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HomeMy WebLinkAbout0192 GREAT MARSH ROAD - Health 192 GREAT MARSH RD., CENTERVILLE A= 210 187 ag I 4 4 , 1 I I `I r I UPC 12534 No.2-153LOR HASTINGS, MN Commonwealth of Massachusetts Title 5 Official Inspection Form lSubsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 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 A. Inspector Information filling out forms on the computer, use only the tab Michael Sears 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 Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 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 OF�As����'/z 2. ❑ Conditionally Passes MI EL 3. ❑ Needs Further Evaluation by the Local Approving Authority o SEARS *: No.SI14430 4. ❑ Fails 'p�Sr iN3Pt�G`O`�p 5-5-21 Inspector's Signatu 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 �� TOWN OF;-B�ARNSTABLE LOCATION f Gl�'GC�o 1,tEih ��� SEWAGE# 90J(p -0L)7 VILLAGE CCt, J-e �;� `P ASSESSOR'S MAP&PARCEL 9-1 D 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IX— LEACHING FACILITY: (type) f 1 ek3 (size) J'L)(S ) NO.OF BEDROOMS LA . OWNER AA0V 'l e, PERMIT DATE: G COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ,S 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 Wtocl� - µ F.a Qp 20, S- -PC-S-7 � 1 'PC.- 12,-7 � 9tss' �-TO �P ©p T 10 SEW E PE RMIT N0. VILLAGE l P� wiI/U'�ilA�/Cf7J INSTAL ER'S NAME ADDRESS B U It D F R OR / OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED I . i r a?a 6�` b;� r pp! 0 �„'��� U a .h� �� e �(�� � a° �•-� 'i c Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Great Marsh Rd. V Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ 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): 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 ��a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is Centerville Ma. 02632 5-5-21 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ,�p Title 5 Official Inspection Form 4I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is Centerville Ma. 02632 5-5-21 required for every page. City(rown 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/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Great Marsh Rd. u Property Address Gary Morris Owner Owner's Name information is Centerville Ma. 02632 5-5-21 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 Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 000 gal Water meter readings, if available (last 2 years usage (gpd)): 2020-2019-93000 gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Great Marsh Rd. �V Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Winter 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Great Marsh Rd. u Property Address Gary Morris Owner Owner's Name information is Centerville Ma. 02632 5-5-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2-24-16 #2016-047 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth belowgrade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): H 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 Commonwealth of Massachusetts �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Great Marsh Rd. -u Property Address Gary Morris Owner Owner's Name information is Centerville Ma. 02632 5-5-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal 2" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Sludge judge, 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.): 1500 gal tank with inlet tee and outlet tees in place, inlet cover 6" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 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 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 4 outlet pipes, cover at 2" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 page. Cityrrown 