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0008 FOX RUN - Health
8 Fox Run Road ,�. e" .Centerville, A = 227 148 No. 42101/3 ORA IPG R, @0-11 mg u m 10%@ `f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w, s 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owners Name information is required for every Centerville ✓ MA 02632 01/29/2016 page. City/Town = State Zip Code Date of Inspection } M+ Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector key to move your cursor-do not REID C. ELLIS use the return Name of Inspector key. ELLIS BROTHERS CONSTRUCTION ,8y Company Name 23 ENTERPRISE ROAD Company Address YARMOUTH PORT MA 02675 Cityrrown State Zip Code 508-362-6237 S 121891 Telephone Number License Number B. Certification I I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving.authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not founVny formation 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: 1D. &,k kx j &fix- 0)-Awa, A45 B) System Co rtionally Passes: p ' I ❑ One or more system components as des ribed in the"Conditional Pass"section need to be replaced or repaired. The system, upon c mpletion of the replacement or repair, as.approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determin d" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years of *or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration ore Itration 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 il structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less tha 120 years old is available. ❑ Y ❑ N ❑ ND (Explain t elow): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �,. 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operati al. System will pass with Board of Health approval if pumps/alarms are repaired. i B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break o t 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 c f Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or repla ed ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further ev luation by the Board of Health in order to determine if the system is failing to protect public he a h, safety or the environment. 1. System will pass unless Board of alth determines in accordance with 310 CMR 15.303(1)(b)that the system is not fun tioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) �/4 2. System will fail unless the Board of ealth (and Public Water Supplier, if any) determines that the system is functionir g in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil bsorption system (SAS)and the SAS is within 100 feet of a surface water supply or tribut ry 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 pres(nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fai ure criteria are triggered. A copy of-the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters V/ 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 Y2 day flow t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts tl Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owners Name information is required for every Centerville MA 02632 01/29/2016 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No El obstructed 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. 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should cont9tee rd of Health to determine what will be necessary to correct the fa E) Large Systems: To be considered a large syystem must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"o "no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet f a tributary to a surface drinking water supply ❑ ❑ the system is located in a nit ogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped one II of a public water supply well If you have answered"yes"to any question in Sec'on E the system is considered a significant threat, or answered"yes" in Section D above the large sy tem has failed.The owner or operator of any large system considered a significant threat under Secti n E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The ystem owner should contact the appropriate regional office of the Department. isms-3/13 Me 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ff, ❑ Were all system components,�c luding 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? ❑ MZ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms (actual). DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of W Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s. 