G/��l/T/=n' t -r— - ASSESSOR'S MAP & LOTl4 d. 63R INSTALLER'S NAME&PHONE NO.Jrlls ��'�' •✓ 77S - 77 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /�dX S (size) NO:-OF.BEDROOMS ' 3M B7IL.DER OR OWNER PERIMITDATE: 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 Feet :..'on site or within 200 feet of leaching facility) >rdge of Wetland and Leaching Facility(If any wetlands exist Feet ..:within 300 feet of leaching facility) Furnished by i .JH01S f S, Xfl�j X� t 0 I V i r 9/28/2020 ShowAsbuilt(1700x2200) LOCATION 7a2/ i J e C�`6e^ �d l Sl_S SEWAGE _ _ vu;t AGE l e�,f e:•J l(p ASSESSOR'S W&LAT - INSTALLER S KAi4MA PHONE NO. F, SfiPTiC TATIK'CAPActFX 7 _ LEACFIING FACII I'I Y:(typ:) f/ S • NO:OFB � BUMbER.OR OWNER Fr1ZA2iTDATE COMPLIANCE DATE; Sopamdo.n Mtence Bewsun[bc: tvlaziuut -Ad' sted GrodndvwaterTabte to t6eBottom of LeachmS Facility Fit PmiateWeter,$uPPlYweliandIeachingFac[li[y tlfmry ertUseztst Feet on srte a—'tWn 200€eat of leacbiag fury) Edge:of Wetlan Raefun d end L ITealitY(If any wedtaads exist Fcef widhlo 300 h ct o 6e ping facility) Rutdshedby n• <c Cle }�y7 . 2 AL tQr i 3 _5:a' �f https:HitsgIdb.town.bamstable.ma.us:8431/Home/ShowAsbuiIt?mp=168038&sq=3 1/1 TITLE V CALCULATION CHART COMPONENT 3 BEDROOMS 7EDROOMS 5 BEDROOMS 6 BEDROOMS SEPTIC TANK 1500 Gallons 1500 Gallons 1500 Gallons 1500 Gallons DISTRIBUTION BOX Distribution Box Distribution Box Distribution Box Distribution Box SOIL ABSORPTION SYSTEM: Cultec Recharger 330's 4 (334 GPD) 6 (471 GPD) 8 (606 GPD) 9 (674 GPD) [NOTE:5 are not enough [NOTE:7 are not Cultec Recharger 330's(with 2'stone surrounding SAS)• -provides only 401 GPD] enough-provides only 538 GPD] Cultec Recharger 330's(with 3'stone surrounding SAS) 3 (332 GPDI) 5 (490 GPD) [NOTE:4 6 (569 GPD) 8 (728 GPD) are not enough-provides [NOTE:7 are not enough only 411 GPD] -Only provides 650 GPD] High Capacity Infiltrators 4 (394 GPD), 5(461 GPD) 7(598 GPD) 8(667 GPD) H.C.Infiltrators(with 4'stone and 14 Inches underneath) NOTE:6 are not enough,only [NOTE: 4'stone is not recommendeed,more infiltrator units are recommended] provides 530 GPD Infiltrator Maximizers 5(342 GPD) 7(457 GPD) [NOTE: 6 9(573 GPD) [NOTE:8 11(689 GPD)[NOTE:10 Infiltrators Maximizers(with 2 ft.stone surrounding SAS) are not enough,only 399 are not enough,only are not enough,only 631 GPD capacity] 515 GPD capacity] GPD capacity] Infiltrators Maximizers(with 3 ft.stone surrounding SAS) 4(357 GPD) 6(494 GPD) 7 (563 GPD) 9(700 GPD) [NOTE:5 are not enough, [NOTE:8 are not enough, only 426 GPD] only 632 GPD] Infiltrators Maximizers(with 4 ft.stone surrounding S.A.S.) 3(357 GPD) 5 (516 GPD) 6(595 GPD) 7(675 GPD) [NOTE: 4'stone is not recommended,more infiltrator units are recommended] [NOTE:4 are not enough,only provides438 GPD] 500 Gallon Chambers 4 (395 GPD) 5 (477 GPD) 6 (560 GPD) 8 (724 GPD) [NOTE:7 500 Gallon Chambers/Drywells(with 2'Stone) [NOTE:3 are not enough, are not enough,only 642 only 312 GPD capacity] GPD capacity] �4 500 Gallon Chambers/Drywells(with 3'stone) 3 (384 GPDI) 4 (477 GPD) 5 (574 GPD) 6(669 GPD) 1 'I 500 Gallon Chambers/Drywells(with 4'stone) 2(355 GPD) 3(462 GPD) 4 (570 GPD) 5(677 GPD) [NOTE: 4'stone is NOT RECOMMENDED,more chambers are recommended] Flow Diffusors(with 2'stone surrounding SAS and 12"deep 4(343 GPD) 6(485 GPD) [NOTE:5 7(556 GPD) 9(698 GPD) [NOTE:8 stone on bottom) are not enough,only are not enough,only 627 provides 414 GPD] GPD] Flow Diffusors(with 3'stone surrounding SAS and 12"deep 3(340 GPD) 5(506 GPD) [Note:4 are 6(589 GPD) 7(671 GPD) stone on bottom) not enough,only provide 423 GPD capacity) Leaching Trench 60'X 4' X 2' or(2) 80' X 4' X 2' or(2) (2)48'X 4'X 2' or (2)57'X 4'X 2' or 30'X4'X2' 40'X4'X2' (4)24' X4'X2' (4)28'X4' X2' Leaching Field 446 S.F. (330GPD) 595 S.F. 743 S.F. 892 S.F. ALL MINIMUM S.A.S.SIZE REOUIItEMENTS LISTED ABOVE ARE BASED UPON THREE ASSUMPTIONS (1) No garbage grinder,(2)Class I Soil(0.74 GPD/S.F.),(3)No wetlands within 250 feet of S.A.S.and groundwater is greater than 14'below SAS J:CHARTITV r COMMONWEALTH OF MASSACHUSETTS