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HomeMy WebLinkAbout0271 GREAT MARSH ROAD - Health 271 Great Marsh Road Centerville P A 210 137 o N 6 G No. 4210 1/3 ORA Pendaflexo 1 0% Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan , Owner Owner's Name information is required for every Centerville Ma 3/27/2021 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 I A. Inspector Information St.� sar filling out forms 1 on the computer, use only the tab Chad Hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. P.O.Box 151 � Company Address Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails i 3/27/2021 Inspector's Sign a Date The system inspector shall sub 6taa-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. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. CityfTown 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: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components.This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass.gov 2 System Conditional) Passes: Y Y ❑ 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 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summafy (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 r= - w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. Cityrrown 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 forth:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. Cityrrown 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 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows.in the previous two.week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. City/Town 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: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 438 gpd 9 ( Y 9 (gpd)): Detail: 2020 -204,000 2019-116,000 with lawn watering Sump pump? ❑ Yes ® No current Last date of occupancy: Date i 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. Citylrown 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: pumped during inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? tank Reason for pumping: maintenance t5insp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �6 Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 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: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 26'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): No signs of poor venting or cloggs. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 811 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal. precast If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'6"x5' Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete Baffles in place. no major decay. tank at working level. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �v Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. Citylrown 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.): I "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.): Dbox is solid and no carry overs liquid at outlet pipes. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts j- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road 9W'P-1 Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 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 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc-rev.7/26/2018 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 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 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.): 2-6'x6' pits. Pit#1 Dry with a staining 1.5' below top of pit. Pit#2 full 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1POP 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately bn ll2WC'L'/ ' '9y rG„ O a ® y ] 6 C�n k, c k _ 4a _`.rid ✓ Q & csccx3,54. 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owners Name information is required for every Centerville Ma 3/27/2021 page. Cityfrown 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: 18 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: town GIS mapping You must describe how you established the high ground water elevation: lot el in area 50' lake Wequaguet el. 32. bottom of SAS 10' below grade.el.40 Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road Property Address Garik Gevorgyan Owner Owner's Name information is required for every Centerville Ma 3/27/2021 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 0260.1. (Town Hall) and.getthe Business Certificate that is required by law. .i DATE: f G f{v c� ,,Fill in please: APPLICANT'S YOUR NAME/S: (= G 2-I G QF T r/CdR sK � C.G�-TF /Lv��`(1 �. 02G BU 1"NES YOUR HOME ADDRESS: � TELEPHONE # Home Telephone Number 3117 59� NAME OF CORPORATION: NAME OF•NEW.BUSINESS PLU 3 TYPE.OF BUSINESS IS THIS A HOME OCCUPATION? YES NO ( g) ADDRESS OF BUSINESS- : - &�lq /Yl r* If 7 2 vtu11 MAP/PARCEL NUMBER Assessin When starting a new business thePe are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S FFICE MUST COMPLY WITH HOME OCCUPATION This individual has been inf m any permit r emerits that pertain to this type of business. RULES AND AEGULATIONS, FAILURE TO fFY !IA tllr IPII Authorized Signatur * COMMENTS: 2. BOARD OF HEALTH ' This individual has Ken nformed of the per uirem is that pertain to this type of business. Authorized,Signature** 11 J. 4MRCY WITH ALL. E�D(JU 'MATERIALS-REGULATIONS kr . COMMENTS: • . 