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0086 GOFF TERRACE - Health
86 Goff Terrace Centerville F/R A = 170 085 a I 1521/3 ORA 10°/® P2 0 �.-.,.•. 'w� wei9e.'.w.`.'�,...wvxJdllM.dYi�lu'a.`.elczr_ ,, No. L_O I q3 Fee s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippliLAtion for Misposal Opstem Construction permit Application for a Permit to Construct( ) Repair()(-Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. ?(a ���� r���(V L4J Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel ,°10 ® er,- Installer's Name,Address,and Tel.No. Tod'—41?-W 1, Designer's Name,Address,and Tel.No. G 8 Ook_ao 3&3 P47-yvWf Type of Building: Dwelling No.of Bedrooms �� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided A16 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) q tj 14'l® 0 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 He Si Date Application Approved by h - Date S ��i Zc Application Disapproved by Date for the following reasons Permit No. y3 Date Issued " .::(94 y >yyt•Y-R,i.l:.{fs.A.. ,-+t'A",'n.`a. _..M1;.., r.._..««...,... _ . 'Y.. r.. y ..+c>t•n F.. r .,-.,y.3,,.-.,44Y.S'AR'T*``.# '... "'i..«•:'I.gT'.ti-,Kt'F!�. ry t No. �(r© "` �� F Fee THE COMMONWEALTH OFF MASSACHUSETTS Entered in computer: Yes� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS z: - application for Zisposal 6pstrm ConstrUrtion Permit Application for a Permit to Construct( ) Repair(AT Upgrade( ) Abandon( ) ❑Complete System .Individual Components Location Address or Lot No. g'(, erog:F= -rft 4V ujt1` wner's Name,Address,and Tel.No. �1 Roaew"�.'t' LA.55 tTC_q.,. Assessor's Map/Parcel 1n 70 io Q cm S Installer's Name,Address,and Tel No. 'S`q . �'�•' 't'1 Designer's Name,Address,and Tel.No. Type of Building: - Dwelling No.of Bedrooms Avl Lot Size sq.ft. Garbage Grinder( ) Other Type of Building - , No.of Persons Showers( ) Cafeteria( ) Other Fixtures A� J Design Flow(min.required) }}- gpd Design flow provided ,to- gpd Plan Date Number of sheets Revision Date Title Y Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) [ Date last inspe ted: Agreeme i-7 r„y. =�lie undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in t accoraancegwith 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 HeWth. - .--. Sigle Date •�' A � ' Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Z07 — ] -3 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance 1-, THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired O ' Upgraded( ) Abandoned( )by f' *Q&T ps at '(� � �1 ((( has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dated 5h"/-M) Installer 2 0j <—* 0 Designer €T TA #bedrooms A—A Approved design flow / gpd The issuance of this permit shall not be construed as a guarantee that the system will function as-designed. Date Inspector No. Fee$ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Vermit Permission is.hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at , "' ", s C14'.nk and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construclion must be completed within three years of the date of this perm = Date Q Approved by ,t ��iwe tqw Town of Barnstable + BARN3rABLB. 6 ,�� Inspectional Services Department prfD MA'S A Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well ❑ A portion of the cesspool is located within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ; ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER (Zoe-�Pd Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S1 14503 on the computer, Micheal Sears use only the tab key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path Company � Company Address South Yarmouth Ma. 02664 Cityrrown State Zip Code 508-477-8877 SI 14430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes ' ` �H OF 1, 2. ® Conditionally Passes � . , ' ? MICHAEL�yN' 3. ❑ Needs Further Evaluation by the Local Approving Authority o; SEARS *: No.SI14430 :i0 4. ❑ Fails �' o o,•Q y ij•.FR T 1 F�� ' �` icy(F•• , , •.•G�``��� 5-11-20 Inspector's Sig ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ® one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.cloc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Goff Terrace V Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if i pumps/alarms are repaired. ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): D box walls are gone needs to be replaced ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in.order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form `-1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 AN, Commonwealth of Massachusetts �n Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is Centerville Ma. 02632 5-11-20 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form ' I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I? <I�� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 4-23-20 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Goff Terrace u� Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank; distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® Not 5. Building Sewer(locate on site plan): Depth below grade: 22"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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 86 Goff Terrace ,u Property Address Robert Lassiter Owner Owner's Name information is Centerville Ma. 02632 5-11-20 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 12" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gal 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 24" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge gudge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with inlet and outlet tees Inlet cover at 12" below grade outlet cover at 4" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 A r Commonwealth of Massachusetts Title 5 Official Inspection Form lI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is Centerville Ma. 02632 5-11-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 r cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form �i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Goff Terrace V� Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 with 2 outlet pipes D Box is no good, walls are gone D Box is 25" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�� 86 Goff Terrace u— Property Address Robert Lassiter Owner Owner's Name information is Centerville Ma. 02632 5-11-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2- 1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 86 Goff Terrace u- Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2- 1000 gal pits both pits are clean and dry Pit 1 is 30" below grade with cover at 1" Pit 2 is 23" below grade No sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form I4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ............. 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is Centerville Ma. 02632 5-11-20 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 13q c Lf A g 01 3e3 1 —►9.8 3 —35ob 0 el y 5 —a5o9 5 �' Z Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of l5insp.doc-rev.7126/2018 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form iIII Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Goff Terrace Property Address Robert Lassiter Owner Owner's Name information is Centerville Ma. 02632 5-11-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: 2-21-79Date ❑ 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: Plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 I c Commonwealth of Massachusetts �n Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 86 Goff Terrace u Property Address Robert Lassiter Owner Owner's Name information is required for every Centerville Ma. 02632 5-11-20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. <71 33 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for IDigpogat bpetem Con.5truction Permit Application for a Permit to Construct( )Repair(�a Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No.5& 4 `r -errace_ Owner's Name,Address and Tel.No. /7 Assessor's Map/Parcel Installer's Name,Addr/�is, d Tel.Nqs „ Designer's Name,Address an Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ' Size of Septic Tank Type of S.A.S. Description of Soil, Nature of Repairs or Alterations(Answer when applic(e) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this B d of Health. Signed Date (� V Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued t a`�1 01 ' i e 33 Feed THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS - 3pprication for ]3i!5po!5ar *p!tem Construction Permit C Application for a Permit to Construct( . )Repair(M Upgrade( )Abandon( ) ❑Complete System 0 Individual Components Location Address or Lot No.,5& G7 e f roice, Owner's ame,Address and Tel.No. Assessor's Map/Parcel �' /7 0 Installer's Name,Addre s, d Tel.Nd. