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HomeMy WebLinkAbout0016 GARTH COURT - Health 16 Garth Curt . Centerville P. 1 149088 I No. 4210 1/3 CPA, � 'j-ov H(9 v 10°I°`' ® 0 i __ _ _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i+ 16 Garth Court A, I�1 Property Address r�`w Lowe ` r1�r Owner Owner's Name M. information is Centerville ✓ MA 02632 12-15-17 : required for t}�� every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information -2-7? — �� forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 rtA Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r wj� (-D- ad 12-15-17 Inspector's Si6Aature 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. /op"t VS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every 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 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: At time of inspection system met all passing requirements. This report can not predict the future performance under the same or increased usage. This report is not to be used for bedroom count determination, the Board of Health has the final say on bedroom count. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5ins-3/13 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 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction Is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, III 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 i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 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 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every 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? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 Per as-built DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: This system consists of a 1000 gallon septic tank d-box and biodiffusers in a 11.3x25 ft area. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N.A at time of 9 ( Y 9 (gp )) insp Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: currently occupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'GSM 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupied Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank original S.A.S installed in 2008 October. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 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: 1000 gallon Sludge depth: light to moderate t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness very light 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? wooden pole Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): If the tank has not been pumped in the last 2-3 yrs I recommend pumping at time of transfer and every 2-3 yrs there after for maintenance. Tank inlet is partially under front of deck, there are no sono tubes that appear to be on the tank but there is a block that the corner of the deck is resting on that is. There is also a irrigation line that runs over the top of the tank on the outlet end and a piece of what appears to be a plastic drop cloth on a part of the roof of the tank inside. I inspected the roof of the tank with a mirror and did not see any clear signs of damage or cracks. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �b 16 Garth Court Property Address Lowe Owner Owners Name information is required for Centerville MA 02632 12-15-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was functioning properly at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 16 Garth Court Property Address Lowe Owner Owners Name information is required for Centerville MA 02632 12-15-17 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Biodiffusers ❑ 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.): The observation port was opened and at the time of inspection were found to be dry with no signs of failure the sand in the bottom of the chambers looked clean as well. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,,. etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 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 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5 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: 11-17 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: design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 16 Garth Court Property Address Lowe Owner Owner's Name information is required for Centerville MA 02632 12-15-17 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION /L rF Lr SEWAGE# 2 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 10�:o- ,Ji A LEACHING FACILITY:(type) 12r�11 rlS (size) 11.1 L QT- NO.OF BEDROOMS OWNER ' Lnwe PERMIT DATE:of(�j COMPLIANCE DATE: / ? Separation Distance Between die: 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 1 3 9- y0' yr 1 Ave,U 2 qb' 3-33' H-5'7' z UP t http://www.townofbamstable.us/Assessing/fIMdisplay.asp?mappar=149088&seq=1 12/17/2017 AA Q-lj tiob ob l �d�� L,pl �y� y��a Q 1 Q t 4U4 �o , I Lj Y ct P su fig Q3:5t 4 S J i ry y�Tar toeIID r c-26 'I f i Ll J% J V Vim' k i .� ` � �� � / � -.� � �' � �. �� � �' Q � �' C -'_ � �. � � � � s s �� -� � n i t i t No. C-�V �" 3 j Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplication for �Bigogal *pgtem Con0truction Permit Application for a Permit to Construct( ) Repair(tl<grade( ) Abandon( ) El-Complete System ❑Individual Components Location Address or Lot Np. 16 6&fio-h Cr Owner's Name Address;and Tel.No. Assessor's Map/Parcel I —0 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 71�6vsle.S A 1-6fpw AAe-SON) Type of Building: Dwelling No.of Bedrooms 0-1 Lot Size a ` )C1 Ad CS sq.ft. Garbage Grinder ( ) Other Type of Building ®cam . No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) � ('� gpd Design flow provided 3 /0 -and Plan Date Numbe of sheets Revision Date Title J Size of Septic Tank t( ll Type of S.A.S. t Description of Soil t 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 not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved by Date Q' Application Disapproved by: Date for the following reasons Permit No. 2 D© , 3 Date Issued fd �� Od {► 50 No. �' 0 �- N Fee / » THE COMMisuWALTH-OF-MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS .Yes ` Rpplication for �Di,q;PoOal *Wens Congtruction Permit Application for a Permit to Construct O Repair(,a Upgrade O Abandon'( ) ❑`.Complete System ❑Individual Components Location Address or Lot No. My& -A l-r Owner's Name Address,and Tel.No. C PNrrIV 