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: a BUSINESS LOCATION: ��f G�� /� � i� �/ /z� ,tom=�/" � c�u-�s INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: 40 yi ,--,fee , INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: ' Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Photochemicals (Fixers) Gasoline, Jet fuel,Aviation gas Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes A/v 14 u 1-f A C Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Appli an re Staff's Initials 13;9 &dl-v,,-t A^Gx d9i s7 117 nO.A C��Iw•r�0, 1 ZZ � a -------------- i W I � f / , 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Rd Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M "r 271 Great Marsh Road Property Address Lind Owner Owner's Name information is required for every Centerville Ma 02632 11/14/14 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. General Information on the computer, use only the tab 1. Inspector key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. � Company Name P.O.Box 151 Company Address Forestdale Ma 02644 City/Town State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes _ ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/14/14 Inspector's SignatureTcoy Date The system inspector shall subspection report to the Approving Authority(Board of Health or DEP)within 30 da inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection ubsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 271 Great Marsh Road Property Address Lind Owner Owner's Name information is required for every Centerville Ma 02632 11/14/14 C' /Town State Zip Code Date of Inspection a e. �Y P P P9 B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank in good cond. concrete baffles in place nosigns of leaks or cracks, Dbox has very little carry overs with no signs of leaks or being overfull. 2)6' pits one origanal 2nd added in 1994. dug up 2nd pit has 12" of reserve from current water level to bottom of invert with no signs of stainig over that point B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health.. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 271 Great Marsh Road Property Address Lind Owner Owners Name information is required for every Centerville Ma 02632 11/14/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipes)are replaced ❑ Y N ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 l < Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 271 Great Marsh Road - - Property Address Lind Owner Owner's Name information is Centerville Ma 02632 11/14/14 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Lind Owner Owner's Name information is Centerville Ma 02632 11/14/14 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road --- -. -- Property Address Lind Owner Owner's Name information is required for every Centerville Ma 02632 11/14/14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ®_ _ ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the-field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] D. System Information 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ILI Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 271 Great Marsh Road Property Address Lind Owner Owner's Name information is required for every Centerville Ma 02632 11/14/14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 342 gpd 9 ( Y 9 (gpd)): Detail: 2012- 119,000 2013- 131,000 Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM s 271 Great Marsh Road Property Address Lind Owner Owner's Name information is Centerville Ma 02632 11/14/14 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (cont.) current Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner 1 year ago Was system pumped as part of the inspection? ® Yes ❑ No 1000 If yes, volume pumped: gallons How was quantity pumped determined tank size . Reason for pumping: owner requested Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Lind Owner Owner's Name information is Centerville Ma 02632 11/14/14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: tank and pit 1 1974.. Dbox and pit 2 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: - 1.25' feet__ — Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 26 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal 4" Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Lind Owner Owners Name information is Centerville Ma 02632 11/14/14 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 3" --- -- .. - -- - ---- - . . - - -- -20" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump tank every other year or less Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Lind Owner Owner's Name information is Centerville Ma 02632 11/14/14 required for every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) - Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M °r 271 Great Marsh Road Property Address Lind Owner Owner's Name information