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. Cityl-rown State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 7W information in this report.) Laundry system inspected? ❑ Yes 740 Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? � ❑ Yes &KNO Last date of occupancy: Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) j Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: -=� 1�i b LA*5 Source of information: Was system pumped as part of the inspection? / d Yes ('5/N0 If yes, volume pumped: gallons How was quantity pumped determined? - d Reason for pumping: -- Type f System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Jet 144.0�14#11 l /— 02- sv � � - o?ao� Were sewage odors detected when arriving at the site? ❑ Yes /- No Building Sewer(locate on site plan)-- Depth below grade: 2H feet Material of construction: El cast iron /40 PVC El other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Ay Septic Tank(locate on site plan): f 14 t10 1� J wo- Depth below grade: tt feet 7Mat ial of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) !� J L vo �� If tank rs i metal, I' tag y '7' Is ag confirm d by a Certificate of Compliance?(attach a copy f certificate) /❑ Yes No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information isequired or every very Centerville MA 02632 01/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness ;C V Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels s relate to outlet inv�rtt evidence of leakage, etc. AA a� Grease Trap(locate on site plan): 4.4 Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fi erglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee o baffle Distance from bottom of scum to bottom of outl t tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official insp ection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, in outlet tee or baffle condition structural integrity, 9 Y, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pump d at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal E i fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float sw ches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate o Itl plan): Depth of liquid level above outlet invert © ° + /� �/V 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_): It aw Lapis 3e }C t'S C D�l� CAL 4-7-0 CA11, Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, co dition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,••r 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11-x-� 46c" E �-110 Type: ❑ leaching pits number: zrl 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,ot ): �Jd4 A/0 -C1100,10,11 4� Cesspools (cessp of must be pumped asp o inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Ins pection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) /� Comments(note condition of soil, signs of hydraulire, level of ondin condition of vegetation, etc.): p 9, 9 , Privy(locate on site plan): WO Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydra ilic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts won Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. C4frown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate whey public water supply enters the building. Check one of the boxes below: hand-sketch in the area below t a� ❑ drawing atta ed separately ,ice �d 14/ jv CS Ck d, a L t5ins•3M 3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required fore very Centerville MA 02632 01/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water Ab ❑ Check cellar 66go ❑ Shallow wells ✓r/��- Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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 establishedd high un water vatin: d itD�3 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Amm. Title 5 Official Inspection Form 4 c Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Fox Run, Centerville, MA 02632 Property Address Matthew F Gardiner, Robert W Gardiner IRR TRST Owner Owner's Name information is required for every Centerville MA 02632 01/29/2016 page. Cityrrown State Zip Code Date of Inspection E. Re ort Completeness Checklist nspection Summary:A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Fam Subsurface Sewage Disposal System•Page 17 of 17 M D Pereira Plumbing&He 5087902686 P.1 M D Pereira Plumbing&Heating P O Box 2128 Invoice Centerville Mass.026U 508-790-2686 Number. 