111 C cv,*ofc. Assessor's Map/Parcel 14 0 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: `, Dwelling No.of Bedrooms Lot Size . ',) A A(I PS sq. ft. Garbage Grinder ( ) Other Type of Building cT>1! No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 120 gpd Design flow provided 3?0 gpd Plan Date Number of sheets Revision Date Title :. Size of Septic Tank l -­,rA11C2t.,N Pxlstiq Type of S.A.S. -(�( Description of Soil �J Nature of Repairs or Alterations(Answer when applicable) f Date last inspected: 1 e 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 of Health./� Signed Date Application Approved by ([ Date 1"f 8 -d Application Disapproved by: y Date for the following reasons Permit No. 2 04 - 3 9 Date Issued / r -C) ———————————————————————————————————————————- THE COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE, MASSACHUSETTS J V Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( ) Abandoned( )by , at %& CM(,4)N (,k f 2\"c)1 has been c nstructed in accordance q with the provisions FTitle 5 and the for Disposal System Construction Permit No. a04-30-- dated Installer l Designery1f� S(j� #bedrooms 1 L Approved design flow 710 1 gpd The issuance of this permit shall not a onst/rly uarantee that the system wi Iu ct• n as designed. 7 Date // •✓ Inspector i No. d` DO"— 39-)— Fee (� --- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=i!9po!9al *p!gtem Construction Permit Permission is hereby granted to Construct ( ) Repair (s/<Upgrade ( ) Abandon ( ) System located at 10 6e�(�, k f t e.-.j f V 1 ro 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: Consttuction must a completed within three years of the date of this permit. Date -f rg -A� Approved by To—win of-.Barnstable IME..r: .. N� Regulatory Services Thomas F.Geiler,Director + BAI;N.SFABEE. + a Public Health Division aTFa. a " Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: 0 2-3 ZaO�j Designer:, �' A1V112 12. Installer: Address: . 1j l^ ��( j Address: On ,cE7 was issued a permit to install a -(date) (installer) septic system at 1& 6c,_&V\ C k- based on a design drawn by (address) • �i✓`�"`� dated (designer) 1.,;certify that the septic system referenced above was installed substantially, acco ding•to `' :he design, which may include minor approved-changes such as late relocation of the distribution box and/or septic tank. r. I certifyf that the septic system referenced above was installed with-major changes than . (Le.e, greater an 10' lateral reloeatiiin of the SAS any vertical r6l onent ocafiisn of any comp of the.septrl system)but in accordance with State &Local_Regdiations. Plan revision or certified as-brlt`oy designer to'follow. ,{ M .tc��Mto�+Mas >bnvID taller's Signature) Z B• 14'�4SON '.rn 5" 9 Nd.M66 FQ,S�GP�, SgNITAR�A� • (D er s Signature) (Affix er's Sta pp Her PLEASE RETURN TO BARNSTABCE'PUBLIC:HEALTH DIVISION C RTIFIC , OF.- COMPLIANCE WILL=`NOT'XE •SSUED BOTH=:TUTA. FQIIM IRUILT CARD ARE RECEIVED 1a'Y T`HE:B _ S`] i_BLLE PUBLi[G AI TD`DTV�SION THANK YOU. t. , Q:Heal&Septic/Designer Certification Fora TOWN OF BARNSTABLE LOCATION rpr rVk C - SEWAGE#. DO VILLAGE ���,� -�� � � ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. -e./;t� -b� y SEPTIC TANK CAPACITY �( X74�v�oc LEACHING FACILITY:(type) (size) NO.OF BEDROOMSzf,� �b OWNER PERMIT DATE: � �(� COMPLIANCE DATE: 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 ti o CIO' ".. H- S'7� r� "IN 0 P Town of Barnstable P# Department of Regulatory Services Public Health Division Date S039. 200 Main Street,Hyannis MA 02601 n Date Scheduled ) ime Feed. 1 Soil Suitability Asseys�sment for Sewa e Dis� osal Performed By: v �l '' �y Witnessed By:' ��� �C✓ �C U LOCATION & GkrkEAAL INFORMATION A M Location Address 1�/rl'� a j Owner's Name 1)9 � M�At'r6 a 1✓ Address AIM �' Assessor's Map/Parcel: /��ESY Engineer's Name NEW CONSTRUCTION ` R"EPAIR Telephone# Land Use ` •' `y Slopes(%) °v Surface Stones 1 Distances from: Open Water Body ft Possible Wet Area f ft Drinking Water Well / ft Drainage Way / ft Property Line / ft Other ' ft SKETCH:(Street name,dimensions of lot,exact 1 ations of test holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) 1 Depth to Bedrock _ Depth to Groundwater. Standing Water in Hole: �,�+ Weeping from Pit.Fsce Estimated Seasonal High Groundwater Q/ DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: - __in. Depth to sgll Mottles: in. Depth to weeping from side of obs.hole- in, Groundwater Adjustment ft• Index Well# Reading Date: Index Well level,, ... Adj.factor Adj.Groundwater level PERCOLATION TES`' Date�. Time_,_„ Observation Hole# Time at 9" Depth of Pen; Time at 6" Start Pre-soak Time @ Time ff'-V) End Pre-soak Rate Min./inch M t Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back ***If percolation testis to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICVERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other L Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. t nsis e c Gravel) �r G DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistenc %Gravel) FT —DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Y Soil Color Soil Other • Surface(in.)' — (USDA) (Munsell) Mottling--(Structure,Stones,Boulders. onsi to c Gravel) t , DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Foil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Corisistency, QQygll Flood Insurance Rate May: Above 500 year flood boundary No_ Yes Within 500 year boundary No. Yes, Within 100 year flood boundary Nov Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u a ial exist in all areas observed throughout the area proposed for the soil absorption system? �, If not,what is the depth of nat rally occurring pervious material? Certification I certify that on l b (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was perfor by me consistent with the requir training,exp ise e en e a described in 310 CMR 15.01 . Sign at ' Date Q:\SEPTIC\PERCFORM.DOC 1 TOWN OF BA.RNSTABLE LOCATION (® �cJ TG� � SEWAGE IIyLAGE 1 &17�er v 'I le ASSESSOR'S MAP&LOT� " d w INSTALLER'S NAME&PHONE NO. I SEPTIC TANK CAPACITY .i LEACHING FACILITY: (t)pe) �r i (size) 100 NO.OFBEDROOMS a E r BUILDER OR OWNER PERMITDATE: � COMPLIANCE DATE: Separation Distance Between the: ; Maximum Adjusted Groundwater Table to the Bottom of beaching 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 f leaching facility) / t, Feet Furnished by wez ��(�� It, �� CCt e 'S Peek o � o A 6- a3' d-c- ag, A-f- O � SECTIONSENDER: COPPLETE THIS COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signat item 4 if Restricted Delivery is desired. � �0 Agent ■ Print your name and address on the reverse Xt'�i--�'AUdressee ■ Attach this cad toso that we can urn the card to you.the back of the mailpiece, B. R ( jv� CAbatet4of De(rvery or on the front if space permits. to 1c. D. Is deliverraddress different Rem 1?