is Centerville Ma 02632 11/14/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert o 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.): no visable cracks or leaks Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: nd 2 pit 12��of reserve pit has 2 of stone around perimeter t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road Property Address Lind Owner Owner's Name information is required for every Centerville Ma 02632 11/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road Property Address Lind Owner Owner's Name information is required for every Centerville Ma 02632 11/14/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, i etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 Great Marsh Road . Property Address Lind Owner Owner's Name information is required for every Centerville Ma 02632 11/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately s J ti b P q9 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Ins ection Form P Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Great Marsh Road Property Address Lind Owner Owner's Name information is required for every Centerville Ma 02632 11/14/14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells _ �- Estimated depth to high round water: 16' P 9 9 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: usgs dept of interior g/w survey map You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 271 Great Marsh Road Property Address Lind Owner Owner's Name information is Centerville Ma 02632 11/14/14 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION m °1 n .. ...._..__ Spa F W � o DEC 2 2003 TITLE 5 L OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION IMP e� PARCEL Property Address: 271 GREAT MARSH RD CENTERVILLE 02632 Owner's Name: C/O DAVID HOLT-TODAY REAL ESTATE LOT Owner's Address: 271 GREAT MARSH RD CENTERVILLE 02632 Date of Inspection: 11/6/03 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X.Passes _ Conditionally, ses _ Needs Furth valuation by the Local Approving Authority Fails Inspector's Signature: Date: 11/6/03 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect' n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Tith- 5 Tncnantinn Fnrm (,/i s/?nnn 1 Page 2 of 11 ' s. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon.completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. 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: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 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'/2 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 NOT IN THE.LAST YR- 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 1 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 I1 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. d Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B- CHECKLIST Property Address: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 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. g - 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)] 5 Page 6 of 1 I , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 1 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)): b`L !' t 000 Sump pump(yes or no):NO r`( Last date of occupancy: n/a - ' - - V lJ COMMERCIALANDUSTRIAL 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 YR. 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 i _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: 1974 PER AGENT Were sewage odors detected when arriving at the site(yes or no): NO F Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C_ SYSTEM INFORMATION(continued) Property Address: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 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 " W 4' 10"H 5' 7"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 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.): THE SEPTIC AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS. 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 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 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: LEVEL 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.): DISTRIBUTION BOX IS STRUCTURALLY SOUND. 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 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C_ _ SYSTEM INFORMATION(continued) Property Address: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 6' X 6' 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.): THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.BOTH PIT WERE EMPTY-ONLY ONE WAS EXPOSED.ESTIMATE 2' OF STONE AROUND PITS-BOTTOM AT 8'-SYSTEM SHOWED NO SIGNS OF FAILURE AT TIME OF INSPECTION. 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 4 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 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. 