2996 Date: 10/2712015 B81 To: Ship To: Catherine Jones Catherine Jones 8 Fox Run Rd. Centerville.Ma. PO Number Terms Project Date Description Rcurs Rate Arnosnt Install New Circulator On Heating 10/27115 System And Purge Heat Parts and $0.00 $335.00 Labor Install new Kitchen Faucet Single lever $235.55 Parts and labor REplace A8 Tank Flappers On Toilets $65.25 Pans And labor Extra Instal New Boller Feed Valve $65.55 Plus Remove Garbage Disposal SubTotal $701.33 0.00%on S0.00 S0.00 0.00%on$0.00 S0.00 0-30 days 31-60 days 61-90 days >90 days Total S0.00 $0.00 $o.o0 $701.35 S701.35 COMMONWEALTH OF MASSACHUSE'I O BARNSTABLE,MASSACHUSETTS Cs-J-, Certificate of (Emnphatut THIS IS TO CERTIFY,that the site Sewage Disposal system Constructed( } Repaired(/�} Upgraded( ) Abandoned )by � lk-. U -- at �/ ��j � �' has been constructed in accordance j with the provisions of Title 5 and the for Disposal System Construction Permit No. >I l—L 2 dated + Installer Designer ,�/ #bedrooms Approved design flow 1+� 7' gpd The issuance of this permit s#Wl no be construed as a guarantee that the system tgned. Date V Inspector g` ========E TOWN OFf BARNSTABLE L M LOCATION IU �x R✓� �`� SEWAGE # 2Qo a -/0 3 VILLAGE n n�° rI� ASSESSOR'S MAP & LOT 2,2 7- P/00 INSTALLER'S NAME &PHONE NO. I�uvvi u! y�o r 7L O— 6.70 SEPTIC TANK CAPACITY O LEACHING FACILITY: (ty 1 /� / - ,-rt (size) l / "y NO. OF BEDROOMS 3 BUILDER OR OWNER y/dl PERMITDATE: 1: 02 COMPLIANCE DATE: Y13,91a ? Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �y 57 S 55�5� 55 Q 'S j 2t r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:,�✓� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Oiopogal *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Ad ss or of No. Owner's Name,Address and Tel.No. C"J �X Lot /I( Fp�P2��Cp Assessor's Map/Parcel '1 _ Installer's Name,Address,and Tel.No. `� �'� ��- Designer's Name,Address and Tel.No. �- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building qqC)— No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow g� gallons per day. Calculated daily flow gallons. Plan Date a,a' 6a' Number of sheets r�r— Revision Date Title a� Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and of to place the system in operation until a Certifi- cate of Compliance has been issue by this Board f Health. Signed Date Application Approved by AV&_ Date A- Application Disapproved for Re following reasons Permit No. on,2=i Date Issued �� a 'No. t 4 � �._.... Fee i!U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 2-PpYtcation for Mtoo.5al *p5tenm'Cowaructton Permit Application for a Permit to Construct( ,~)Repairs( )Upgrade( )Abandon( ) El Complete System El Individual Components d } f F Locution Add or LtiptxNo� ( P� //p Owner's Name,Address and Tel.No. Assessor's sor'ss Map/Parcel- Installer's Name,Address,and Tel.No. ( ^j (_p"j ®=• Designer's Name,Address and Tel.No.. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow 461K. gallons per day. Calculated daily flow gallons. Plan Date t a n- c-a' Number of sheets Revision Date Title OU Size of Septic Tank Type of S.A.S. Description of Soil ---Nature of Repairs or Alterations(Answer when applicable) OL tj w 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 of to place the system in operation until a Certifi- i,; cate of Compliance has been issue by this Board f Health. Signed Date Application Approved by - Ani. _ Date 3 1C1 G Application Disapproved for the following reasons Permit No. ��Un,2 — Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS i Certificate of (Compliance THIS IS TO CER ,that the d On-site Sewage Disposal System Constructed Repaired( )Upgraded( ) Abandoned( )by a r at o x ,,,- r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. S00.1 '103 dated —11/0 Z Installer Designer The issuance of this permit shall not be construed as a guarantee that the syste u6tio�as es_gned. Date Inspector_F - ----------------------------- No. )00 ) —jo3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS wtgoal *pgtem Con5tructton permit Permission is hereby granted to Construct V J Repair( )Upgrade( )Abandon( ) System located at ilk 1G, i2cE./ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. i �� Date: 'l y�d Approved by�G.