^,`tO Yes q 1. Article Addressed to: If YES,enter delivery addre 4zel N JS?S rC-Q-k Z n C1� CLl on �>�•A 3. Service Type 9 i�'3a IS Certified Mail ❑Express Mail ❑Registered' ■Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number — = - (transfer from service labeo . .7006, 2150 0 0 0.2 11038 7244 ; PS Form 3811,February 2004 Domestic Return Receipt J 1'0`2595A2 -"1540 UNITED STATES POSTAL SERVICE First-Clacs Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • I --— �� 0 Town of Barnstable I Health Division I 200 Main Street Hyannis,MA 02601 � I � k I -J I l I� t l Town of Barnstable Barn �r Regulatory * " Re ulator Services Department OftedcaM .ANTBM 1 1 059. ,� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO April 25, 2008 Citi Residential Lending Inc. 10801 6th Street Rancho Cucamonga, CA 91730 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 16 Garth Court, Centerville MA was last inspected on April 22, 2008,by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure°to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE OARD OF HEALTH as cKean, S. CHO Agent of the Board of Health CERTIFIED MAIL# 7006 2150 0002 1038 7244 Q:\SEPTIC\Letters Septic Inspection Failures\16 Garth Court.doc ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Garth Ct L.�q Property Address Citi Residential Lending Inc. 10801 a St Rancho Cucamonga, CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. Cityrrown State Zip Code Date of Inspection Inspection results[Host be submitted on this form.Inspection forms may not be altered in any way. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Cify[Town State Zip Code 1-800-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addressand thathe information reported below is true,accurate and complete as of the time of the inspection.Tire,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 1�340 of. Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails 1 ❑ Needs Further Ev ivation by the Local Approving Authority 1 4-22-08 '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. t5insp•03/08 T--5 OfficW Utspecknicbm Subsurface 'Sewage Deposal System•Page 7 of 15 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. City/Town state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiftration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ry ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga CA 91730 Owner Owner's Flame information is required for Centerville MA 02632 4-22-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times'a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp•03108 Title 5Offcial inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: . **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overioaded 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. t5insp-03/08 Tine 5Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 16 Garth Ct Property Address Citi Residential lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owners Name information is required for Centerville MA 02632 4-22-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [Phis system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either°yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered°yes° in Section D above the large system has fair.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5insp•03/08 Tdfe 5 Official hspection Form:Subsurface Sewage Dtsposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 16 Garth Ct Property Address Citi Residential i Lending Inca 10801 6th St Rancho Cucamonga, CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 at 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. CitylTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? n Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 3-08Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp-03l08 - Tine 5 Ofrrcial tnspecbon Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.M 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owner's Flame information is required for Centerville MA 02632 4-22-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) General Information 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: 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/Altemative 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 (f known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No t5insp•03/08 Ti fe 5 Official Utspecdon Form:Subsurface Sewage D4osal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 18" 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. Septic Tank(locate on site plan): Depth below grade: 12" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------ ------ Dimensions: 1000 Gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 II Distance from top of scum to top of outlet tee or baffle 6" I. Distance from bottom of scum to bottom of outlet tee or baffle 16' How were dimensions determined? Tape t5insp•03108 Trite 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 in good condition with all baffles in place. 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: x Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp-03108 Title 5 Oftial Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order:, ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•03108 Tdte 5Offk3af Inspeebon Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, .CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leachingchambers 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.): Pit had clear signs of hydrolic failure with stains above inlet invert. t5insp•03108 We 5O ficmd Inspection Form.Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owners Name information is required for Centerville MA 02632 4-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp-03/O8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r< 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 a St Rancho Cucamonga, CA 81730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. cityrrown State Zip Code Date of fnspection D. System Information (cola.) 