6ric IL �ee(L GC e ��31 P/is v AJJ I 30 V M �n Pagel 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ART C SYSTEM INFORMATION(continued) Property Address: 271 GREAT MARSH RD CENTERVILLE 02632 Owner: C/O DAVID HOLT-TODAY REAL ESTATE Date of Inspection: 11/6/03 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: ---- - ' Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting properly/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: GROUNDWATER WAS DETERMINED BY HAND AUGER-NO WATER AT 12'-THERE IS A 31911 ADJUSTMENT FROM MIW 29 i TOWti.N OF BARNSTABLE r}y L'OC . ' ON C- ReAf EWAGE # x 9�f VILLAGE C e N T e P, y/ L L ASSESSOR'S MAP Cz LOT 2/U, INSTALLER'S NAME & PHONE NO. J y7,Ac o A 1SeP 4- 5QA1 SEPTIC TANK CAPACITY / 0 O P i LEACHING FACILITY:(type) pl 7" (size) /. a 6 a NO. OF BEDROOMS .3 PRIVATE WELL OR PUBLIC WATER l R OWNER ll /ld, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �° � � VARIANCE GRANTED: Yes No f ;, �� � �� � ' � � . - , ,. � � �� 3� • d O ' • ' TOWN OF BARNSTABLE L`c` N 7� Cs/�F'AT./UII`M-T,1,k Ab , SEWAGE # .—T ILAGE Ch A/ '��/�� � ASSESSOR'S MAP & POT 0 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY D�nb L LEACHING FACILITY: (type) f"` J (size) NO. OF BEDROOMS A BUILDER OR OWNER A `i'ERMIT DATE: 3 ' 7 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 9 w4 A Ac 3f r a 6 AD of 4 ® g any g6 3Q 6 L� �. TOWN OF BARNSTABLE LOC-`:TION // _ SEWAGE# VII.LAG Der' /w(/E� ASSSES 'S MAP /&L�LOT Qa� � 1 rNAME&PHONE NO SEPTIC TANK CAPACITY AI/A) QGVI _A,S - LEACHING FACILITY: (type) S (size) 6�? . 'NO.OF BEDROOMS BUILDER 16 OWNER 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 �J on site or within'200 feet of leaching facility) /`' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lea 'n c' ' ) Feet Furnished by D fy�— lid , % 3d 3 rrrA TOWN OF BMZNSTABLE LOCATION 2{�I ( Nfflf SEWAGE # VILLAGEVlAa- ASSESSOR'S MAP & LOT _CD INSTALLER'S NAME&PHONE NO. . SEPTIC TANK CAPACITY 1A v LEACHING FACILITY: (type) (size) U 0 NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any w lands exist I l within 300 feet of leaching facility) I ` Feet Furnished by IA OOA r' 46 2cp A13 310- 0 a � A� (DC, 30 � 2� _f 9/0/ 7 o._I APPROVED Flcs...$....3 8f stebte Consenretlon Department THE COMMONWEALTH OF MASSACHUSETTS �-� BOARD OF HEALTH Signed Date TOWN OF BARNSTABLE Appliration for Uinpooal Worko Tonotrnrtion Permit e Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 271 Great Marsh Road Centerville ........-•-•-•-------••-----•-------------------------------•--------.......•--•-................. ••-•••--•---•-•----•----•---•------•------•-••----•---•-----•----•------..........----------....•. Location-Address or Lot No. Da v i d...Hu f f-----------------------••--......---------------••--•----------.._.... Owner Address W Jr .J .P .Macomber a •... • ........ Installer Address d Type of Building Size Lot............................Sq. feet V DwellingX-X No. of Bedrooms.................4-------------------------Expansion Attic ( ) Garbage Grinder ( ) p, LOther—Type of Building ---------------------------- No. of persons---------------------- _..t Showers ( ) — Cafeteria ( dOther fixtures .----•.....................................................••----...-----........... ....------------------------...............-------••••-•.... W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width.......--------- Diameter--.............. Depth................ x Disposal Trench—No. ............._---- Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No---------------------- Diameter...:............---- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,al Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .................... 0 Description of Soil-.Sand...& Gravel . •-.. -�- x W •-- ••-----------------------------•------------•-•------•----------------------------------------------••-------------------------------•-------•---•-••-------••-•----•--•---••------•-•--•-•---•----- UNature of Repairs or Alterations—Answer when applicable.-...-..1-1000 g--11 on p i t Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has�/eossue by the b rd o health. Signe ... ----5/3--/9 4 Dare Application Approved By ------------------ .......... .... '""' .....------------------------------------------------ Application Disapproved for the o lowing reasons.: . .......... ...... .. . ............. .. ................ .................................... ................................................................................................................................................................................................................ ................Da.e.................. Permit No. ......... -L-/.........) -.L.-,5------------- -- Issued .. ------....... Dare No........................ Fxs.. ....3 t7.0 0... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Uiupu!ittl Workii Tomitrnrtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 271 Great Marsh Road Centerville ...................•--•----•-•----•------....---------.....-------------••-••--.._.......----•--•• -•--••---••••---•-----•-------•-•--•--•----•••-----•-..........-•--••--••••......•-•-••......