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of,Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other I pe of Building No.of Persons Showers( Cafeteria( ) Other Fixtures, Design Flow J� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. t Description of Soil Nature of Repairs or Alterations(Answer when applic le) ... r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until /a Certifi- cate of Compliance has been issuedrby this Board. of Health. ,���Signed C (�/�-�- �� Date Application Approved by Date Application Disapproved for the following reasons Permit No. -' t Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance C THIS IS TO CER FY,,,that the site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at E77 0 '7Lf {� �iLC,/ /"� 0 llastK&V A dtructed in accordance with the provisions of Title 5 and the for Disgosal System Construction Permit No. b �{ ' 3 dated t!/2 installer Lil Designer !1 The issuance of this permit shall not be construed as a guarantee that the syst will function/ designed. Date 11_ t> U`t Inspector .. "t• _ �� �r -----�J---------------------------------- No. / ���� Fee A�o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETM-,��,--�, Miqu of 6p,5tem Construction Permit Permission is hereby granted to Construct( )Repai (� )Upgrade( )Abandon( ) System located at <_7/ I —4 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. � Provided: Construction ust be completed within three years of therdate of thi. pe, t. Date: �I I��' I Approved by------ TOWN OF BARNSTABLE LOC,ATIG i �� \-�'f`C`CtLe SEWAGE # AQ 33 VU;.AGE e�` \�e- ASSESSOR'S MAP & LOT 170-Orr INSTALLER'S NAME&PHONE NO. 70 CAS SC-I t �04�-1 79+'I gig SEPTIC TANK CAPACITY k Q17C7 C*c.` l V" O, i n5� � , LEACHING FACILITY: (type) +2 c T (size) 7 7ica NO.OF BEDROOMS BUILDER OR OWNER L ,ri VIA PIA rr 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 /C7) © � I /i .l h i o. f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS z a DEPARTMENT OF ENVIRONMENTAL PROTECTION IW It ti She _ DEC 15 2004 t,y �. T OM,,,0Y"BARNSTABLE TITLE 5 "E"�TH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner's Name: CAMMARANO Owner's Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Date of Inspection: 11/22/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the *. tion. The inspection was performed based on my training and experience in the proper function and mai en c of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of i e (310 CMR 15.000). The system: _ Passes / X Conditiona as es _ Needs Fu luation by the Local Approving Authority Fails Inspector's Signature: Date: 11/22/04 The system inspector shall submit a py of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectio . If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shal submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM CONDITIONALLY PASSED TITLE V INSPECTION.D-BOX IS STRUCTURALLY UNSOUND AND OFF-LEVEL AND NEEDS TO BE REPLACED. *.***This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 1ncnPntinn Fnrm 6/15/ 000 1 r Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: 11/22/04 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: SYSTEM CONDITIONALLY PASSED TITLE V INSPECTION.D-BOX IS STRUCTURALLY UNSOUND AND OFF-LEVEL AND NEEDS TO BE REPLACED. B. System Conditionally Passes: X 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. n/a 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. ND explain: n/a n/a 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: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: 11/22/04 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. I. 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. _ 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: 11/22/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n1a. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. 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. 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. a f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: 11/22/04 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S Page 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: 11/22/04 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):tie 1/ 1 Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL C)Z- - qD 6C Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YEAR PER OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1978,NEW SYSTEM 1996 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO F 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: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: 11/22/04 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6"H 51711 W 4' 1011" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: I1/22/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(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.): D-BOX IS STRUCTURALLY ROTTED,UNSOUND AND OFF-LEVEL. PUMP CHAMBER:-(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R f Page 9 of 11 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: 11/22/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GALLON 6'X6' LEACH PIT leaching pits, number: 2 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.DID NOT EXPOSE OLD PIT.NEW PIT WAS EMPTY AT TIME OF INSPECTION.PIT HAS NEVER HAD MORE THAN 1"OF LIQUID IN IT.BOTTOM IS AT 10 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: 11/22/04 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. V v A- v- A C 0 a D to jPage I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 GOFF TERRACE CENTERVILLE,MA 02632 Owner: CAMMARANO Date of Inspection: 11/22/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. tt TOWN OF BARNSTABLE , LOCATION ��? \-��(`rc LE SEWAGE # 2tm Y-633 VILLAGE ASSESSOR'S MAP & LOT /70 ors' INSTALLER'S NAME&PHONE NO. O V�e�A5 SL 1 —1 -Iqciq SEPTIC TANK CAPACITY c k O�3 0 i h 5 LEACHING FACILITY: (t)pe)�,2 (size) NO.OF BEDROOMS BUILDER OR OWNER C vtn n4 Cb ^ PERMIT DATE: 2 O COMPLIANCE DATE: I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of LeachingFacility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I , 11C) 0 -z 0 C3 � I TOWN OF BARNSTABLE Lgc7AknO14 SEWAGE # VILLAGE OntO AM 10 ASSESSOR'S MAP & LOT '�iJ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY -LEACHING FACILITY: (type) (,z) .(size) NO.OF BEDROOMS I BUILDER OR OWNER W d l-(J PERMITDATE: 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 byl �30 � a 3S(7 b Zr] � a BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508428-8926 FAX: 508428-9399 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI1���, N�,���FQQ��I1V1��, PART A � UtRAAI .,..:,),,. ... CERTIFICATION ®," _PARCINO: Property Address: Date of Inspection: -� - Inspector's Name: Robe,r ,J er's Name and Address: CERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes C nditionally Passes eeds;Further valuation B the Local Aproving Authority Fails Inspector's Signatu Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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. INSPECTIONSUMMARY: 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. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,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,cracked,structurally unsound, shows substantial infiltration or exfiltration,or.tank failure is imminent. The system will pass.inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due td 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): -.1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER 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 FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC-HEALTH AND SAFETY AND THE ENVIRONMENT: i The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. JID)STEM FAILS: have determined that the system violates one or more of the following failure criteria as defined in 3 10fiM 15.303. The basis for this determination is identified below. The Board of Health sho be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. ischarge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day flow. clogged or obstructed '�tequired pumping more than 4 times int the last year)!LQT due o gg pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. .Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 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 I1 of a public water supply well The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: i"-Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. /The site was inspected for signs of breakout. e—All system components,excluding the Soil Absorption System, have been located on site. 'ne septic tank manholes were uncovered,opened,and the interior of the septic tank was in- pected for condition of baffles or tees,material of construction,dimensions,depth of liquid, Al depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(cominued) V The facility owner(and occupants, if different.from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL Design Flow: T 3egallons Number of Bedrooms: 13 Nuyiber of Current Residents: Garbage Grin er: A& Laundry Connected To System: Seasonal Use: Water Meter Readings,if available: Last Date of Occupancy: A_16r6/) COM_MERCLAi./INDLiSTRLAI.:f�/ Type of Establishment: Design Flow: aallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 414cll A6004 /71 System Pumped as part of inspection: —' If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: Lj� Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AOROXE%IATE AGE of all�mponents,date ins talled(if known)and source of information: Sewage odors A..detected when arriving at t e site: -4- r. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Y Depth below grade: Material of Construction: A,-c-'O'ncrete metal FRP Other (explain) Dimisions: .5'X `X'S' Sludge Depth: Scum Th ness: O Distance from top of sludge to bottom of outlet tee or baffle: ,3 Distance from bottom of scum to bottom of outlet tee or baffle: y Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation t utlet invert, structural integrity,evid nce of le age,etc.).�4S a--/QZ v -C'IS:L Cep rf re GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK:�lU Depth Below Grade: Material of Construction:_concrete—metal_FRP—Other(explain) Dimensions: Capacity; gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: V Depth of liquid level above outlet invert: W Comments: (note; el and distribution is equal,evidence of solids carryov r,evidenc f leakage int or out of box,etc.) j PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) A _5_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (couthmcd) 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: Comments: (note condition of soi signs of hydraulic failure level o nding, ondition of vege n, etc. GGc' _ E'Q C'6' i o� ' r J' CESSPOOLS: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,.condition of vegetation, etc.) PRIVY• Q Materia s of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. DEPTH TO GROUNDWATER: Depth to groundwater: /,3 Feet f Method of Determination or Approximation: -7- No. `/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYtcatton for Mtgool 6pgtem Congtructton permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. g 6 ® ��r/ e Owner's Name, ddress and Tel.No. Assessor's Map/Parcel /6efo Inst �'s N Address �d Te�N� Designer's Name,Address and Tel.No. 77�`Cs7�< Type of Building: Dwelling No.of Bedrooms 3 �- Garbage Grinder Other Type of Building�Rfi&e eNo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow ,3 a gallons. Plan Date Number of sheets Z. Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) �9/ TZ_� 5r-e ee"5 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued ' B He �/�/� Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ———————————————————————————————---—————— Ogg No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS d 2pprication for Migpooar 6potem Con6truction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: i Location Address or Lot No. Owner's Name, ddress and Tel.No. Assessor's Map/Parcel J ��� r S Inst er's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �0/�7`OLD GO���`, -7.7 9'39 Type of Building: Dwelling No.of Bedrooms 3 y Garbage Grinder Other Type of Building e 14Qr &6 e-No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date .3 /qJ9 Number of sheets Z.- Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) �9��� ILI IL Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site�sewage disposal system in acaordance'with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issued . s B d of He � Signed Date (> Application Approved by Date Application Disapproved for the following reasons a, Permit No. Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 170 - 0 gs BARNSTABLE, MASSACHUSETTS Certificate of Compliance . THIS IS TO CERTIFY,that the On-site Sewage Dispos 1 Syst m'nstalled( )or repaired/replaced( )" on by Installer ©/ AT 6t:P!l CQ�✓�" at g/, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Constructio ermit No. ' 3 75' dated Date !? 9- Inspector THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE - T THE SYS- TEM WILL FUNCTION SATISFACTORY. r ———————y——————————————————1 —— — No. � �.� ! 7,01 — Fee J � e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogar 6potenYyLC1on�t^ruction Permit Permission is hereby granted o ��/ �e/ / to construct( )repair(Lan On-site Sewage System located at No.# v w Ilem sweet l and as described in the above Application for Disposal System Construction Permit. 7,16 No.:a7Jr' Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. ``� Date: .� - 7 7� Approved by N' �k J Board of Health �s Al PeJv. �� T,'-,7-ezACe- �v / /o o,o 0 1 ca- -7¢ A � o ,2/ �N � P hJ 7?�oe E Y 1► nFox u + Now- 67.tvA�,,✓s 8'4sED oti Ass o tir-a DA-rv.y ` 4L CERTIFIED PLOT PLAN LOCATION .G�'T!7 ViC.G E� .Miss.. . . . . SCALE . . . . . . 