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. t fd peck i A-O-D`76" 8-0- A -f- 33" g'L"- of` t5insp•03= Title 5 Offic!W Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Garth Ct Property Address Citi Residential Lending Inc. 10801 6th St Rancho Cucamonga, CA 91730 Owner Owner's Name information is required for Centerville MA 02632 4-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 30 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 maps show groundwater at 30'. t5insp-03/08 Title 5 Ofrtcial Irtspection Form:Subsurface Seamge Dsposal System-Page 15 of 15 Town of Barnstable �p 1HE tpk Regulatory Services &UMSTABLE ; Thomas F. Geiler,Director Muss. . 9$ i639. Public Health-Division PIED Mp'i A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862 4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. YOU WISH.TO.OPEN A BUSINESS? L our Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in tust do by t111:G.L.-it does not ive ou own [which 9 y permissiontooperate.) Business Certificates areavailable at the Town.Clerk's Office, 1 K FL., 367 Street, Hyannis, MA 02601 [Town Hall) r� Fill�in' lease; APPLICANTS YOUR NAME:v�' l ��4Av0 X-�Jr/Jr- w' BUSINESS YOUR HOME ADDRESS: TELEPHONE # Home Telephone Number S06 NAME OF NEW BU34NES's-N�IJ VJO>ZC — P.UC7 l Ury 1'S`J�a . _ T�'PE OP BUSIN .S'S: n IS THIS A-HOME 0=0PATION? ' . :ES MIA ADDRESS*OF BUSINESS Vo C=SLe7ia MAP/PA NUMBER_ When starting.a new business there are several things you must do in order-to be in Compliance with Barnstable. P h the rules and re ulati le. This form ons of the T rm is intended to assistyou-in obtaining the Information you g own of Rd. & Main Street) to make sure you have the appropriate permits and licenses.requir d to legally operate you your in this(corner of Yarmouth Y �s town. 1. BUILDING-COM ISSIO ER'S OFFIC This ind.ividu I h en->nf .ri ed. y permit requirements-that pertain tq this type,of butt T COMPLY WITH HOME OCCUPATION Au hpriz S tttr�e RULES AND REGULATIONS..FAILURE TO " **CPMMENTS �in COMPLY MAY RESULT IN FINES. 2. BOARD OF HEALTH This individual hgAorized n in for ed of the p requirements that pertain to this type of business. Signature* COMMENTS: . 3: CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature.* COMMENTS: Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS`` nnON-SITE INVENTORY NAME OF BUSINESS: N.Ew \jj0P-,Lf7 COIVSTKUC'J"t" 11y G BUSINESS LOCATION: t(o �`rb INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: � 2.80 -A:) O-� CONTACTPERSON: o 11K GJS_M'JQ [k A -24TASA EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: �RLUw1NG" INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS T Board of Health and the Public Health Division have determined that the following products exhi 't toxic or h zardous characteristics and must be registered regardless of volume. Obse ed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Auto atic transmission fluid Disinfectants Engine d radiator flushes Road Salts (H ite) Hydraulic fl 'd (including brake fluid) r Refrigeran Motor Oils Pestici s NEW USED (ins ticides, herbicides, rodenticides) Gasoline, Jet fuel, Av tion gas P otochemicals (Fixers) Diesel Fuel, kerosene, # heating oil ___- NEW USED Misc. petroleum products: ease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and meta Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, es Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW SED ny other products with "poison,' labels Paint &varnish r overs, deglossers (in uding chloroform, formaldehyde, Misc. Flamm les hydro loric acid, other acids) Floor&fur ture strippers Other pr ucts not listed which you feel Metal p ishes may be toxi or hazardous (please list): Laun ry soil & stain removers (i luding bleach) pot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS++ ON-SITE INVENTORY ` NAME OF BUSINESS: Nr-vi WoF.Li) CcwsS-( u C-no 1\1 1 N C BUSINESS LOCATION: 16 �tA C'T INVENTORY �- MAILING ADDRESS:' - TOTAL AMOUNTS TELEPHONE NUMBER: 2eo -A 0� CONTACT PERSON: GJSTaV J ►)E a-C�To�A EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS. INFORMATION/RECOMMENDATIONS: Fire District: s Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: i Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhii iit toxic or ha ardous characteristics and must be registered regardless of volume. ` Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive NEW USED Cesspool cleaners P Automatic transmission fluid Disinfectants Engin\nd radiator flushes Road Salts ( lite) Hydraulic fl id (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (inse'cticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes;'stains,dyes Other chlorinated hydrocarbons, Lacquer thinners \hyproc n tetrachloride) NEW SED products with "poison" labels Paint &varnish r. movers, deglossers chloroform, formaldehyde, Misc. Flammables c acid, other acids) Floor &furn re stri ers ucts not listed which ou feel pp Y Metal polishes may be toxic�rhazardous (please list): Laundry soil & stain removers _ (in/uding bleach) Spot removers &cleaning fluids / (dry cleaners) •x Other cleaning solvents -� Bug and tar removers I Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS COMMONWEALTH OF MASSACHUSETTS RECEIVED EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS AUG 2 4 2004 DEPARTMENT OF ENVIRONMENTAL PROTECTION L TOW HEALTH AOF BARNSTABLE LTH DEPT. V44-19 I`f 9 ©yf Lo Cf3 4AP I4� PARCEL , TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATIONProperty Address: ��r t GI C 7 4& o Owner's Name• /'✓10 Owner's Address: 7— � r✓i Od�G3�. Date of Inspection: lease print) cFe�� _[_1.Seitll ca Name of Inspector �� ;�. Company Name: dr — �.- Maiiling Addreu.