-•--- David Huff Location-Address or Lot No. W J.P.Macomber Jr. Owner Address Installer Address UType of Building Size Lot............................Sq. feet DwellingX-X No. of Bedrooms----------------_4-------------------------Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of--Building ---------------------------- No. of persons------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------------------------------ 4� -----------------------------------------------------• W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter...--........--. Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter........--.....----. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �"""` - aPercolation Test Results Performed by-------- ----------------•--•-•-•---••-------•-••--•-----••-----••---..... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 --•-•-•---------------------•-•-•-•--••-•••••-•--•-•----•---••---•••-•-•--•--•--••••--------................................................................. 0 Description of Soil..Sand...& Gravel W UNature of Repairs or Alterations—Answer when applicable......-_-1-1000 gallon pit -•-------------------------------•--•-------------------------------------...••••---•••-•-------•••-•------•----• ---•----------••--•-------•--_...••--------•--•-•-•--••---•-•••........._....._.-•-••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o health. - { /� 5/31/94 Signed ... - ---------- . <r!-flrr!,�,��� JJ _ .................. ....---------------------------- Dare Application Approved By ................... ....-- ---.----- -�..- - ` 1.... ---_ ..`-1...... Dace Application Disapproved for the Allowing reasons: .......................... ................................ . . ...... ..................... .............--------...............--------------------------------------------------------------------------.._............-----------------.....................-----........_.............- ---------------------------------------- Permit No. ......... - - Issued Dare...... .. Date - ---------_.— ._ ---.----_.,------_.---.—_.— --- ---.--.—_---.--------.-----_. ---�1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�extifi ate of Q-1ortylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or RepairedX(XXX) by J.P.Macomber Jr. ............................................. ... ................... .......... ............ .............. Insraller 271 Great Marsh Road Centerville at ...... ................................ ............. .......... ----.........-------------------.-.................----------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 cof The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..... -/:--.__. ._.g ...... dated ..........---------------------------------_. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. '� DATE..........��'--..�-"` �� - Inspect 'r• -_ -- .� ..._...�-/........_��1 .... ------------ ------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No... � FEE./5 TOWN OF BARNSTABLE $....30.00 �:. ._... --....... . .... .......... Diupuuttl Workv Tunutrudiun "pamit Permission is hereby granted....J_.P.Macomber Jr. --------------•-------------••••-••---•--••-------•••--•--•---.....-----------•--•••---••-•------•---•-•-•-••--•.---•- to Construct ( ) or Repaii—(Xs an Individual Sewage Disposal System at No..271 Great Mar., Voad Centerville • . • .....-•-••----••-•----- -•-••--•------•-.....••-•---•--------- -----------•••--••---•-••-•----••••-••-•--------................................. Street cc, as shown on the application for Disposal Works Construction Permit No._1�--�.. Dated_-_--_f�-.-'. .-•- ............... q ••........................ Board of Health DATE...............�_.---�•-'----�--�L-,�-------- FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS `'� Fug. ..�......... No..... ------- THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HEALTH .......-oF:.. la.�l.Z� Appli.ratinn for Riivnoal 19orkii Tons rurti.on Prentit 1 Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual ewage Disposal systemkal.... _ -- - -- --------- ---------- ------- d Locaen or o. J/ Owner Address Installer Address -� Q Type of Building., Size Lot__J�/ld...____Sq. feet U Dwelling No. of Bedrooms----------------- _.-_-Expansion Attic ( ) Garbage Grinder ( ) Other—Type, of Building _________________ _________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............... W Design Flow.........................(.� ..___,gallons per person per day. Total daily flow........... __C�-.-- .-.- ----gallons. L4 Septic Tank--Liquid capacity�dgallons Length--------------­ Width---------------- Diameter---------------- Depth.--_-____- W Disposal Trench—P ..................... Width_._________..___._. Total Length----- Total leaching area....................sq. ft. x Seepage Pit No_____ _________ Diameter-__— " Depth below ....... Total Total leaching area___ _ _.___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date...................... Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_---_ _____.____.__.. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ ----------------- -- -------------- 0 Description of Soil--------------------------- ---.