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.): 1000 gal pump chamber in working order * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 12'x50' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 page. Cityrrown 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 a 12'x50' leaching field, the field is clean and dry with 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.): Lt5m.pxdoc-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 1' In Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts NP Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Great Marsh Rd. u Property Address Gary Morris _ Owner Owner's Name information is Centerville Ma. 02632 5-5-21 required for every _. _ _. page. Cityrfown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3- 5'41 34C K OP-20.S" PC-5 7 oG,;_, LIPC;, ._ h z 2. - vp-�� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is required for every Centerville Ma. 02632 5-5-21 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: 8'6"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: 2-4-16 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: groundwater at 8'6" per plan 5' seperation from SAS 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 c°" Commonwealth of Massachusetts Title 5 Official Inspection Form too} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 192 Great Marsh Rd. Property Address Gary Morris Owner Owner's Name information is Centerville Ma. 02632 5-5-21 required for every page. CitylTown 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 G�de 6" 4S �<p•v �O Grovo�/ wo-f�r t5insp.doc•rev.7/26/2018 Title'5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 « + � U I At No 6 ,4. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Mie-posal �bpstem Construction permit Application for a Permit to Construct( ) Repair(V1-*U*'pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1 cj,:k C64cc+-AAoic k\ I Owner's Name,Address,and Tel.No. Ce-N per v 0)e C,t,I 1�c7r c+S Assessor's Map/Parcel 02 y - I £' `T Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Jl�Os fnut74i NC. %-06 "4400-7155 Type of Building: Dwelling No.of Bedrooms !� Lot Size Y3,(G y sq.8. Garbage Grinder( ) Other Type of Building !f 5(cx'i 1 A) No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) H Lin gpd Design flow provided gpd Plan Date a-1 O 1(e Number of sheets Revision Date Title Size of Septic Tank ex lsir-a.?c ico� yCh Type of S.A.S. 'Ft e.1� X.So Description of Soil Nature of Repairs or Alterations(Answer when applicable) (g-jSk<A\1 cL n9 a�.J r) %C>h a-,30 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. Signed Date Application Approved by Date �-(- Application Disapproved by Date for the following reasons Permit No. t ro Date Issued ,No. r✓_+Q V Fee THE,COMMONWEALTH OF MASSACHUSETTS ' Entered•incomputer: r; Yes i 1 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,-MASSACHUSETTS 2pplicatlon for Misposal*pstrm Construction Permit Application for a Permit to Construct(") Repair V11 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. l q a.C 4C'C+- AAC-(q,,k\ f Owner's Name,Address,and Tel.No. Cc-ut-CrvI1)f L�ce4y vrdIC. Assessor's Map/Parcel a°I 1 _ 15-7 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. g1u5 A -t3 rc��� NC %06 Vc 'CF. Type of Building: A Dwelling No.of Bedrooms y Lot Size GG°/ sq.ft. Garbage Grinder( ) t� Other Type of Building /C5(5e jt is l No.of Persons `-Showers( )I Cafeteria( ) Other Fixtures -' N" , Design Flow(min.required) L� gpd Design flow provided 41 q 9 gpd Plan Date 1-1 O — I Co Number of sheets I Revision Date A Title Size of Septic Tank Cox lsf�JS 4cz} p,;,Arndi Type of S.A.S. e% [ ,X•SCE I Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,;,�,�C��> a_ eV C'.J C� \bcm c.