- / `-' ✓t'' 141 Vol Telephone Numbeq o — G CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information rtedr '— below is true,accurate and complete as of the time of the inspection The inspection was performed based on training and experience in the proper function and maintenance of on site sewage disposal systems.I am a D P approved system inspector pursuant to Sec ' S.341!of Title S(310 CMR 15.000). The system IP Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails /J Inspector's Signature: S Date: a /1 0 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 10,0M gpd or greater;the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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,name or different conditions of use. Page 2 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• C— ,, nn �H v`� Owner: /�0I -L Date of Inspection: zy / ,p�( Inspection Summary: Check AJ4C,D or E/ALWAYS complete all of Section D A. System s: h have not found any information which indicates that any of the failure criteria describes in 310 CMR 15.303 9r in 310 CUR 15-M4 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 4"C 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 nepaur,as approved by the Board of He alth,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiihation or tank failure is imminent. System will pass inspection if the existing tank is reptaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s)•The system will pass inspection if(with approval of the Board of Healtb): broken pipe(s)are replaced obstruction is removed ND explain_: i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: W vy rvd of Owner. .9- Date of Inspection: // 0 C./Further Evaluation is Required by the gourd of Health: /V Conditions exist which require farther evaluation by the Hoard of Health in order to determine is failing to protect p�C}�1th,fit,-or h;-environment. �f the system L System will pass unless Board of Health determines in accordance with 310 CMR 1&303(1)(b)that the system is rotAMAioaing in aver which will praftd public aAh,-Wets and the e5Mre t: — 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 Z. Sy..*m will fail unleyg the Board of Health(and Pulttic-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,too 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 detamme distance **This system paste 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 ppcn,provided that no other failure criteria are triggered.A►copy of the analysis must be attached to this form 3. Other; 630 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Addrew Owner. Date of Ins : // D. System Failure Criteria applicable to all systems; You must indicate"yes"or"no"to each of the following for all inspections: Yes No� kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool scharge or ponding of e8luent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or A esspool li�d depth in GsMI is less than 6"below invert or available volume is less than, day flow pumping more than 4 times in the last year NOT due to clogged or obstructed of times pumped pipes}.Number / Y portion of the SAS,cesspool or privy is below high ground water elevation. pottiott of cesspool or privy is within lOn feet of a surface waw tupply or tributary G/ ater supply, ry to a surface portion Of a cesspool or privy is within a Zone 1 of a public well '_/ny P�� a cesspool or privy is within 50 feet of a private water supply well. — �y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a supply well with no acceptable water system p private water quality analysis. This stem asses 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 le."than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form,} es/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. Large Systems: To be considered a large system tLe system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd You must indicate either`yes"or"no„to each of the following; (The following 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 the system its within 200 feet of a tributary to a surface drin_kin$water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped _an_e II of a public water supply welt If you have "yes"to any question in Section E the system is considered a significant "ycs"in Section D above the large system.has failed The owner or o syste threat,or answered significant threat under Section E or failed under Section D shall u Aerator of any large system considered a 1_5.304,The system owner should contact the a upgrade the system in accordance with 310 CMR appropriate regional office of the Department, �� T Pap 5of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: / �a�'� C Owner: a440 Date of Inspectioifi. Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes/�To �47Pumping 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 syskm moved normal flows in the previous two week period Have Lupwimnes of-water been introduced to-the system nocentiy or as peat of this inspection Were as-built plans of the system obtainedand examined?(If they were not available note T as N/A) Was the facility or dwelling inspected for signs of sewage back up v Was the•site inspected for signs of break out Were all system components,excluding the SAS,located on site Were the septic tank manholes acid uncovered,opened, the interior of the tank inspected for the condition of the es or tees,material of construction,dimensions,depth of limed,depth of sludge and depth of scum _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenanI of subsurface sewagedismal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health _ _ D me Determined in the field(if any of the U criteria related to Part C is at issue approximation of distance is unacceptable)P 10 CMR 15.302(3)(b)] Page 6 of 11 'OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: (6 e-f G T- rivb Owner. Date of Inspection: / 0 1tESIDFNI7AL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 C?,15.203(for example: 110 gpd x#of bedrooms): 3 Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no)./VP [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:()es or no):LO Water meter readings,if available(last 2 years usage(MM) Sump pump(yes or no):�(,0 Last date of occupancy: G COA MERCIALIMUSTRIAL Type of establishment: Design flow(based on 310 CMR I5103): end Basis of design flow(seats/persons/sgft,etc.): Grease tap pr+esent.(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title'S system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): Pumping Records. GENERAL INFORMATION I Source of information: ' e d 0A- 0 w L-e v Was system pumped as part of the inspection(yes or no): If yes,volume pumped:__�Ilons_How was quantity pumped determined? Reason for pumping: TYPPOF SYSTEM Septic tank,distribution box,soil absorption system _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): PPrw►/ f Approximate age of all components,date instatied(if!known)and source of inf "on: Were sewage odors detected when arriving at the site(yes or no): �" C I Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: ! !