---------------------------------------------------------------------------------- x W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Co e—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been s byte ar f he It S 7� Si d . --- Date Application Approved B} - ---- - ----UAlt ...... Date Application Disapproved for the following reasons------------- ----------- ------------------------------------------------------------------------------ -•-•-----•--------------•---•--------------------------------------------------------•--••---•-••--------------••--------•---------------------•----- --�a/e ............................... No......................................................... Issued..-_(. — .�-...-ate.-•---- ------------------------------------------------------------ --- -------------------------------------- ------------------------- No.....; -- ---•---- FED... .. ""'........... THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH OF..... ...,: . Appliration for Disposal Works Tonstrurtiou Vrrmit Application is hereby made for a Permit to Construct ( Plror Repair ( ) an Individual Sewage Disposal System t .... ° ... .-- ............................ nA dressocati or N . 4444le.................. ....< � ......... . w er Address- ar+�Y .4................................ t�L� 4�e�6.4,.4!r'a� ��z _ ------------------- Installer /" Address ..E.- UType of Buildin Size Lot.. __._ ____f-Sq. feet Dwelling No. of Bedrooms..................... -------------------.-Expansion Attic ( . ) G/bage Grinder ( ) pa-, Other—Type of Building ................. . -. No. of. persons- _•-----_________-__--__.. Showers ( ) — Cafeteria ( ) p' Other fixtures ---------------------------- Design Flow....................... ......""°"o------gallons per person per day. Total daily flow........... «___ allons. Wseptic Tank 4 Liquid capacity allons Length---------------- Width---------------. Diameter_.-.-.__--__--_ Depth-----.------___. x Disposal Trench—No-____________________ Width.................... Total Length.................... Total leaching area....................Sq. ft. Seepage Pit No.-----I------------- Diameter.... .`" Depth below inlet........ee---.____ Total leaching area--- _ _'sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date..........------------- a Test Pit No. 1................minutes per inch Depth of Test Pit_-______-__--_---_. Depth to ground water_-...� --..__..____.__., 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_------a....__.._-____-_ f - D Description of Soil-----------------------•-•• �°�f ... x W VNature of Repairs or Alterations—Answer when applicable.---__-________________________________________________________________________________________. --•----•--•----•--------------•------------------•-----•-•------.---------------•-----•------------------------•--------------------------•-•-•----••-----------------------------•-•--------•----.-._.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in .operation until a Certificate of Compliance has been pygd by the boardfof healt s f Sid-;-i%- > ` - '- ! p '�"�=----------- . --{D to -•---- .... Application Approved B .._���d� r� - ------�--- --- -U.a'�`�-- Date Application Disapproved for the following reasons:. ---•--------------•--•--••-•-•------------------•---------------•----------•----- / Date Permit No........................................ - Issued... /.- 7 ate THE COMMONWEALTH OF MASSACHUSETTS f�77ARD Pf HEALTH , TrrtifirFatle of T> mptinurr HI S TO CERTIFY, That he Individual Sewage D' 'osal Syst b -- em structe (�or Repaired ( ) b .fi k y - -...� �' = -�=------- ----- •- --•---•-- - --- �,;�'_..-------��� � ------------------------------ --------•- Instal r ....sL... ... at. _ ^ -------2-=- ---------- - has been installed in accordance with the provisions of Article XI of. The.State Sanitary Code as described in the application for Disposal Works Construction Permit No________________--- dated....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL FU CTIO SATISFACTORY. DATE ` ---- Inspector------.. _ lt* . THE COMMONWEALTH,OF MASSACHUSETTS BOARD OF� IEALTH �...... ..oF..............p " � � s{ : . No.. FEE_ ` .._ Dispos al or fans � r#i�ra �rrani� Permission'is hereby granted.__... ° a to Construct (' or Rr ( ),a ,I ividual ew D'isposal System at No.. `s------. .1' •� Erect. �? - as shown on the application for Disposal Works Construction P it`No f__1.. •.___ Dated___� �f -------- ----------------- Board --.----_-- �--/�1- !7 2 of Health DATE--••-- / ....................... FORM 1255 ORBS & WA INC.. PUBLISHERS,- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' O , 24 O ck' �c DEPTH T.O.rGt� U1PWATER„ DEPTH TO QROUNDWATER METHOD OF DETFEIWINATION OR APPROXIMATION: Hy is U,�ed U��^� wl 20042� 71 S{e�� — — -- —Sere � �2x10 foisus � uGi►I fe From ee-m joroefk 10015 / —2flo i voVe,' �t 16' (�• C. E e f N C ti ' ::.r'" �,I i9' �'•.�' '� --+'rn ( .may a 1 , 72 i a �9i, \ ""^^v;- .wi.gv�aw��' ,}•,.�, v -r f z� _p MAI 9F�l f f po/zzv oi. ' f3 i 1 I _ l V E WA k a 0 6 9• FI G PLACC r_ w o 0 �r 4 j—+tee �v k or q'ta.` yq 5 i w i j 16 5 i ' CD � 6 t Y �9` V i V5 r b.-..,__. m i r � r