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Home My WebLink About0072 HARRISON ROAD - Health 72 Harrison Road Centerville P A = 229 .078 UPC 10259 No.H..�1630R NANTINGIL NN Town of Barnstable IMRNSTASM Inspectional Services p'f039. Public Health Division Thomas McKean, Director 701-1--loiO �;F�c �xL'��{Qf1�! 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 16, 2021 Paul Mello 72 Harrison Road Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE. The property owned by you located at 72 Harrison Road Centerville, MA was visited on April 16, 2021 by Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted in response to a complaint filed with the Public Health Division. The following violations of the Town of Barnstable Board of Health Regulations, Chapter 54 Building and Premises Maintenance were observed: §54-3 Outdoor Storage Observed multiple trash bags with garbage in them on the front deck not within a trash barrel with tight fitting lids as required by above Town code. You are directed to correct the violations within seven (7) days of receipt of this order letter by either removing said items from property or storing all garbage /trash in garbage barrels with lids. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S. Director of Public Health Town of Barnstable 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. i Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601. (Town Hall) and get the Business Certificate that is required by law. . DATE: `� ` J 7 Fill in please: APPLICANT'S YOUR NAME/S: BUSINESS Fi YOUR HOME ADDRESS' 7 z Ne�� raa RJ it Y!V 0263 Z TELEPHONE # Home Telephone Number '7•� Y PP a '�"•`J�vt`��`�"� SOC-IAL SECURITY OR EIN #: 0/-2-70-02g -E-MAIL: /'�� o ��/�7 ��oo. ��✓ NAME OF CORPORATION: NAME OF-NEW BUSINESS fleyt-V/r TYPE OF BUSINESS .Tien Ste— <+e IS THIS A HOME OCCUPATION? . YES ✓ NO ADDRESS OF BUSINESS 7Z •!?v( /7,A— 006;3--z- MAP/PARCEL NUMBER �" (Assessing) When starting a new business there 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 CO%A, 'S OFFICE MUST COMPLY WITH HOME OCCUPATION This individirT�. d f n per it e uire Brits that pertain to this type of business. RULES AND REGULATIONS.. .FAILURE TO Si natu ** COMPLY MAY RESULT IN FINES. OMMENTS: I vnTT 2. BOAR OlUEALT This individual has beer;,?, formed of h ermi r uirements that pertain to this type of business. _ MU ONIp1Y WI'I`hl"ALi _. HAZARDOUS MATERIALS R0UkT(4NS A,6thorized Signature COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Date: q/ S / 17 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: #Om BUSINESS LOCATION: INVENTORY MAILING ADDRESS: 7Z Hoi'16011 fd TOTAL AMOUNT- TELEPHONE NUMBER: //yr CONTACT PERSON: �2 14e//o EMERGENCY CONTACT TELEPHONE NUMBER: -1'08 36 0- // MSDS ON SITE? TYPE OF BUSINESS: _ �/� /j, 5.0 vet-e INFORMATION / RECOMMENDATIONS: Fire District: i 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 14 /',\ 11 i'die 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 icant's Signature Staff's Initials y TOWN OF BARNSTABLE .ocAmIorr 7� /-(g��:sa►., iPf SEWAGE # TILLAGE �QK f�� r�(� ASSESSOR'S &LOT NSTALLER'S NAME&PHONE NO. lEMC TANK CAPACkTY , .EACHING FACIUM (type) P.'�-_ - - (size) /— AfC v - (0.OFBE®R.oOMS__ .2—_, IUILDER OR OWNS-R-. 'E DT®ATB:_,._-.— COMPLIANCE DATE: separation Distance Between the: Aaximum Adjusted Groundwater"fable to the Bottom of teaching Facility ._ eet 'rivate Water Supply Well and Leaching Facility (9-wiy wells exist on site or within 200 feet of leaching facility) e,et ;dge of Wedand said Leaclting facility(if any wetlands exist within 300 feet of caching fsaci'' '}� � eet /,f Vrnishcd by� 4 w� '!ter�—��i� e,, �e r O 1 , �F r �f Commonwealth of Massachusetts W Title 5 Official Inspection -Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name , k 29 Atwater Dr ' Company Address > E. Falmouth MA 02536 _� City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number f 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 9-21-12 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•11/10 Titl91ff, VI.n :Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 page. Cityrrown 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 is in good working order with no sign of failure. 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-11A 0 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 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 page. City/Town 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 0 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 l v Commonwealth of Massachusetts ` W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 page. City(Town state Zip Code Date of Inspection B. Certification (coot.) 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 '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 s Commonwealth of Massachusetts q7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 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. ❑ ® An portion of a cesspool or privy is within 50 feet of a private water supply well. Y P P P vY P PP Y ❑ ® 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 'v 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,boogpd. E ® 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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 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) ® El 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form "m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments q„ 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 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? [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 Last date of occupancy: 8-2012Date 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M0 72 Harrison Rd Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 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: Today Real Estate-pumped 9-21-12 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gal gallons How was quantity pumped determined? Receipt Reason for pumping: Required for inspection 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 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Harrison Rd Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 42"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condiiton. Septic Tank(locate on site plan): Depth below grade: Cover on gradefeet 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: 6x8 Cesspool Sludge depth: 12" . 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 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 48" Scum thickness 0 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 6x8 cespool acting as main tank in good condition with baffles installed. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 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: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 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 h Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .° 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers Y number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ Teaching 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 in good condition and empty at inspection with stain line at 36" below inlet invert. 