� 6—e2✓ & C 7 Gw ✓'v, Oa�6 �� Owner: P� Date of Inspection: If Q BUILDING SEWER(locate on site plan) Depth below grade: g �/ Materials of construction: cast iron _✓�0 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANIX, ovate on site n per) l/ Depth below grade:� Material of coon concrete_ _fiberglass_polyethylene —off( ) If tank is metal list age:_ Is age j confirmed by a Certificate of Compliance(yes or no):_(attach a copy of 5X Sludge depth: y Distance from top of sludge to bottom of outlet tee or baffle: i Scum thickness: d Distance from top of scum to top of outlet tee or baffle: j /v0 —Sc (^ wl Distance from bottom of scum to bottom of gullet tee or e: How were dimensions determined; /fie/c a Xe v I c Comments(on pumping recommendations,inlet and outlet t or baffle condition,structural integrity,liquid levels as to outlet invert,evidence of leakage.etc.): A h GREASE'I'RAP:/l/ (locate on site plan) Depth below grade:— Material of construction:_concrete_metal fiberglass_polyethylene—other (explain): — Dimensions: Scum thickness: Distance hum 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 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, as related to outlet invert,evidence of leakage,etc.): liquid levels Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Adak: /6 Ga 0-114 cry Cam✓► /'r/r t. h OO`� �� Owner: A t Date of Inspection: TIGHT or HOLDING TANX:A�-(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(expb.): Dimensions: Capacity: llo� Design Flow: Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(cundtion of alarm and float switches,etc.): DISTREMUTION BOX: N (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:AfQ d�-_ o K R s 6..,'/•f- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage or oyt of x,etc.): PUMP CHAMBER r��ocate on site plan) Pumps in worldng order.(yes or no): Alarms in woddng order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address; 7— �n owner.- Date of Inspection: !! 0 SOEL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: leaching m number:L (JY G✓ leaching number: 1 gsalleties,number: Icach(ng trenches,mmrber,la%&. leachingfielck nu nber, arcs overflow wool,mm*=- innovative/alternative system TyWhame of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding etc.)- ,damp soil,condition of vegetation, I CESSPOOLS•Z(cesspoo,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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:&(/locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): • Pagp 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addrem /10 ;a-4 C 7- Owner. PC,/ Date of Inspection: / v, 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, d ,14/ - 23 'fa `~Rw- 4j I page I 1 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) property Address: 6 G e H' c 'e. �} Owner. a r �- Date of Inapeetion: ii D Slope X (p (p Surface water Check cellar Shallow wells � 0 1 Estimated depth to ground water)9- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans an record-If checked,date of design plan reviewed site(abutting property/obsovation hole w thin 150 feet of SAS) with local Board of Heakh-explain: (/"t R'5 Checkod with local excavators,installers-(attach documentation) �0F Accessed USGS database-explain: You must descnU how yqu estabjished the high ground water elevation: Gr 1NaTey i -S W1,• - (a wv S o tv zones T a P o ' G-,% de oDo co •. 00o106 1 ' `90 ID AI 1-9 9.3 - COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 �y I yJ�y WILLIAM F.WELD TRUDY COXE Govemor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 16 Garth Court, Centerville Address of Owner: C Kenneth Leavitt Date of Inspection: //—/ 7—(? -7 (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: 64M E Robinson Septic Service Mailing Address: PO Box 1089 , Cent_Prvi 1 1 p., MA 02632 Telephone Number, 5 0 8 7 7 5—f17 7 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address arid that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on myCtraining in erfunction and maintenance of on-site sewage disposal systems. The system: YPasses T! 08e Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: A2 k,k Date: A/ 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: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] YSTEM 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. Indicate s, 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 system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http://www.magnet.state.ma.us/dep ej Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 16 Garth Court, Centervill&e Owner: Leavitt Date of Inspection: BJ 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 CJ F RTHER 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 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 less 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: 16 Garth Court, Centerville Owner: Leavitt Date of Inspection: //-17—%7 D] YSTEM FAILS: You st indicate ei;•.er "Yes" or "No" as to each of the following: 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 he failure. Yes o 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. EJ LAR E SYSTEM FAILS: You m st indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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: 16 Garth Court, Centerville Owner: Leavitt Date of Inspection: /1-17 ?1 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 t% as part of this inspection. Y _ 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. _ 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 16 Garth Court, Centerville Owner: Leavitt Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no): /1'o Laundry connected to system (yes or no):XS Seasonal use (yes or no):� Water meter readings, if available (last two (2) year usage (gpd): 1 995 — 21 , 000g Sump Pump (yes or no): .fi v 1996 — 23 , 000g Last date of occupancy: J / —1 COMMERCIAUINDUSTRIAL: Type o establishment: Design fl w: gallons/day Grease tra present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non-sanitayy waste discharged to the Title S system: (yes or no)_ Water me r readings, if available. Last dat of occupancy: OTHER- (Describe) Last da of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System p mped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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: _S Sewage odors detected when arriving at the site: (yes or no) pt.O (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16 