�.�tY ti'jy_ TOWN OF BARNSTABLE C LOCATION ox R✓ SEWAGE # �Qoa -/()? VILLAGE -7- ASSESSOR'S MAP & LOT 2,2 7- Y� INSTALLER'S NAME&PHONE NO. T�e/,✓' X G- 6.78 1 SEPTIC TANK CAPACITY LEACHING FACII.ITY: (ty § v / r�/1 (size) 1 / X NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: 3 t4 02 COMPLIANCE DATE: 0 hi 2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist an 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 �JT l � 3a = e4 5 55�5 55 j" ::Of-73 1 Ism LOCATION SEWAGE PERMIT No. VILLAGE -� � — cm - � � INSTA LLER'S NAME i ADDRESSs,5�. �9�3 I/ /r ,r I U I L D E OR OWNER z41 C.1, f 6� ' DATE PERMIT ISSUED ` �cac, �.S7 l9ig.< ' z DATE C0MPLI °ANCE ISSU'ED� g g� 'f`i�P7N 5 Ji sa i No..W..�.r1 Fxs....l..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH kq;2/!y-----------....OF.....f.. 3 Ys. - ........................................ Appliratiou for Diipusa1 Workii Tonstr7an ' n rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ndividual Sewage Disposal System at: // < . Qcl �g .................................i`i -e �:..6-N f..rl-! ----•-----.... a............................................................ Locat - ddrs � Lot,N� /f ,J Q. �lrz�rionA e or .< .�.E ts.... �3 _�i�� moo,er / ./T 1% Installer Address Type of Building Size Lot......td�. . Sq. feet U Dwelling—No. of Bedrooms.............................. .. .....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures .----•-•----•-•-•--••--•------•. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.___-_______-__--__-__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -••--------------------•--•-•-•-----•--••-•-•••-•---------------.....-----------•-•-........................................................................ 0 Description of Soil........................................................................................................................................................................ W V -----------------------------•-------•-•-------------•----------------------•---•----••-•-•------------•-----------•---•-.-----------•-•-----•- ----------- ----•-•--•--•------------------••---------------------------....--•--........------------•-•----•------••••--•----- V Nature of Repairs or Alterations—Answer when ap 1p Icable. _�C_rY-t�- - _____._.. d�, . o va ° =/! --------------- -----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. r Si ned....: U�c. ._..//.............. ..•-------...------------------ ........jq.tf5 Application Approved By. �--�' /��% = ---•-- --- =�� ......•••... D e Date Application Disapproved for the following reasons------------------------------•--••------••---.------•----•----•••--•--•---------•----•-••----•••--._......--••-- ..-•................•---....--------------------.....------------•---.......--------...----•-------....--•-----------------------------••--•-••-------•-----•----•---•---•-----•••---•-•--•-------------' Date Permit No.---- _- j -------------------_-__ Issued-----......---- - --- D ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . --'-----------OF----------- ` ` �� .°°��� ` �/��������wwu� Disposal Works Tat0itrurtiviK Q�rruKi4 Application is hereby made for u Permit to Construct ( } or Repair ( ) an Individual Sewage Disposal 8�m��� at: ' Address p or Lot No. Installer Address Type o Building Size Lot feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of ycraous---.-.-'...-----. Showers ( ) -- Cafeteria ( ) {]t6cr fixtures Design Flow................. per person per day. Total daily flow............................................ � Scot� Ixuk--L�n�� _----0uDnoa Length................ Width................ Diameter------- Depth................ / Disposal Trench -No. ---------' Width.................... Total Length.................... Total leaching area....................ag 8. ' Seepage Pb IVo----------- --------- Diameter.................... Depth kclm. inlet---------- Totu leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) ~~ Percolation Test Results Performed br.......................................................................... Date........................................ $ Test Pit No. l................minutes per inch Depth of Teat Pit.................... Depth tv ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.-'-----'-- Depth tuground water........................ 9 ......'............'..'......................'............................'.......................'.............................�� . .� | 0Desor�¢�nuf3n�---'---------.-------'--__'_________________________________________________,. ........................................................................................................................................................................................................ 11� -------._-_--__'_-'----.-_-_'__----___'-_---_' Agreement: � The undersigned agrees to install Weuforedescribed Individual Sewage Disposal System in accordance with the provision oofIITIE 5 of the State Sanitary Code—The undersigned further ugr eea not to place the system in opccmdou notJ u Certificate of Compliance has been issued bv the board ofhealth. S ........... ..........................-.... ~.~ Application Approved By.'.----_ ----------- Application __- � . _- ' ���-- /lyplicatiooDi»oppcovedfo, the following reasons:.....................................................................................'........................_ ------_-----'----------------'-'----------------'----_.-----------_--------------------_..---''------ --- PerozitNo......................................................... Issued...................................................... Date � A ~ THE COMMONWEALTH ormxssAoeussrTs ^ � BOARD OF HEALTH � � ---.-_-- ���� � '--''--� ---------_--'-'---'--------' ~---~~--~~~~r of T°~°°�r°~~~~~a THIS IS TQ CERTIFY, That the Individual Sewage Disposal System constructed or RepairedSTRUED Installer has been installed in accoraance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No--------!2R.,17---- ........... date( XI-Ai THE ISSUANCL?IIF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE ON SA � .............a THE COMMONWEALTH OF.-MASSACHUSETTS BOARD OF HEALTH to Construi� .,�,Repair an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit No...........z2k.?.. Dated..!�-J_ ................. Board of Health FORM 1255, A. M. SULKIN, INC., BOSTON _ � ~ ' _ ~ � ' GL'i/zr� L9 DG �� + I .E Lo7 J, J 40.27 • t.1 .t � �j1 art.. •�� �. r l J ' .. ` -CERTIFI ED . "PLOT PLAN a s LOCATION /YItiE�S70A/S /y/LLS s SCALE . .�.��~30 '. , DATE ..3 . PLAN REFERENCE 44 4P�",�/ram ' . ' � '`' s,�w.v, o� ,A .pl�� • .fix- t- �, ` -ae ZB F �+ Eq a. t /.KELLEY (s . 91 1 9 �s1�sTi,�G �o�•� , CERTIFY THAT THE ?�Y17 .... �o 9HOtiVN ON THIS PIJW IS LOCATED ON THE (;ROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REOWRE RENTS-OF THE,TOWN OF = - f7? ti%.LC" . Y . .�� . . .. • .WH[AI CON�7RUGTEQ DATE £TITIONER G'Ea,��Ll 8/5SC' TT i, �r wx t y sv �f Brix �va p"FOI.STEREn [J►ND S(:!R. r - -- .,.�,.I--I-I-._.�_�-I..�,:_,.�.:l I.�I_;�-.�I II.`,.,..�,:�,.I,-.,-i I,��,��:i.,�'.�I�-I,-'.1,.I�,t\^.,e..-,.:I,!F_.�I.,�...�z-7 I-�,�7l.,�,�..,.1�I I.,..I-1.,_��;�,�1,..I_.�..��"�_��..;,Z..n.1..,_f II,.i,. 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S's TCPSOIL N U NL,;,' )PSCIL , H.10 W N N T H 1S . A '4 . C 5 H U."- la" ET AUTKORUZED :.ByF `Cc N F 0 R TO T H LE E-4 U N:G 4 BACK R �Ct:U:1 ,R E W N T 10- GARBA.GE. G R 1.N Df R -4 10"YES p TOW N -TA P L OF, EARN�S ME D 't� - ELE r o N s:` L4,-. T 'A: J:J, N,,� Ff ET C'S E" C$E ASS'UMED' ng A, STETON KMAXV,- e.g wl. 77, /SJM�WWA "Y �S4 C C 1!71P.- 151-lr mi 4 --ACCESS COVER TO WITHIN 6" OF FIN. GRADE ACCESS COVER WITHIN 6" OF FIN.(WATERTIGHT) 1.0 GROUND SURFACE AT EL, 23.0'± (PROP,) LONG POND TABS GROUND SURFACE AT EL.` 23.0;± TOP OF FNDN AT EL. 24.0' �N MINIMUM .75' OF COVER OVER PRECAST GROUND SURFACE AT EL. 23.0'± (PROP.) 21 .0' _ 2% SLOPE REQUIj_D OVER SYSTEM TOP PRECAST EL. 20'0' 7- . r 5-- 8.0, 1/8" _ �/2,. P J STON �._'.,: FILTER FABRIC PS[�F _ OVER 3/4" STONE �. ��'�' LOCUS 14 b -- - 2.0.7 57:' TEE 1_-�.'""m`_" _ ` 1500 GAL H-10 r r oao° 0'01 . +_.l _ -t( �n� c� �c °000UOQo°a "�V�� R N sE PTIc TANK GAS BAFFLE 20.5' 20. 17 ; �`_ 20.0 a o fey n f�1, 1 i . 