\3 r 1�.X Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewag4isposal 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 r Compliance has been issued by this Board of Health ti Signed ,Date• Application Approved by C_ Date Application Disapproved by Date for the following reasons Permit No. o 0 Date Issued � � 110 - -- ---------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( f� Upgraded( ) Abandoned( ) at I C( ', Co f Pc�� /ylra rS�n 1Zc) i f?tv� P has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No�w 6`1t1�� dated e Installe ,t `GS pF c _,.trJ L.rJC Designer I e�N C—e% or TC t�C%N rc�rtiNV #bedrooms 4-} Approved design flow L4 k10 - gpd The issuance of this permit shall not be construed as a guarantee that the system will funcCn bLigned. ----------------------------------------- PDate (/) Ins ector �1----- ----------------/-------------= = - - -- =- ------------------------------------------------------- - No. `' v — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Vsposal 6pstent Construction Permit Permission is hereby granted to Construct( ) Repair(Y) Upgrade( ) Abandon( ) System located at J 9 1— (P,r low t- AA c<(c,1n 'Q ("P n)�-P_(y M Y 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. �i Provided:Construction,mustbe completed within three years of the date of this permit.�� Date `i [ Approved by / a S�TjQ= 4 T_ Thomas lTc K:c eam,Director 9.001Maliu S�tn eat,�y�a��s,IV ®�6�71 Fax: 51]3-790-6304 Office 5a8-862-?644 Lstallll�u@sii�mem tCen ��ncatna�� 'mrm e� sewage permie Z- cW)G.— C A.ssesaor s map 1Tarcell �� a . l�atea a @sii�oie>re 0 V,) n dip t Installer; 0 �d[dn ess: 13 / Adldu esse T-Q B� f yc _�y�� G �� 4 s w was i sued a permit to install a (date) q (taller) septic system.at ` ��1 based on a design dravmby (address) (dESlgt].eT) I certify'chat the septic system teferenced above was ins Called substantially according to the desigo wbich may include minor approved changes snch as lateral relocation of the distribution box and/or septic tank. I cerffy that the septic systera referenced above was ilstaLed with major changes (i.e. Beater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Flan revrsiou or certifed as-Built by designer to follow. 0F AAgss�cy DANIELA. �s OJAIA tiller's 'igCLature) CIVIL "' No.46502 �CJSTER� l/4 ' FSS/ NAL (Designer' Signature) (l L 1DesipDI:'s Stamp Neie) �tJI�I� 'la>' � 11� L Y u����u 1 .4L UH DIVISION. r ER�� + CA� OF �e�l �C� WILL Not ! 6�Q-U— tTrq-� god T�ffi FO1 AKA A•S-BUILT CARD ��B ER EI 7�J TEE Br 1ST'.�ABEEK I�MUC EXAl,'Ji H RIY—IS10:�1, TIff�1 IK 0U 04 . . . c Deitax6mut of Regulatory.Servieell ±� a lar�nrr Public Heaftb..Daisaon cri Date P h� 700 Main street,Hyannis MA.02601 !p p. Date Scheduledl Fee A� , Time 1 •. m 07 Soul Suitability Assess ent liar Sew 6 Disposal I'crformedHy: Qan'/ 2 I GOhi�u/ye"5 witnessed By: ��i f Location Address ll� �P�R.�-l� Owner's Name /"Lp✓YU' Ge�tf i le Address Assessor's Map/Farccl: oC d 0��� Dnglncer'S Natnc (���.. j�e . NEW CONSTRUCTION REPAIR Telephone# d �601 Land Use:L•Q 4AI' / Slopes(%) 0—� surface stones Poi e / Dlstanec9 from: Open WaCerBody? �a tt Possible WetArea� r q O ft Aritilcing Water Well Draihaga Way >(Gy ft Property Line � � ft Other ft (Strcet name,dimensions of lot,exact locations of test holes&parr tests;IOcatc vtet]andsn pznximity to holes) DWe Ili �aq0 �3 ZOOParent material(geologic)G�aL a I G u"f WuS Depth to�3adrgck Depth'toGmundwatcr. SLandingWaterin Hole: O Weeping fro. PitFaa ' Estimated Seasonal High Groundwater DETE Method Uscd: 0 6 5 er ve n Depth Observed standing in obs.hole: 1641 _�Iq, .Geptla to..s4li CnQulaB-. 1iL Depth to weeping from side of obs.hole: itl, a roItawaterAdjuetmank fir• Index Well#k Reading Date; Index WelI1pVUl—.:.