Garth Court, Centerville Owner: Leavitt Date of Inspection: 1/,,117—q,7 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construct' _cast iron _40 PVC _other (explain) Material of construct'�— Distance from privat water supply well or suction line Diameter Comments: (conditi n of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on Site plan) Depth below grade: Material of construction: LA oncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) t r�;'• y . N fi Dimensions: Sludge depth: 3-Z/ Distance from top of sludge to bottom of outlet tee or baffle: ZTO' Scum thickness: ) 3 , , t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: )A How dimensions were determined: 6 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of Iii id level in relation to outlet invert_ structural integrity, evidence of leakage, etc.) //s i> .y �T�- I C 26 Z ICXP t /h. G tY s .O GREAS TRAP: (locate o site plan) Depth be ow grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimen ons: Scum t 'ckness: Distance rom top of scum to top of outlet tee or baffle: Distance f om bottom of scum to bottom of outlet tee or baffle: Date of las pumping: Comments (recomme dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16 Garth Court, Centerville Owner: Dpavitt Date of Inspection: '//�/.7_9 .7 TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate n site plan) Depth low grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensi ns: Capaci gallons Desig flow: gallons/day Alarm le el: Alarm in working order_ Yes; _ No Date of p evious pumping: Comment (condition 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, evidence of solids carxover, evidence of leakage into or out of box, etc.) A-1 D YS 6 05. PUMP HAMBER:_ (locate on site plan) Pum s in working order: (Yes or No) AI s in working order (Yes or No) Corn ents: (note ndition 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: 16 Garth Court, Centerville Owner: Leavitt Date of Inspection: /1-17-1 1 SOIL ABSORPTION SYSTEM (SAS): (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 h, draulic failure level of po ing, condition of vegetation,�etc.) —/ 6 v � ,d/ /bn .dG '�i; 0" 6 �6 oaf' d CESSP O15: _ (locate o site plan) Number a d configuration: Depth-top f liquid to inlet invert: Depth of s lids layer: Depth of sc m layer: Dimensions of cesspool: Materials o construction: Indication f groundwater: .flow (cesspool must be pumped as part of inspection) Commen s: (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate n site plan) Mater Is of construction: Dimensions: Dept of solids. _ Comm nts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16 Garth Court, Centerville Owner: Leavitt Date of Inspection: )1 olri-e 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) lVj i i pia I ' LI 1 / t. (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16 Garth Court, Centerville Owner: Leavitt Date of Inspection: y Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 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 l Describe in your own words how you established the High Groundwater Elevation. (Must be completed) O G�� TLC GvL�/4 . (revised 04/25/97) Page 10 of 10 LOCATION SEWi,CAE PERMIT UO. I �j� 7--- VILLAGE IWSTQLL IJ�►ME QDDRESSS BUILDERS Q &VAE �. ADDRESS DIaTE PERMIT ISSUED DATE COMPL I &MICE ISSUED : CIA, l No....... Fics... ®.............._ THE COMMONWEALTH OF MASSACHUSETTS BOARDXQ,_FHEA ......-.OF..... .................................................. Appliratiun -fur Uhipouttl Workii Tomitrurtiun Vautit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a aa -•--------------------------------------- e� p ---------. _3.....•••-- .-----••-----•-•- c cation_Ad s or Lot NG 5 .. .--•....... ............../--- ---------........._..---• _ -- ej Address .. ..... . ................................. ............................ ................... ---------------------------- Installer Address d Type of Building Size Lot_./�__: �_Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtu es ---- ----- -------------- - - Design Flow.___.__. �tllons per person per day. Total daily flow....... ,?__�p......................gallons. WSeptic Tank—Liquid capacit✓ allons Length-------_------- Width.......--------- Diameter---------------- Depth.-__---_.-_--- x Disposal Trench—No- ____________________ W i.............__._ 1 Len otal leaching area __ ..-;.�,sq. ft. Seepage Pit No..... :......._ e n Y tal leaching area------- ----------sq. ft. Z Other Distribution box ( )� Dosing tank ( ) '����''ff,, �i'�'7& aPercolation Test Results Performed by.......................................................................... Date---------------------------------------- a 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__.-.._--_-_._..__...--. 0 ---�------- {} .t p t v-v .-d 2__.. 7 (� Descr tton of Soil `.. . I .-` `��` ` Y - y- W VNature of Repairs or Alterations—Answer when applicable...--------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ; sued by the board oVhe.,,h. Signe ! Date Application Approved By--.-- -- --- ---- .•-- - G ..,-- -- ----------•---•- "_ .5 _...74--------- �' Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------••-•---•--......- •------•--------------------------------------------------------------------•---------••--••------••-•••--------••--•---•---------•----•-•------•------------------- ................................... Date PermitNo------------_----------•••--.......................... Issued........................................................ Date `t . 2 7 Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................OF......................................... ........................................... AVVIiration -for Ui. yoiitt1 Workii Tomitrnrtinn Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --------------------------------------------------------------------------------------------'-••- ............................................... Location-Address or Lot No. .................................................................•-.............................. ----------••----•-•••------------------...._..--•-•---.....••----------........................... Owner Address W Installer Address d Type of Building Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms............................... . .Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons..___-_---.