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HomeMy WebLinkAbout0020 GUILDFORD ROAD - Health 20 GUILDFORD ROAD Centerville A = 172 — 063 w S M EA D No.2.10LOR UPC 12SU wmMd m • Waft to USA .NVU 1ltWM1i�/WI�W SC' rs�ss�souan�uwwR ` GFlf�lloYooWl �acs+o T . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 20 Guildford Road a Z Property Address IV Thomas Holmes U Owner Owner's Name information is required for every Centerville ✓ Ma 02632 1-16-17 = page. City/Town State Zip Code Date of Inspection W W Inspection results must be submitted on this form. Inspection forms may not be altered in any m way. Please see completeness checklist at the end of the form. Important:out forms A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. Excavation Company � Company Name 374 Route 130 Company Address Sandwich Ma 02563 Cityrrown State Zip Code (508)477-0653 SI13640 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 1-16-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface 72Msposal System•Pa e 1 of 1740 V Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. 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 H , 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _ ❑ . _. broken pipe(s) are.replaced - ^ _❑ Y_ .❑ N ❑ ND (Explain below): _ ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wh 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the.SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is_equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is Centerville Ma 02632 1-16-17 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. y ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10 9P 000 d. ❑ ® 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. s 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. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 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 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 C Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 See below 9 ( Y 9 (gP ))� Detail: 2015-50,000gallons 2016-91,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Jan 2-17 Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 O fficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Last pump unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 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 ^M 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town 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 gallons Sludge depth: 6 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Guildford Road Property Address Thomas Holmes Owner Owners Name information is required for every Centerville Ma 02632 1-16-17 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 30" Scum thickness 4 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 13" 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NAfeet 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 M 20 Guildford Road Property Address Thomas Holmes Owner Owners Name information is required for every Centerville Ma 02632 1-16-17 page. Cityfrown 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: NA 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.): i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System^Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is Centerville Ma 02632 1-16-17 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 0 11 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was in working order at time of inspection with no sign of previous back up. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ 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.): Leaching was in working order at time of inspection. Pit had 1'6" of standing water when inspected. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. CitylTown 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. Cityfrown 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 A Al-4 ' B . 2f r5 97 2-�' - 5T814 2''4512" Q2j d. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Guildford Road Property Address P Y Thomas Holmes Owner w r O ne s Name information is required for every Centerville Ma 02632 1-16-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW 12' 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: Sept- 1-84 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM ,. 