S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �) DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 WILLIAM F.WELD TRUDY COXE Governor ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 72 Five orners Rd, CentervilAlcWress of Owner: Chris Bartlet Date of Inspection: 3— 41— 9 99 (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: WM E Robinson Septic Service Mailing Address: PO Box 1 089 , Cen Prvi 1 1 P� P.9A 02632 Telephone Numberv,; 5 0 g. 7 7 5—R 7 7 F 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 Inspector's Signature: 4 e l Date: 3 —yam 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: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] S STEM 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. Indic e yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The P system will ass inspection if the existing septic tank is replaced with a conforming septic tank Y as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:ltwww.magnet.state.ma.usldep ej Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 72 Five Corners Rd, Centerville Owner: Bartlet Date of Inspection: 3—�/`% V B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass. inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER VALUATION 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 the publi health, safety and the environment. 1)'M`;'-SYS EM WILL;PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER W ICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTE WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE S TEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIR NMENT: The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or ess than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 72 Five Corners Rd, Centerville Owner: Bartlet Date of Inspection: D] SYSTEM FAILS: Yst indicate ei:•,er "Yes" or "No" as to each of the following: o mu 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. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an 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 112 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a.public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE YSTEM FAILS: You must ndicate either "Yes" or "No" as to each of the following: he following criteria apply to large systems in addition to the criteria above: he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) The ow r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 72 Five Corners Rd, Centerville Owner: Bart let Date of Inspection: :5 9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. Lf _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 Five Corners . Rd, Centerville Owner: Bartlet Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: % g.p.d./bedroom for S.A.S. Number of bedrooms:_ey S� Number of current residents:, Garbage grinder (yes or no):L® Laundry connected to system (yes or no):-.�S Seasonal use (yes or no): /L c> Water meter readings, if available (last two (2) year usage (gpd): 1996 — 130, 000a Sump Pump (yes or no):_,f-0 1997 - 102, OOOg Last date of.occupancy:3^,1/— 9' COMK ERCIAUINDUSTRIAL: Type of tablishment: Design fl w: gallons/day Grease tra present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non-sanit ry waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available. Last da e of occupancy: OTHER: ! escribe) Last dat of occupancy: GENERAL INFORMATION PUMPING RECOR�S and source of information: System pumpe as part of inspection: (yes or no) � If yes, volume pumped: J-0°-d gallons Reason for pumping: Alz cnJ S S TYPE OAF 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 3 --T Sewage odors detected when arriving at the site: (yes or no) /L d (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Five Corners Rd, Centerville Owner: Bartlet Date of Inspection: BUIL ING SEWER: (Local on site plan) Depth low grade: Materi o _f construction: cast iron _40 PVC _ other (explain) Distan a from private water supply well or suction line Dia ter Com ents: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) i