-___------------- Showers ( ) — Cafeteria ( ) QI Other fixtures ----•------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity--------___gallons Length................ Width------- .._..... Diameter---------------- Depth---------------- xDisposal Trench—No--------------------- Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No.-_.________________ Diameter.................... Depth below inlet 3......,. ......... Total leaching area-------...........sq. ft. z Other Distribution box ( ) Dosing tank ( ) Q/✓' , �j ��- 7(i aPercolation Test Results Performed by---------------- ----•---------.----------------------- --- Date--------------------------- ----------- ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water.._.--_-_.--..-._-.----- 1:14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-------------..-._---.__. Description of Soil ..� y �+. .'t�-�� = - d Z t...... ��t-�- (f�c�s . p = _- x 7 W - ---------- ------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------................. VNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------. a ---------------•.----•---------------------------••-------••---•----------------------------------•-----•---•-•-----------------••---•-------••-----------------------•--------•--------•------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to lace the stem in operation until a Certificate of Compliance has b issued by the and of alth. /7 ---- ------------------------------ --------------- - -------------- -------------------------------- Date tgne _..:-. Application Approved By--.._. .�'^.::....�-- ,! '' 1/� ----•------•- --• Date e Application Disapproved for the following reasons---------------------------------•------------------..---------•-•-------•-------------------•------------------- ------------------------••---------•------------------------------------.----_--•-•----•-•-•------------------•----•---••---------•-••-------------------------•---------------------------------------- Date PermitNo..........................................-•-•........... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trxtifirate of Trrntphaure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---•---•--------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------•--------------- Installer at--------•----------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------------- has been installed in accordance with the provisions of Ar -")e XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._ __%z_?_ ________________ dated...-_-_r2_"_�_-.-_: -� TOLE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM 7 FUNCTION S TIS�CTORY. DATE._...-•--•--••-•-...... . .........-------• Inspector.... ------ ------•---•------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (� 2 ..........................................OF...............----._........................------------......._......----------- No.--•---... .............. FEE........................ Di pagal xk�, n�txnrtinn rrntit Permission is hereby granted......4 T' to Construct ( ) or Repair ( ) an Individual Sewage Disp/Osal System atNo...................................................................................................... ---------------------------------------------------------------------------- ............ Street / as shown on the application for Disposal Works Construction P r No._.. ___._ _. ated---- S'_�G.._..__.._. �' i Board of Health DATE.............................................................. ................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS x - M a � OV w '' 1. 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FLOOD ZONE: �v <¢ r� C,, SOIL EVALUATOP. 1 The installation shall comply with) p y h Title V and Town of Barnstable Board of _.�_ _.. . _.._.... WITNESS : -DCLO W4 >�l t t?I ► 1 ¢' REFERENCE: �k_0_7- ,a�e�,� DATE: 1b CSC) Health Regulations. 2) The installer shall verify the location of utilities, sewer inverts and septic n-�- PERCOLATION RA � � TE' G t components prior to installation and setting base elevations. ��� < �►!/ � \d� �� ► 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first tit - TH- 1 TH-2 two feet out of the d-box to the leaching shall be level. -1 (� 4) This plan is not to be utilized for property line determination nor any other l ? �1 purpose other than the proposed system installation. veo �7 Low y L 5) All septic components must meet Title V specifications. � & 13 2 6) Parking shall not be constructed over H10 septic components. Lb - A _ _._. 6�� 29 l W � ��, 7) The property is bounded by property corners and property lines. LOCATION MAP '1��"!�L 5mq!2 L 1-14, 5Ww 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt of payn"ent for the plan and installation based on the plan shall be deemed tW � approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material f�2, w ,} per Title V abandonment procedures. Those within the proposed SAS shall 'V �� - �i��. � �•�, �I be removed along with contaminated soil and replaced with clean sand per w At— Title V Pecs. � s1 / l -— 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40.PVC with ends grouted if "� I applicable. The proposed SAS is being installed below the water service -DQI YtfV�/ 1 4 SEPTIC SYSTEM DESIGN line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the ,,�.. -fir •s-�, +..- =: _ „ JFLOW ESTIMATE owner to ensure such. i' "`r •� 12)The installer is to take caution in excavation around the gas line. 51 , ` - �' BEDROOMS AT 110 GAL/DAY/BEDROOM -Z2-O GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer lines exitingthe dwellingprior to the installation J T c ~ SEPT!C_ TANK___--__'_- 14)If the existing tank is not a 1000 gallon minimum then it is to be replaced 44D with a 1500 gallon tank. 1D2 GAL/DAY x 2 DAYS - GAL 15)Per State DEP approval, clean washed sand is to be backfilled around the t? D bio-diffusor's. ►K USE} UD GALLON SEPT I C TANK (��t5nLi „ � •„ SOIL ABSORPTIONSYSTEM _Sz - W SI DE AREA: BOTTOM AREA: 1JL4(& ;Ftlql S1R LT'.= `1y�$L�� I&VA117 [� lfiJ ' lv4Sr SEPT, 1 C SYSTEM SECTIONZO � � - 'A "` W ► - - �, r l I� ► w ��10�'1yw1 ��v�i ►, wl��l � SP�n�.l �d��. �MM�► to 1000 GAL Z D (031Z! Z 5 SEPTIC TANK 2 A{Vu/5 b VAIII SITE AND SEWAGE PLAN ►� LOCATION : 1 C, �&' TH LD'Y'T MIA 0',' "�.=ry.»=t PREPARED FOR : ti SCALE: W DAV I D B . MASONI'R5 DATE: 9ZWS 0 DBC ENVIRONMENTAL DESIGNS z EAST SANDWICH . MA 3 DATE HEALTH AGENT W ( 508 ) 833- 2177 Z