20 Guildford Road Property Address Thomas Holmes Owner Owner's Name information is required for every Centerville Ma 02632 1-16-17 page. Cityfrown 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 w t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 required for every page. Citylrown 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 0 cursor-do not Sean M. Jones Z use the return Name of Inspector key. w Capewide Enterprises =� Company Name y 153 Commercial St. Company Address Mashpee Ma. a2649 , Cityrrown State Zip Code 508-477-8877 S14522 c �" 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 2/25/2012 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should^be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the,system will perform in the future under the same or different conditions of use. t5ins•11110 Title 5 official Inspection S bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 � I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): _ ❑ _ obstruction is removed _ ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 required for every page. City/Town 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 El or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.- E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 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 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No vacant 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 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 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 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: original system 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No a Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron N 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): _ 5 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 --- 1000 gallons Dimensions: 5" Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Guildford Rd Property Address Helen Bourloukas Owner Owners Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top 9 of sludge to bottom of outlet tee or baffle 3.5' 2° Scum thickness 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 10" opened covers and took How were dimensions determined? measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was intact and in good condition 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts i I - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 required for every page. Citylrown 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): F Dimensions: Capacity: gallons _- Design Flow: Per day----- - - --, _Flow: _ 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-11/10 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 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 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 0" Comments (note if box is.level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was functioning as intended 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leach pit was video inspected and found to be dry with a stain line approx 2' below inlet invert. t 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•11/10 Title 5 Official Inspection Form: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 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is Centerville Ma 02632 2/25/2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < 20 Guildford Rd Property Address Helen Bourloukas Owner Owners Name information is required for every Centerville Ma 02632 2/25/2012 page. Citylrown 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 Pr cs 0 A-1 KS T3-il Zy - - - - - - - ❑ A-Z SZ - - ----- - - - . /-�3 -57 t5ins-11MO Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow°wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Guildford Rd Property Address Helen Bourloukas Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 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 a t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 U.S. Postal Service,.�� CERTIFIED MAILTM RECEIPT (Domestic Mail Only;No Insurance Coverage Provided) For delivery information visit our website at www.usps.conno Postage $ OFFICIA.L USE � Cerldfied FeePostmark �® RestrictedM Return Receipt Fee Here (Endorsement Required) Delivery (Endorsement Required) Total Postage&Fees $ • , f�i� PS Form 3800,June 2002 See Reverse for Instructions i Certified Mail Provides:■ A mailing receipt (es—ea)zooaeun r'oose Wjo=i ad a A unique identifier for your mailAece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mailo. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ® For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is li required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. I i ti Town of-Bar-nstable OF THE Tp� Regulatory Services Barnstable ti�P� ti� Thomas F. Geiler, Director a*-AmericaCity Public Health Division I 9B"RN Mnss. Thomas McKean, Director 1639• a`` 200 Main Street . FD MA'S Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 26, 2012 Seat Via Certified Mail— 70051160 0000 0190 9816 Sprios and Helen Bourloukas c/o Thomas Holmes 20 Guildford Raod Centerville, MA 02632 As of October 1, 2006, a new rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. According to our records, you own the rental property at 20 Guildford Road, Centerville, M.A. Enclosed is an application. Please use a separate application for each rental unit you own. Should you need more applications, they are available online at www.town.bamstable.ma.us. Go to the Health Division page by looking in the Department Menu. There is a link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2012 fees included. This must be completed within (14) fourteen days of your receipt of this letter. Failure to comply with this ordinance will result in the issuance of a non-criminal ticket citation in the amount of$100. Each day of non-compliance is considered a separate offense. Should you have any questions, please.feel free to call 508-862-4644. Thank you in advance for your cooperation. Karen Herrand Division Assistant Health Division Direct#508-862-4072 Town of Barnstable OF 1HE T Regulatory Services Barnstable Thomas F. Geiler, Director ASAmerica City Public Health Division I BARNSTABLE, y MASS. Thomas McKean,Director Zoos `bAr 1639' A`` 200 Main Street . FD Mp'l Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 26, 2012 Sent Via Certified Mail— 70051160 0000 0190 9816 Sprios and Helen Bourloukas c/o Thomas Holmes 20 Guildford Raod Centerville, MA 02632 As of October 1, 2006, a new rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. According to our records, you own the rental property at 20 Guildford Road, Centerville, MA. Enclosed is an application. Please use a separate application for each rental _ ;0 +.., you,,, own' 'Should you need more applications, they are available online at www.townAbarnstable.ma.us. Go to the Health Division page by looking in the Department Menu. There`is'a`link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2012 fees included. This must be completed within (14) fourteen days of your receipt of this letter. Failure to comply with this ordinance will result in the issuance of a non-criminal ticket citation in the amount of$100. Each day of non-compliance is considered a separate offense. Should you have any questions, please feel free to call 508-862-4644. Thank you in advance for your cooperation. , Karen Herrand' Division'Assistarit' Health Division7. ' Dtr`ect#508 862'4072 U.l L.i13F 3{- �.l•r J t, 10 ki-I i.t.li a( i ; THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct (A or Repair an Individual Sewage Disposal System at: Owner Type of Building Size Lot... ...Sq. feet Percolation Test Results Performed by..... ... Date-75,44, �,k Test Pit No. I------<.'7—.jninutes per inch Depth of Test Pit.... ---bepth to ground water.A/-" ­4-------- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITHLj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation uIntill a Cer�iffiicate of, C pliance has been issued by the board of health. Date Date _-- . _______' - oat" � Permit No.. �� _. r i Fxs.............................. + THE COMMONWEALTH OF MASSACHUSETTS 0_1 ' G BOAR® OF HEALTH :� L,• ... � .. .. ...... .....OF............��. .��" N�� �-� _ Aliptiration for Diupuqal 10urk.5 Tutuitrurttott Tirruti# Application is hereby made for a Permit to Construct (K or Repair .( ) an Individual Sewage Disposal System at: �tion•Address "i p o t N , _. ......... .......... �� eo , / r Owner s11 dr s �r ....................... ' �r - '°�•g,"..-�•-u.�/ ,_JIF .. Pam ' �.... -- •'`_ Installer Address Type of Building "? Size Lot... .�q...Sq. feet Dwelling—No. of Bedrooms....................:..................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building ............................ No. of ersons__--________------__-----.-_ Showers p., yp g p ( ) — Cafeteria ( ) dOther fixtures ....................................................§---••--..........---•-------••-------------•---..........a -----•----••--------••-•--•...