30 J. . . DAtE ` PLAN REFERENCE �7"�G. . 407. .iS.A5 I CERTIFY THAT THE E37!Sn�vG �iwa*�7o� SHOWN ON THIS PLAN Is LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE i7G // SETBACK REQUIREMENTS OF THE TOWN OF j,e�GC / fJ 3 _ E. . . . . . : . . WHEN CONSTRUCTED. U�,el I✓/. DATE )tL: Z� y/A ' PETITIONER; �� J'✓�//= �%�I ems", REGISTERED LAND SURVE N59345 TOP OF FOUNDATION „•� CONCRETE COVER j.�• ,,• CONCRETE COVERS • ; 4"CAST IRON 12"MAX. � r PIPE (OR 12"MAX "nF/41 EQUIV.)- MIN. 4"ORANGEBURG(OR EQUIV.) PITCH 1/4"PER, PIPE- MIN. LEACH PITCH 1/4"PER.FT PIT °•' ST NV RT NG INV RT INVERT : W SEPTIC TANK DIET. 40 EL... . ,Bo . 80X EL......... >s V.INVERT .. . . GAL. INVER�TEL..... 7 INVERT V1 v n I F/2EL9?!7.� W W Q• D 2�-- -6'DIA --+-) -� .• . . �+--- /o 1 DIA.---+� n/oNtt PROF1 LE OF GROUNDWATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE PRELIMINARY 3 SOIL LOG WITNESSED BY : DATES.Z;!%.%�. TIME. �-30..a,� p��G . !`>�!e,� BOARD OF HEALTH TEST HOLE I TEST HOLE 2 774> ^40 E' P.E• ENGINEER ELEV. .¢Z,B. . . . ELEV. .. .. . . . . . . �. . . . Arr °Dw,+)e E G.S. /j Wc�vL�oi►-.y . DESIGN DATA .' NUMBER OF BEDROOMS -3 TOTAL ESTIMATED FLOW . 3-3o GALLONS/DAY JA*�D BOTTOM LEACHING AREA �B„So SO.FT. /PIT /Zo SIDE LEACHING AREA �BB'. SO.FT./ PIT Fi,vE S,Aaip i3 z •' GARBAGE DISPOSAL (50% AREA INCREASE) htDiu.7 TOTAL LEACHING AREA . ?47.9p. SO.FT /"„ PERCOLATION RATE 44'Ss .7?,- ! .7;,,!o MIN/INCH LEACHING AREA PER PERCOLATION RATE So. . SQ.FT. /Vo .WATER ENCOUNTERED NUMBER OF LEACHING PITS 4,'17- Wirt/ Tvo. APPROVED . . . ... . BOARD OF HEALTH "le-4 S/pm /s, R" R177 . . . . . . . . . . . . . . . . . . . . . . . . . . DATE. . . . . . . THOMAS E. KELLEY CO. AGENT OR INSPECTOR ENGINEERS-SURVEYO 346 LONG POND DRIV / SOUTH YARMOUTH,MA S. P��H OFM Lpr 46 QF+y��� ` 62664 2 ti God KEUEY o!Y6 S V,f 1 yy . �' ► p No.2426e O -7-7� 7 -o rYq !7D.tJ ��/V�" !;. ` + +n' C 9p�FG/ST6Q`�.�►�' PETITIONERrv.e��3 . . FS/pNALE�6\ Gt!fy• CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERAII1'(WITHOUT DESIGNED PLANS] I, l�0��'i' �a/�/7`�hereby certify that the application for disposal works construction permit signed by me dated �/6/�.6 , concerning the property located at 61 6©� Ie���Ge meets all of the P Y following criteria: '/ Ti cre are no wcllands within 300 feet of the proposed septic system /Tlic icre arc no private wclis within 150 rest of the proposed septic system observed groundn•ater table is 14 rect or greater below the bottom or the leaching racility V ere is no increase in (low and/or change in use proposed There are no variances requested or needed. SIGNED: DATB: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAttach a sketch plan or the proposed system. Also If the licensed installer posesses a certified plot plan, (his plan should be submitted]. ?`,Gi=t""'�,�.'^,�s'q'rs�.l✓�."'" yr .���rp�3�� Y-,�.y.; _..�_' .�_tits .1`f r +7�.�?.x„ .1t ��L...#' "_, 4.;;,fir R.> r a' `� r :, ' f`• 'tL ' �r^.;;tz ,�'�.+ 4 "' y .,:ur�;,,,�. ".,.y#' "`x,�=�.0.'`F�. �..;e r� �.,;:s� -. ,' °:.�tw s � t..'�r".�....�s ,__ :�"d•'.`.sx=t ^ -.`�..r x � �.';'i� i., ;. ..-. .R'�>.- aid ,�-��`a�._✓.� a .ESA >a,:; ''t.�x.wf` �5�``-.yat,�:.e-�:t'u i ..rr-'f�' -�--�s*�r�*8f t, .;Cy Ss 't��,wr�$ rk ;}_='f�7{+�1 �.; ��,y ,aN.FY7 e�. a .��,k"'•r � ��,. *,.. 5•y�.-n�.�A..w+�:. W���"��. t s M a i- TOWN OF BARNSTABLE 1 LOCATION �� 0'/,0 SEWAGE # fV1 VELLAGE �i yl 7�'/�Lai Cle ASSESSOR'S MAP & LOT Zj�-eg_ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �/T �� / (size) OF BEDROOMS 3 BUILDER OR OWNE PERMTTDATE: 7`" COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of 1 ching facility Feet Furnished by �,. 3o b 40 b '� t, j71 �o J:51 �� LO=CATION SEWAGE PERMIT N0. 5- cm VILLAGE INSTA LL R'S NAME & ADDRESS �� OLD BUILDER OR OWNER DATE PER IT ISSUED L/ ZZ DAT E COMPLIANCE ISSUED • _. �� ��'�. -. .�., .,` � r ., \ �. . ®�_, �.p s ... ................F.R is... ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR-Q OF HEALTH ............T 41C................................... ..........0F.T.A.W..1 Appliration for Bhipogal Workii Tomatrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ........CO F.....Tg......DL................... ........................... ................................ ................ ....................................................... '—Y. cation-Add 5- or t ......aa S ------- ......D'A...... Owner dr s,.j.r ........................ .... ..... ........................