— AdJ.fat<tdt'—A41-0411ti_YYlltarLaYg1— Observation Bole# DepihofForc• Z Time At 6" Start Pre-soak Time @ -- `l'irno End Fro-BORIC L Rate MInAach 6lt;5ultability,As5e5smeut; BINFRllcd: Additional Testing Needed(Xli'i)1—_- Original: Public health Dlvlslon ObseriE tlon Ho1Q Data To Bs Completed on Bach---- --- **9=1E percozatio' n test is to be maductod with 1.001 of wetland,you loaaast first=tdfy the Barnstable Colase)rvataon Division at least one(1)weeR prior to bei g- QASJZPT1CIPERCFORM,DOC 40 �� DEE N P.QPME11" ITT, K-AM i LOG Depth from Soill-lorizon Sail.Tcxturc ShclColor soil•. Officr Sttrfacc(in.} a , (USDA) jMunsell) Mottling (Strndarc, Stones;Boulders, • -o i`tcn cy.9�'Cravcll 0- 1 N-30 OR 3 , 30-3Z 32- 00 L S ' 10\1 4 w-120 Aj 2,5Y7/3 Depth from Soil Horizon Soil Texture Soil Color Soil. Other Surface(in.) (USDA) (Munsall) Mottling (Structure,Stones,)3ouldars. onsis en Co Greve 10YR 2.,S-V L S Y RV(v 5y_ 20 S �, 7\/ 713 Role W,. Depthfroni Soil Horizon SoiITcxture Soil Color Soil Other' Surface(in.) (USDA) (Munscll) Mottling (Structuzo,Stuncs,Boulders. Colislltcnn Qmycl) 1 1DPI P M19 R�".�.' ION ITOTIV+ LOB: Role# D4 from Soil Horizon Soil Texture Soil Color SOLI 17t6cr Surface(in.) (USDA) (Muusell) MMUing (5tructure,Stones;Boulders. - Ca si tatt b _, • a 'Icod7x�s�sranc'��ate'1VJCm�. � . Ahovc 560 yeai flood boundary No Yes Within 500 ycarboundnry, No V+ 'Yes Within 1.00 year flood boundary No.� Yes..- - . JOe�flr.ofltil'airpairyQ�ccryrxln�-�'®rvyous141st�oni�Y • Does at least four Feet of naturaliy occurring pervious Miterlal exist in all areas observed throughout tho area proposed fbr the soil absorption systaml If not,what is the depth of haturally occurring pervious mater call Certi�catia� - rcertify that on /1 L (date)Z have passed the soil evaluator examination approved by the Depaitment of. Bnviromnental Protection and ttlarthe above analysis was porfbnned by me consistent with . the required training,experdse and experience described in�10 CUR 15.017. ILI Signature Datb ' Q:ts.�r�rlc�r�iz.c>?a1�M.Dac yt--' '_�,=.t••Mt e.1 e=a�B�p�.'__A f e_�• 7__e='e 8 t 0 r i DEED RESTRICTION 192 Great Marsh Road Centerville,MA 02632 WHEREAS, Gary R. Morris of 192 Great Marsh Road, Centerville, MA is the of the property and home located at 192 Great Marsh Road in Centerville, MA and being shown on a plan entitled subdivision of land in Centerville (Barnstable) MA,property of Gary R. Morris et al, on November 18, 1999 duly recorded in Barnstable County Registry of Deeds in Plan Book :3 l'l , Page (Map# 210, Parcel# 187); WHEREAS, Gary R. Morris as the owner of the said lot has•agreed with the Town of Barnstable Board of Health to a restriction as the number of bedrooms which can be included on said lot; NOW, therefore, Gary R. Morris does hereby place the following restriction on his above referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. 192 Great Marsh Road (Centerville, MA 02632) may have constructed upon the lot a house containing no more than four(4) bedrooms. 2. Gary R. Morris agrees that this shall be permanent deed restriction affecting his property located at 192 Great Marsh Road, Centerville, MA . For the title of Gary R. Morris see the following deed; Book l i , PagO 2 Executing as a sealed instrument this 17th day of November. ;"'P . U�,r2 Gary Mo is My commission:expires Nov.1 n,240ju0 i First Floor Plan / Basement Public Health Division Town of Barnstable PO Box 534 Hyannis,M s 3344etts 02601 Fax(508)7 Phone(508)790-6265 Kitchen ��,1 9 Bathroom Play Room Utility Room Office Pool Room Work out Room/ Exercise Equipment v-1 f � b ........................................................................................................................................................................... � t I F-1 ....................... ........................................... n\ r c Third Floor Plana '( 4��� A 1 p 17 pp > g y Child's Master Bath Bath t� Master + 1 ,�M � � Hall Hall Closet + , ,��� Sjw 4":� Washer/Dryeri, 1 '�, Childs Childs Room 2 Mastery ��;., , ,� � Room 1 Bed `y , f.j. II 1 ..d i s + Deck off of Master Bedroom f r ASSESSORS MAP NO• ..