-----• W Design Flow.......................... __.._...._.__.gallons per person per day. Total daily flow----_.....__.....:............___........gallons. 9 Septic Tank—Liquid capacity..�_�-zt=_allons Length-----�_�------ Width.....:.......... Diameter---_--__--_-_-_ Depth__2:_-........ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No................... Diameter_-___-jU_ __ Depth below in''et_.._ ............ Total leaching area..',IE'--�.....sq. ft. Z Other Distribution box ( G-f' Dosing to ( ) a Percolation Test Results Performed by-------------------------------------------=---------'1- 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........................ -- O , ' 6. ._ / t. � � �.... � � t ,_ .�` mot ............................. --------------- ------------------------------------------------------........................................---------------------------------------------.......................................... U Nature of Repairs or Alterations—Answer xi�hen applicable_______________________________________________________________________________________________ ......................................................•................................................................................................................................................. Agreement: The undersigned agrees to install.,,t- e aforedescribed Individual Sewage Disposal System in accordance with f^iT!!1' the provisions of :T. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...............................................'......................---............. --------••- r} Date Application Approved By---•-•----•-•--•---.... ......•---•----......-- /......-....... -------•--•----------- 1�0Date Application Disapproved for the following reasons:--------- •-----------------------------------------•---•-----------------••--------------------------------. ...................•••._.....----------•---•---------•----------------•----------•-•----------•--•-•-------------••-•--------------------•----------------------•-•-•-----•----•-•---•------•----------- Date Permit No.-------- --•-- -�&�•---------------- Issued_.........1.0.....�_.'9_�............... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ®` 1......I........OF......... vyrrtifirate of Toutphaure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............................................................................. .-------------Installer J `/ at. - has been installed in accordance with the rovisions of TIT�4 5 of The State Sanitary Code as described in the , application for Disposal Works Construction Permit No.__-._�_...._s..... 5............. da.ted... ------I------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..-------.I red.- --......-••---•----•----------. Inspector------ ------- ------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF.. VrYL ` .................................. No...... FEE._....�.............. Dhipoal Norkii O'LlInatrt ivit rruti# Permission is hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Ind* d l S D* l S s i _. as shown on the application for Disposal Works Construction Permit No..................... Dated..................................... -••..................•--•--•-•---•----------•-•----•----------•---•--•----•--•---..--•--...--•---..----- Board of Health DATE..................................................................=----........ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS +�, ,� _._ J� , . � �; _. .. � _.. i 5' b �� 9 i (Q � �l � �� �1 �� �"``_ "� � �-^�7 O .1 cA rt � � '� S I a i I � . L LOCATION— j g SEWAG PERMIT NO. VILLAGE L D Fo RTC A & B C�SSPOOL SERVICE 128'BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED/,- -- � f i r � - --- - ----- --- -- FINISHED FLOOR= 5 c,-►+ _ TYPICAL SYSTEM PROFILE � AREA PLAN FINISH GRADE= 53 NOT TO FDN TOP � SCALE : I "= 4 - FINISH GRADE OVER TANK= FINISH - 't I 10 GRADE OVER PIT= � � PIL oo PVC OR v ' di� ���"' + ` t _ '� 1 , s7 C. 1 . TEES 48.(o� 4_ 3 • 1 • • • • • • • 0 c)N,� tii C` { \ `+.-/1�.-� Ft f'Vl �...! •�+ M-...