Depth below grade: );L � Material of construction: LEoncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: -� -A ) b 9 Sludge depth: O 11 ` Distance from top of sludge to bottom of outlet tee or baffle../ 3 Scum thickness: Q _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:)t� How dimensions were determined: A Li-LA/ 1-:6 < Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) /L L Lc/ d,S'b _6 �'� �� �' s �` b fd c GR SE TRAP: (locat on site plan) Depth elow grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimen ions: Scum t ickness: Distan a from top of scum to top of outlet tee or baffle: Distan a from bottom of scum to bottom of outlet tee or baffle: Date of st pumping: Comments: (recommen ation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, a idence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Five Corners Rd, Centerville Owner: Bartlet Date of Inspection: 3 _V— `3 y T T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locat on site plan) Depth low grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dime sions: Capa ity: gallons Desi n flow: gallons/day Alar evel: Alarm in working order _ Yes, _ No Date o previous pumping: Comme ts: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_✓ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evi ence of solids carryover, evidence of leakage into or out of box, etc.) G�InJ PUMP CHAMBER:_ (locat on site plan) Pum s in working order: (Yes or No) Alar s in working order (Yes or No) Com ents: (note ondition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Five Corners Rd, Centerville Owner: Bartlet Date of Inspection: ,3—V—`? 7- / SOIL ABSORPTION SYSTEM (SAS): i/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition ofyegetatioonn etc.) S /�LJ f�20 S 76 /,u' eceC�o/ CESSPOOLS: (locate on site plan) Number and configuration: 6 Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Com ents: (note ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate n site plan) Material of construction: Dimensions: Depth o solids __ Comme ts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Five Corners:-:; Rd, Centerville Owner: Bartle Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 V) �5 � C 6 6� 1 I 4/S, m 1/ —SG-9_ (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Five Corneres Rd, Centerville Owner: Bartlet Date of Inspection: 3_G/—9 x Depth to Groundwater /�L Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 1//Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) 3--3--9 7 (revised 04/25/97) Page 10 of 10 { LEGEND CENTERVILLE PROPOSED CONTOUR ` ROUTE 28 I ® PROPOSED SPOT GRADE EXISTING CONTOUR . I, + 96.52 EXISTING SPOT GRADE ( W— EXISTING WATER SERVICE _ / t TEST PIT ART �p ti1j4 SCALE: 1"=30' 2 DRAIN LOTS 3 & 4 AREA = 30521 sf+— r LAND COURT PLAN 31043-A JJ7 BUMPS RIVER RD• PROP. 2000G ASSR MAP168 PCL 38 a SEPTIC TANK N�° LOCUS MAP TP® �------ _. LOCUS INFORMATION Ty-2 PLAN REF: LCP 31043-A \ TITLE REF: LCC 224196 PARCEL ID: MAP 168 PAR. 038 < ° g m ° ° ° ° \ ° fig' FLOOD ZONE: PROPERTY NOT IN FLOOD ZONE I , 24-,------- � I BENCH MARK n i TOP OF FOUNDATION SEPTIC SYSTEM 25.32REPAIR PLAN O m I � , BARNSTABIEGIGIS DATU � o ,' LOCATED AT: z 72 FIVE CORNERS ROAD z POLE UTILITY ; CEN TER VI LLE, MA T 20 ft /lJ 24 O /�' o (� \ o , PREPARED FOR m z ' WALBER MOURA 0 22 i,, z z I NOVEMBER 30, 2020 D w Q+ K i Z z U �% Ln LL N J \� OF MAJ O 20 \`` X II X ��,Q�. f9�1 CL w °w O o DAR N . Gi+ a c 1 M Q 1 0. 20 ft QNITAR�a� -1j0 ' PAVED DRIVEWAY ' N -• MEYER & SONS, INC. P.O. BOX 981 22 20 18 PLAN -� EAST SANDWICH, MA. 02537 SCALE: 1 in = 20 ft ' 0 20 40 PH: (508)360-3311 0 t0 20 40 FAX: (774)413-9468 I meyerandsonstitle5@gmail.com SHEET 1 OF 2 J 1894 ELEV. TOP NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS FOUNDATION: BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE (upper) FINISHED GRADE (25.0) = 25.32 a�F.G.EL: 24.50 F.G.EL: 24.50 F.G. EL: 25.20 MAINTAIN 2% MIN SLOPE OVER LEACHING AI�A d F.G.EL: 23.15 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2" STONE OR FILTER FABRIC DOUBLE WASHED STONE e" " 4" SCH 40 PVC :4 10"I s ®®®®®®e a' TEE'S ARE TO BE 14 © S= 1% (MIN.) :g 4" SCH 40 PVC INV. 2,1 .47 2'. EFF. DEPTH ®®®®®®®®®® INV. 21 .87 GAS - INV. 21 .27 qkaW0E 2 X 8.5' 4' EXISTING OUTLET BAFFLE PROPOSED DB 5 INV. 22.32 DISTRIBUTION BOX EFFECTIVE LENGTH = 25' INV. 22.12 Am (H20) INV. ELEV.