�-------- C ' --- - ~-- � '` PpRCEL No. NO: f Fee-- �-- � BOARD OF HEALTH TOWN OF BARNSTABLE Application Ar Well Cootruction Permit Application is hereby made for a permit to Construct (t/j Alter ( ), or Repair ( )an individual Well at: 1�, _�aLC4�" u✓sL �_,— e&Allvc//v _MuT ajV 1$Z-- Location — Address Assessors Map and Parcel _ — M —~`-o r/'-1 - - - - --- -- -—— ��- �'��� s k-dd-= Owner Address Q-A '_ eU� _� _ _` _D.���� - P_a. Qo rGo ------ Installer Driller _ Address Type of Building Dwelling- ------------------------------------------------- Other - Type of Building---______—____________ No. of Persons--------------------------------- Type of Well_.5l --------- - ---------- Capacity--------------------- --- - - ---— Purpose of Well---- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of ompliance has been issued by the Board of Health. Signed -—----- -- - ------- date Application Approved By —�-- - -- � date Application Disapproved for the following reasons: ------ ------------------------------ -- ---------- ------- �,r date Permit No. -1i�' -- — Issued— =- ---"-= ���-�- -- ------ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance j THIS IS TO CERTIFY, That the Individual Well Constructed (`I, Altered ( ), or Repaired ( ) Installer _has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit N - -1 � ated4�=-6 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--_---- - - Inspector------ -- - ----------- �, i .. ..- .. , - �.'"d.:ti.,'!" .`ter"'""� . . •TiY t.^a-�i�faa�V4i i Fee-- No.- --------- r BOARD OF HEALTH TOWN OF BARNS ; ABLE ,{ Application1brVeYl ConoructionPermit Application is hereby made for a permit to Construct:(T Alter ( ); or Repair ( )an in itlual Well at: L'o"cation--.Address 'Assessors Map and Parcel Mf MOB! S /'cLY /t�lG� L /'icJ _' CN �c/V,II /u—CA — Owner Address it ti� -- - -- ------ - - -- Installer — Driller A dress 1 Type of Building j Dwelling----7—• -- ------- ------- ---- " Other - Type of Building---------- ----------- No. of Persons------------------ ——------- { Type of Well y Purpose of Well---- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate.of ompliance has been issued 6y the Board of Health. Signed-�'-µ'=y- --- -----= - �� ��_v ----- — _ —_ — - —— -- — .date I' Application Approved By date AP lication Disapproved for,the following reasons: =-----------_ ' -___ - I u �— ��► �N�i � I -- --------- ---------- ------------- Permit No.. - . -- Issued=- --------------- BOARDOF HEALTH j TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (`"j; Altered ( ), or Repaired -Installer --- — atJ9J G.�� .K,. .s� ✓i'� has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described.in the application for Well Construction Permit Nk_9WzQ="a ted of 2 V--" THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY: r DATE- ---:--- - - --- --- Inspector- - - - - - --_-------;- $ !res�a.tiTi.Pi430i9rSa!"u$... .Ti!IbTDTipa430rli�i:�fS!}R►9a4Y!±YILTiQa43$�i3iP4T,r4696piN-a}i1961F..iO3}1!a$}fi:}iFB4r4a4i49iR6K!.�+r!Y}!•;?'�44"4r}daY}sy-}®p}$6Fr9}°!}!}^ili�i!.}'ta BOARD OF HEALTH TOWN . OF BARNSTAB LE . Ivell Conkruction Permit No. � - - `,V Fee A J G4N 1� Permission is hereby granted Jl A to Construct( f, Alter ( ); or Repair ( .) an Individual Well at: No. /. 1 4 /c��1 : e J��i�. —_---_— -_ - - -------- Street as shown on the application for a Well Construction Permit �Q6 Dated-- --�_�_! 'n- h "l _ - No. _ - _��-- - --- Board of Health p DATE -- l