+ �r -1C�. �� • • 1 • • • • • ♦ • • e 4 -- = BSMT E?c i 5T �, f 0�?C? e �: ] . ^ t P ic��5(! FLR GAL. Q$.2S 1 • • • • • : • • Tc, V\ +` f w �... .T� t:, . . T� REINFORCED DIST. BOX 1 CONCRETE l ' e ' • • • • • ° a TO BE INSTALLED ON e • 1 • • • • • 1 • o , -`(PARTIAL 51.Ab -ON- o , .: A LEVEL STABLE BASE400 1 1 a 1 • • + • 1 1--- � o � . a.. �, .o E GRAL1 F. 1W T-VAIS AKEA) 43'+ SEPTIC TANK ° • • ° • e(FRC*-)T) TO BE INSTALLED ON A LEVEL STABLE BASE c - 2"-t/B" 1/2 "WASHED PEASTONE ALL 1 • • • • • • • ° 1 1 ! ►. BRICK a MORTAR COURSES AS AROUND FREE OF IRONS, FINES ' ' ' ° • ° a " REQUIRED TO BRING COVER TO GRADE AND DUST IN PLACE 0 L> 5T, ( OVER zaoo G. P D.) LEACHING PIT w O 4 '� CRUSHED 2 >.1 MANHOLE COVER 81 3/4 TO I 'I 2 ` WASHED y �+ _ FRAME OVER 2000 G.P. D. STONE ALL AROUND FREE OF BASE 10 BE LEVVEL Il� it — Q: - - IRONS FINES AND DUST IN Bul .-- }�i3'+ PLACE Uv1 I TT" M T �*... ;. :.,....: . _ :: . . DRFOR FIN. GRADE ri c SCE SYSTEM PPwww. ,OFILE SOIL AND PERCOLATION 1z'+ Icc.:� %2, - - a. 1v1. so.,-; ; a� � - ,: 4„ DATA LGT I .0 So_ _ - - - -- -- ` + Y its �- J 8. �/ _ TB„ PERG. RATE ' MIN IN, �` PARK ; 4 , -`.°,, •�'° ',' , _..15�..� + TQV+t4� FOR INV. ELEV SEE C. D. SPOHR P. E, - YVATIE r+c 1waC 1 S T \ ° \ C,g� „ TAKEN BY INLE o , SYSTEM PROFILE i I 1IV ►-IC�tJSE I LINE 0 6 ° ._ .ROMAI.D CTIFFOc� I. .RiJ�T tF'.i H p SEt2Y1+� .47 -t - ,° _ 0 OPENINGS W/4-1i8" ,gyp WITNESSED BY. a 9 \ ° e DATE : =DEFT i _ � I t : OD ,a•• 1� +52',• c::ok.N�:{-2 L-EaT } _ - •. ° � - ,� 0 OUTER CIA. a I -3/4 0 - ° � �• � � � 7' INSIDE DIA . TEST PIT-GND ELEV. -4- 5+ '}' EXIST. . - R :I PRoPOSC a� 4 i o - 6i 0 0 TOTAL D p t 'RkA4M _ D ►- co s 3 - I 3 8.1Z. RAMCr D o AREA t ti G. O R fsk[7 p 4 F'J11- r`.i 4T, s�` jtuC) 0 G 3- L�A-+1 N Uu�'.0 LZIOGE 1 I KIT. '" _ , ggTH $R.+�6 ° • ° ° 0 D 0 0 .% �• 0 0 0 _ �, SUS, U 1 L- U YVAT4 '�. tS t' .4 ` 0 0 0 p 0 a 0 0 p • 1 CLk.> �'.� �. 6 6 D I A 2 I PRC3W CC ::' i•AL . P9,�E :liST gi+-� TANKSEF F-k,YoOf A=,lI1►�E BOT. PERC. NOSE EFFECTIVE DIA. �N : DOWN VVEcAsr Cow V.TlE LEA�:�G # -rb `+ C) v, L E A C H I N G PIT - SECTION PIT, SEE ►-`h�bFILEL 9, IJETAIL�, T0T ( � f . r IT NO SCALE DESIGN DATA : PRFc1►s-Tr :tz c o-13ox, _ 3F F2A rtG a. � �_ �� ;- �- � L NOTE*., DO NOT RUN HEAVY EQUIPMENT OVER SYSTEM No. of BEDROOMS „ _ DISPOSAL ` LEACHING PIT NOTES: EST. TOTAL DAILY EFFLUENT 3 GALS . 5T1C. SETtS`�f SEPTIC TANK �� ) G A L. mow low �- . I.W I . CONC. TO BE ;40001'P.S.I � 28 GAYS . GR0'IND WATER ELEV• N STK"'SET+SSt l ) 2 . REINF W 6 x 6 6 GA. W. W. M. --F i � 3. 2 'AND 4 ' SECTIONS ARE AVAILABLE FOR GENERAL NOTES O'�I` Eh`_� I L7, � �" AREA PLAN : OTHER DEPTH REQUIREMENTS • I . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN NOTE : 3�, 5 ACCORDANCE WITH TITLES of THE STATE SANITARY CODE `'E - f:;�``' „A �sys _40LA I —�-- EXCAVATE TO ELEV. OR LOWER AS DATED DULY 1, 1977 BiANY LOCAL RULES APPLICABLE. - 4 � 1 � ,� REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING 2. ANY CHANGE TO THIS PLAN MUST BE APPR'D. IN MATERIAL BENEATH PIT, REPLACE EXCAVATED MATERIAL WRITING BY MR. CHARLES D. SPOHR. �, •,� E �(� "( ;;, �. • .• III �!11) � I.� A`� ��� WITH CLEAN CLAY FREE GRAVEL MECHANICALLY ,�' t COMPACTED IN PLACE. 3 WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING, 1C)-7 1 F0 PE ( � ..t�-�' - ,` �' NOTI FY THE ENG 1 NEE k AND BOHnL OF HF 4LTH FOR INSPECTION. {wy +�.-, _ ,4/,,���G�.�} �, •'� .,'. , , �.„_` , ,�. _ .,, SIDE AREA = -- S. F.0 _ GAL/5. F. -- GALS ,"�L � � �.�. "''-- '- "~a'�„3�r,,'`Sf� ..� a�1<�'�'.�,1 ., I ,� � 4. FOUNDATION ELEV. MUST BE CHECKED WHEN COMPLETED. BOTTOM AREA= S. F.@ GAL/S F. GALS YAR.�1OO� r�� tvl ` TOTAL AREA =. �$_ S. F TOTAL 5 ,..- GALS 5. THESE ELEVS. MUST NOT BE CHANGED WITHOUT WRITTEN APPROVAL BY CHARLES D. SPOHR. LEGEND 6 FOUNDATION INSPECTION REOD. WHEN EXCAVATED. -� 50.0' EXIST. GROUND ELEV. �� M. ItiCTE: PLAN REF: , ALL ` � �-�• /yi 1 �^ :-•�, ,�•�� 50.0 ' FINISH GROUND ELEV."UNCERLINED" f" LL ���+rAi ,t.l1��j ���.C'"_ '�.3 �..�f�—� ' REv DATE DES R I P T 1 0 N S P i�•1 D LE Cam' O}C 1;,��, 4•��``(�"?MCA VV'� @. � 14�� �1���•� �'� 4 7.5 O PIPE i N V E R T ELEV. T, P. 0 TEST PIT LOCATION AREA / SEWAGE DISPOSAL SYSTEM FOR nn BU I LDER' -- ® o SEPTIC TANK IVATTHEW _�nF Itilvr�N N tCk: SEYMOL)k ❑ DISTRIBUTION BOX _ L IT ' 18 J, GU ( LFjF0RG F,%3A %050a Bo"D T 4 TU M CAE RT M I L LSN OLD STAGE R�JAD MA,kl"eok�oj MA♦ 752- 4 " C. I . OR PVC PIPE (SCH 40) 1� of M�Scy� t TEt- , • - -48�- -581ro ttttI it+- 4" SCHECULE 40 PVC. i-�IPr ;o , cna:l•a D" ,-4C Et1?'ER �' I LLt��ARN�T�` R�E�N1A i SPOHR I .._ % W + DESIGNED: C.o.SPOHA DATE: I S�N� " ' � DRAWING N0 o ,p�Na 7468�o \r4, , -- -- - PROPERTY LINE � � A� /STG� 1 9 Li \oFE.SS�UtiAt �, DRAWN: •S. SCA LE:AS SHOWN MAP SEC P L LOT HOUSE AREA S, F. Y� MIN. CODE DISTANCE CHECKED: C. D. S .