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...............I.......................Expansion Attic Garbage Grinder,; Other—Type of Building ............................ No. of persons.....................__.___. Showers Cafeterta A4 Other fixtures ................................................................................................................................. ...................... Design Flow............ ......................gallons per person per day. Total daily flow-------- .... .................;.-gallons. P 04 Septic Tank—Liquid capacity./.Q.OQ. allons Length................. Width................ Dianieter��......... Depth......_.._...... Disposal Trench—No. .................... Width_............_...... Total Length......._............ Total leaching area............ sq. f t. Seepage Pit No--------------------- Diameter.........___.__.___. Depth below inlet......j ...*�� leaching area..................sq. f t. 0 _ . Other Distribution box Dosing tank Percolation Test Re ----------------------Y_ Date.... ,jults-_,,,yerformed by. .......................... ................. 1 !:�V... Depth t� .............. Test Pit No. 1-05.Nr.....minutes per inch Depth of Test Pit----- ground water.... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........._.........._... 04 ------------------------ ------------------41---------------------------I..................................................................... 0�4 Description of SoiLlp........W A.9..n.. ...... ................. ...4'*VAJI-)0 .. '"7. '..3,J -.-/_/. .......M..C.0.jCA1JjM......PaAm..t)�............. U 1.01-a..— .p a.. .......r ...........J .... . /.V ....................................................................................................................................................................................................... U Nature 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 TL I'�M 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sied...... . ip,bl;............................................................................ .............................. Date Application Approved By.=.... .......... ..... ..... . ..... ....................................... Date Application Disapproved for the following reasons:............................................................................................................... .....................................................................................................................----------------------------------------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Taw. -v Appliratinn for Bispnial 10orkfi T=34rurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal systQ Er....T: . Location-Address ......................................... . -------�--Y&O . -.-1O.-----// '4'4 fp► Owner fddr ss w _ .fi._... ., -----------------------------------------•-----•--- �' ► --- °�- ... ` = I ' s t.c�: ..... a Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.........._. .._..•..•--•.-______....Expansion Attic ( ) Garbage Grinder (( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ............................................................... w Design Flow..........._1.0.......................gallons per person per day. Total daily flow........ ...+ ...................gallons. WSeptic Tank—Liquid capacity.f gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..:.................. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin�p.,tank 4 ) 4 - /�� � ~' Percolation Test R Its ,Performed b V'_V_fi t?_. Date.. ;.lr? Test Pit No. � p p P ground : 41t.___.minutes per inch Depth of Test Pit____ ____ _____ Depth to water-----''�................. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - -- - --- O Description of Soil.-��""' 1 Q u- j 4.! �� y. r --------------- � ......�-�...... w •-•-----••-•-------••-------••----------------••••--•---••----•-••-•----•---•--•-••••-------•-•--------•---•-------•••----------•-----•------------------•-•----••--•-•-•-•--•------------------....---- UNature of Repairs or Alterations—Answer when applicable______________________________________________•-_--...._.........._............._..__......... ..--•--•----------------------------------------------------•-•--------------------......------•----•---------•--•••---------••----•---••------••••---••-------•-•-•--------•-•----••---•-----.....