4' LIQ, LEVEL �� \ �Of'OSEO FLOW DIFFUSOR LEACH SYSTEM �vN 5 L: ACME OR EQUAL \ „ DEPTH C7F` FLOW 4' L� -��w' ` 3/4"-1 1 "ONE - . 3 19.46' DOUgL_. �,; 4iE7 i� c 5 'firE SIZES: INLET DEPTH -= 10 �:-� �-* '� +� i OUTLET DEPTH I4„ ACME 089 H-10 OR EQUAL 1 �' �1 N GC��A�3V&A P -- INVERT LEVEL FOR 1ST 2' ,-- 6" GRAVEL & MECH. COMPACTION (TYP.) 11 j MIN 2� SLOPE MIN P I BOTTOM OF TH 1 EL. 5.77' CPO ( ) ( I o SLOPE) (MIN 1% SLOPE) FOUNDATION --- -- 10' ---SEPTIC TANK -- 33 D' BOX 2.3' LEA(,FNG FACILITY LOCUS MAP SYSTEM PR r LE sc���: Nis (N07 TO SCALE) ,#1 1 ASSESSORS MAP: 227 PARCEL: 148 1 ZONING DISTRICT: RC , MINIMUM YARD SETBACKS:* FRONT = 20' I �! ' SIDE = 10' ' TN i TV-12 REAR = 10' Z 1 DEPTH (IN.) =LEVATION (FT.) DEPTH (IN.) ELEVATION (FT.) PLAN REF: BOOK 326 PAGE 73 0" (� -i� 17.77 Q" 0 24.18 FLOOD ZONE: C '' ORGx,�;I ORGANIC GROUNDWATER OVERLAY DISTRICT: AP ' - EDGE OF WETLAND ,' UTILITY '' �/ 11 (ovERcr�a eoc) CLUSTER �'� 2 - 17,6 2 24.01 SOIL CLASS: I VERIFY WITH TOWN OFFICIALS f ,' A A 24' GAL, POURED: IN 7:08 TEL, ELEC CAry `r LOAMY S�IND LOAMY SAND PE;RC RATE: <2 MINJINCH /�, E 4 10 YR /� 17.43 � 10 YR � 2 23.84 TOP PERC: 48>' DATE: MAY 21 , 1998 ENGINEER: DAN OJALA, S.E., P,L:S. s LOAMY 3�AN`1 LOAMY SAND WITNESS: JERRY DUNNING, BOH ar o � I 28" 10 Y,R1 ��� 15.43 30" 10 YR� 6/6_ ' 21 .67 a. _ („_ ,. r���. • /' -N aENCHMARKI �� ', �j, ti 144"I _ .,f -_. 5.77 144>,� ?.5 +6/E.+ 12.17 If�I0 IF n CATCH BAS1 { ELEv = 10.44 NO WATER �:CUNT NO WATER FOUND 1 . THE LOCATION OF EXISTING UNDERGROUND UTILITIES SHOWN ON ti THIS PLAN IS APPROXIMATE. PRIOR TO ANY EXCAVATION ON THIS TEST HOLE ACME PF,ECAST DB9 _ SITE, THE EXCAVATING CONTRACTOR SHALL MAKE THE REQUIRED 72 UTILITY t�� D BOX (OR EQUIVALENT) (NOT TO SCALE)^ HOUR NOTIFICATION TO DIG SAFE (1 -888-34=I- 7233) AND ANY CLUSTER ' ` TEL, ELEC` w OTHER UTILITIES WHICH MAY HAVE CABLE, PIPE, OR EQUIPMENT a aIp �, IN THE CONSTRUCTION AREA FOR VERIFICATION OF LOCATIONS. V.C) , � , f�Y ��, � (6) 4' X 8 -LOW DIFFUSER LEACHING FACILITY oo* 2. MUNICIPAL WATER IS AVAIL/� L PROPOSED------ Ps` PROPosED 16.9• �� 7 � � 3. ALL SEPTIC WORK AND MATERIALS TO CONFORM TO 310 CMR SILT FENCE ` \ a ((+ r E(�' (���cj� /, 15.00 TITLE AND BARNSTABLE HEALTH REGULATIONS. DWELLINGL�� �ILhY��15 LL 5 Tap OF FNDn� 4: MINIMUM PIPE PITCH TO BE 1 8" PER FOOT. A7' EL 24.0' SEPTIC DESIGN:� (GARBAGE DlsposER Is NOT ALLOWED) 5• DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H I 1 DESi ( ) 5. PIPE JOINTS TO E3E MADE WAi_ERTiGHT. PROPOSED RETAINING WALLS "'N FLOW: 4 BEDROOMS 110 GPD = 440 GPD (DESIGN BY OTHERS) SEPTIC TANK: 440 GPD 2 880 7. WATER TEST D-BOX FOR LEVELNESS. yt, PROPOSED 1 ,500 GALLO'I'T _ _ ��� TH1 ��� SEPTIC TANK - CEn'TER TEES (TYP.) -� USE A 1500 GALLON SEPTIC TANK 8. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE LEACHING: USED FOR LOT LINE STAKING. �g 9. PIPE FOR SEPTIC SYSTEM TO BE SCH. 40-4" PVC. y" 0 �Q� LOT 1 ri SIDES: 2(49 + 1 1 ) (.96) (.74) = 85.2 10. COMPONENTS NOT TO BE EiACKf-ILLED OR CONCEALED WITHOUT ul 18,808 SF± l BOTTOM: 49 x 11 (.74) - 398.8 0.43t ACRE INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED TOTALS: 654 SF 484 GPD FROM BOARD OF HEALTH. x LOT 2 NO '>/ , +. . _ES OR CONSTRUCTION EOUIPM;N T ALLOWED OVER (1) ROW OF (6) 4' X 8 FLC �t ! F-USORS I ; Q - Y� . -, WITH, 0.5' OF STOIw`E AT mac- F" `_, AND I'RO-r':s�E:D SYSTEM. Ci�.I�.,C��C� N[1 d `� ��°�- 5' AT THE SI --- -;: 3 DE- r, ER` i_'!j4.. DATUM AP>==ROXIMATE._' FROM G�I,AD. ;'I,C)r Q,t? D WATER LINT � �,s AP KOXiMATF; LOCATION ,.� r { PLAN X � �, 16 E�OPO, 5PQ GRADE I y} * ; I T , CONTOUR ...9 t L T ; H 1 ;. f -; ,- ti •� v -� - ,�; ., a. ,,x 5�:�8 .�C2 �38p � SOIL I�:'S HOIL 0` �aGA! 1 30 vw. ; .,_ r ., .. '' ni G. ,, LOG(S) ,E TES: ! : _ . ,• T't l -Y 'r'OLE_ w ,t o ('oAt� `G��s��' �;rr�?gl�;e�'r�l"��i�.9 "3' '� �� �i�l I�ER�/( �LE LARNSTABLE M)T A.L $YM6%5 MAY aaP&g Its trN,AW Ns 1 v� � PREPARED FOR: _ 4.. _.. ,.�,.. FLF6MANHOLE I\. IL`` F1' GINEERS RaBERT & LORRAINE GARDINER LAN D SURVEYORS „ covk R t. ys 30 0 30 60 90 X.i -M„� ,:, BOARD OF HEALTH � ri -_:W 3'. 39 main st. y arrnojt.h, rya 02675 1 „ 30 - SCALE: - DATE: MARCH 2001 APPRaIEwDDATE� --F DA' t REV. 3/29/0 c t __ .......-:..+...�.aeeon � nr -FmM�xm.ro�eaaac. ounarensm^x»esn-:•-wwar+............ - ...._ y.,: . .:„ . ...:.. .-..,..., �.-..+.,e.r,••P.,-„+ w�..e