= 21 .0 PROP. 2,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON ����� OF sf9 BREAKOUT Mg � OUTLET TEE AS MANUFACTURED BY ?� y� o D RREN M. ✓+ ELEV.= 22.0 NOTES: TUF-TITE, ZABEL, OR EQUAL `" TOP CONC. ELEV.= 22.0 1) CONTRACTOR SHALL VERIFY ALL EXISTING N INV. ELEV.= 21 .0 ®® PIPE INVERTS PRIOR TO CONSTRUCTION E31151EAMIENE3 . ,,gyp ®®®®®®® 2) TANK AND D-BOX SHALL BE SET LEVEL AND TRUE `� '�`GJSfE� ®®B®®®® ' TO GRADE ON A MECHANICALLY COMPACTED SIX NITA?0 BOTTOM EL.= 19.Q ®®®E3E3 INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2) 11 2�10I-lu 4' 5 FT. 4' 3) INSTALL INLET & OUTLET TEES W/ SEPARATION 6.15 FT. EFFECTIVE WIDTH = 13' GAS BAFFLE AS REQUIRED SEPTIC SYSTEM PROFILE BOTTOM OF TESTHOLE EL: 13.85 _ SOIL ABSORPTION SYSTEM (SECTION} (500 GALLON LEACH CHAMBER) SOIL LOGS P#: TPT-20-252 GENERAL NOTES: DESIGN CRITERIA **IN ESTUARIES PROT." DATE: NOVEMBER 19, 2020 1- ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL NUMBER OF BEDROOMS: 7 BEDROOM DESIGN - NO PROP. INCREASE IN FLOW SOIL EVALUATOR: DARREN MEYER, R.S., CSE 1614 BOARD OF HEALTH AND THE DESIGN ENGINEER. SOIL TEXTURAL CLASS: CLASS I (0.74 GPD/SF) # 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS WITNESS: DON DESMARAIS, BARNSTABLE HEALTH DEPT. OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS. DAILY FLOW: 110 G.P.D. X 7 BR = 770 G.P.D. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR �►� TP-2 De TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE GARBAGE GRINDER: NO (not designed for garbage grinder) TP-1 Depth Elev. t DESIGN ENGINEER. 24.85 LOAMY 0" 24.95 0" SEPTIC TANK: 770 gpd x 200% = 1,540 gpd, USE PROPOSED 2,000 GAL. SEPTIC TANK A L S3A/N1D A 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING LOAMY S3A/ND FROM ENGINEER THOSEORE SHOWN HEREONNSTRUC SHHALLTION BE REPORTED EES RTED TO THE DESIGN LEACHING AREA REQUIRED: (770)/0.74 = 1.040.54 S.F. 24.02 B 10" 23.95 B 12" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. USE SIX 6 500 GALLON PRECAST LEACH CHAMBERS W 4' LOAMY SAND LOAMY SAND 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF / 10YR 5/8 1OYR 5/8 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF STONE ON ENDS & 3.75' STONE ON SIDES: 59' L x 12.5' W x 2'D 21.93 35" 21.95 36" HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. C C 7. WATER SUPPLY PROVIDED BY PRIVATE WELL. BOTTOM AREA: 59 x 13 = 767 SF 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED PERC TEST MEDIUM MEDIUM TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. SIDE AREA: (59 + 13) X 2 X 2 = 288 SF r: O EL 20.35 SAND SAND 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE TOTAL SQUARE FEET PROVIDED = 1,055 vs. 1,040.54 REQ'D 11 2.5Y 7/3 2.5Y 7/3 THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. DESIGN FLOW PROVIDED: 0.74(1,055 S.F.) = 780.70 G.P.D. vs. 770 G.P.D. req'd 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 13.85 132" 13.95 132" 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY PROPOSED SEPTIC SYSTEM UPGRADE PLAN AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY PERC RATE <2 MIN/IN. (•C2- HORIZON) 13. NO PRIVATE WELLS WITHIN 100' OF PROPOSED LEACHING. 72 FIVE CORNERS RD., C E N TE RV I LLE, MA NO GROUNDWATER OBSERVED 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. Prepared for: Mourn 15. ALL PIPING TO BE 4" SCH 40 O 1/8"/FT (UNLESS SPECIFIED) • I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 Design and Site Plan by: SCALE DRAWN DATE to conduct soil evaluation and that the,above analysis has been performed by me consistent with the MEYER&SONS,INC. N.T.S. DMM 1 1/30/20 requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eva►. Exam in October, 1999. PO BOX 981 EASTSANDWICH,MA02537 REV DATE CHECKED SHEET NO. 50 -M2= DMM 2 of 2