--•- Agreement: The undersigned agrees to"install the aforedescribed Individual Sewage Disposal System in accordance with provisions of TITLE the p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has"been issued.by the board of health. Signed....... ...............•-------....-•----.........---------------------------•----... ................................ i Date Application Approved BY*-----� ..... I & .................................. .............. Date Application Disapproved for the following reasons------------- ---•••--•----•------------- ---•- •----------------•----•---------------------•---••-...............................................................................................----------------------------------------------------- Date 5 PermitNo................:........ Issued-......................................---=•---=-------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1, .. :t.NU. i. ,ry ................... �� �rr�i�irtt#r oaf �unt�lt�nrr i T IS S TO -C�g ETIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ,�y by - <- - { .. .........................................------------------....--•-------......-•-----•--........ .............-----..............--- _,.y.� Installer / yy at.....4_Q / _.......I _...... : �r..-. �-I - ______________ _ ++. *"! .#t . .f_ _r_ "r, ..........�_.__.___._..______ has been installed in accordance with the provisions off 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit ' dated- .!2_.,�.K_,7_ ,_---------------_....... PP P f -Af-%------------- - THE ISSUANCE, OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNdTION SATISFACTORY. DATE..... .............. inspector.--•------� .-' T........................................ i� THE COMMONWEALTH OF MASSACHUSETTS BO OF HEALTH a ),.;J:.......OF... 14. k .. ► I .. ,. !�'"``............... F sue► Diap al n k �n rnr#uan rnti 4 -� Permission is hereby granted.. .f_'............4t.V.=' to Construct ) o epalr )''` n Individual Sewage Dispos sterq.* r 1 at No. •-•-----•----.. -t'" ... 5�o: .. : . ._ .. .tom. _.f� ----------------------------- Street as shown on the application for Disposal Works Construction Permit NV_ ............ ______ Dated_"�_�_�'_7�✓�..._._....._..._.: Board of Heal DATE---- ----.............-----------------•--....---------••.....---- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - TOWN OF BARNSTABLE - 1 LOCATION Cr /-drlI16Y SEWAGE # VILLAGE&/2 P16-0 ZZIC ASSESSOR'S MAP &LOT( lam$ 'S NAME&PHONE NO. � SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ti (size) NO.OF BEDROOMS �S BUILDER OR OWNE PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by - At A 'N peg V. l 1 A + � I S v � ` � ELEV,7ap �D t��STING X �\ 731 21 PIP r f DfST � � !'"`r fir;i:,.,`'�'.'•� 8ox , l NorE �Z�w�,�.s 8�s,�a ati AS S v y�D DAM CERTIFIED PLOT PLAN I . LOCATION SCALE . . / �/ 30�. . . DATE el ��! PLAN REFERENCE . ,4�D . l0Z-Q9-peZ> . . /N . . . . . . . . . . . I CERTIFY THAT THE E�t!Sr»6 �c.� 0 SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE e - ,,��,� SETBACK REQUIREMENTS OF THE TOWN OF . . . . WHEN CONSTRUCTED. , .v �Ael v,s- DATE PETITIONER. /5' ` � �/AI�//�.j REGISTERED LAND SURVE R N59345 TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 4"CAST IRON 12Xnn- � T3LA PIPE (OR 12"MAX4"ORANGEBURG(OR EQUIV) IT IV.)- MIN. PIPE- MIN. LEACH PITCH 1/4"PER. PITCH 1/4"PER.FT PIT TNVERTNG EL.. /• Z.. INVERT INVERT o .SEPTIC TANK eo DIST. 4 V.EL..�.•. . . . . ......... >INVER? BOX ��9 /D00�.. GAL. INV RT INVERT � ww 0: I/27� u-o �.EL�b:.3o r: SH DW PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE P011ELUMONARY SOIL LOG WITNESSED BY : DATE TIME E. ,3a A?9. /D�xiL M�i,QA2A�/. BOARD OF HEALTH TEST HOLE I TEST HOLE 2 7;ir4yrl�� j � � ENGINEER ELEV. .4Z,63. . . . ELEV. .. .. ... 8.� DESIGN DATA ' NUMBER OF BEDROOMS .3. . . . 30" 3 TOTAL ESTIMATED FLOW 0. . . GALLONS/DAY �B;,So ?,gvD BOTTOM LEACHING AREA SQ.FT. /PIT �Zo SIDE LEACHING AREA . i8B'. SOFT./ PIT Fyti� S,g�p GARBAGE DISPOSAL .�Yq'(?4.00% AREA INCREASE) 13z TOTAL LEACHING AREA . 74.7 as. SO.FT SA^wD PERCOLATION RATE so MIN/INCH LEACHING AREA PER PERCOLATION RATE ��Q. . SQ.FT. Yq .WATER ENCOUNTERED NUMBER OF LEACHING PITS �.P�?' wig/ Two• APPROVED . . . . . . BOARD OF HEALTH � �F•'T r-1,r PA.' SjZ>e',, =1.6:` 7D4.)5 oLSJr.>Nr R&W Ai7'; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE . . . . . . . THOMAS E.KELLEY CO. AGENT OR INSPECTOR ENGINEERS-SURVEYORS 346 LONG POND DRIVE SOUTH YARMOUTH,MA S. OF 00, Gar vw OF VAS 02664 O)EAR`S KELLEY --4 1 Jo ,p No.24260 y AM K /STf������v `w Q F ONAL a6 PETITIONER `GICT�, yo S� E