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 page. City/Town 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f ' Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form Not for Voluntary Assessments 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 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 Ca re. lip E t5ins•11/10 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 ,e 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 a e. City/Town State Zip Code Date of Inspection P9 P P D. System Information (cont.)y c Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high round water: 20' p g g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. 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 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Harrison Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 9-21-12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 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` o operate. Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) Z.vcJ DATE: 4° 1-2-14 � � Fill in.please: aF ;, APPLICANT'S YOUR NAME/S: " ''' n. ! BUSINESS YOUR HOME ADDRESS: �� - ��s��- 2� -'-I� 17•Hci, f ------ ' TELEPHONE # Home Telephone Number 1 `Y NAME OF CORPORATION: M 06 A 6,1 L - NAME OF NEW BUSINESS rYt YO (u U I V-\-- TYPE OF BUSINESS YCt4A 1 tA c- IS THIS A HOME OCCUPATION? NO o, ADDRESS OF BUSINESS :k 'Zi ` �� rC cal MAP/PARCEL NUMBER ��/ O 7 8 (Assessing) When starting a new business there 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 20D 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 OFFICE _ This individual has been informed of any permit requirements that pertai n to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual ha info 9=f e per it requ ements that pertain to this type of business. Authorized 'gnature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual haMn inri of t�he_licen i r uirements that pertain to this type of business. Authorized Si nature** COMMENTS: IVtJ �Q� c 1 I Z27 -7y TROY WILLIAMS t+Z SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION f TFFLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASS�issS ;;FN7�SI��ED SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM `�"� L� PART A CERTIFICATIONN OF Utz Z002 Property Address: 72 Harrison Road TOWHEALTHIDEPT. Centerville, MA Owner's Name: Ellen Lindgren Owner's Address. 72 Harrison Road Centerville, MA 02632 P Date of Inspection: December 11,2002 Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis, MA 02660 Telephone Number: (508)385-1300 Z CERTIFICATION STATEMENT 1 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The svctem VPasses Conditionally- Passes Needs Further Evaluation by the Local Approving Authurn) Fails Inspector's Signature: _ 'f�,�.�z; ..� Date: /z/t 6 /o z The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 off-ice 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 Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification Is not to be construed as a guarantee of future working condition of system.piping or components. This Inspection represents the conditions of the system on the Date of Inspection noted above. ""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 saute or different conditions of use. Title 5 Inspection Form 6/15/2000 pace 1 Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A 72 Harrison Road CERTIFICATION (continued) Property Address: Centerville,MA Ellen Lindgren Owner: December 11,2002 Date of Inspection: 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 CNIR 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 naed,t6 be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the B fird of licalth, will pass. Answer yes. no of not determined(Y,N,ND)in the_ for the following state nis. If•'not determined"please explain. The septic tank is metal and over 20 years old* or the septic to • whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failur is imminent. Svstem will pass inspection if the existing tank is replaced with a complying septic tank as approve y the Board of!lealih. `A metal septic tank will pass inspection if it is structurally so d,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available ND explain: Observation of sewage backup or bre out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settl or uneven distribution box. System will pass inspection if(with approval of Board of Health): oken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The syste required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspecti if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: r 2 Page 3 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 Harrison Road Owner: Centerville,MA Date of 145pectiou: Ellen Lindgren December 11,2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303( b)that the system is not functioning in a manner which will protect public health,safety.and the e . •ironment: _ 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 arsh 2. System will fail unless the Board of Health(and Public W r Supplier,if any)•determines that the system is functioning in a manner that protects the public b th,safety and environment: _ The system has a septic tank and soil absorptio ystem(SAS)and the SAS is within 100 feet of a surface eater supply or tributary to a surface wat supply. The system has a septic tank and SA d the SAS is within a Zone I of a public water supply. The system has a septic tank a SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic nk and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well" . Method used to determine distance •This system pa• s if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and v the organic compounds indicates that the well is free from pollution from that facility and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure tteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 Harrison Road Centerville,MA Owner: Ellen Lindgren Date of Inspection: December 11,2002 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 —,Z 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. �L 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 forma i0 (Yes/No)The system fails. 1 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 esign 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 cr' ria above) yes no the system is within 400 feet of a surface drip g water supply the system is within 200 feet of a tribu to a surface drinking water supply the system is located in a nitroge sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water sup well If you have answered"yes"to an question in Section E the system is considered a significant threat,or answered "yes"in Section D above the ge system has failed.The owner of operator of any large system considered a significant threat under Se on E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system o r should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 72 Harrison Road Owner: Centerville,MA Date of Inspection: Ellen Lindgren December 11,2002 Check if the followine have been done. You must indicate"yes"or"no"as to each of the followinv Yes No information was provided by the owner. occupant, or Board of I ieald, 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? ,v/A 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 '? kt/19 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: Yes no _ ✓ 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)(3I0 CMR 15.302(3)(b)] 5 'Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 Harrison Road Owner: Centerville,MA Date of inspection: Ellen Lindgren December 11,4VbW CONDITIONS RESIDENTIAL Number of bedrooms(design):--.,)L Number of bedrooms(actual): a -+ i7rN DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): a z 6 Number of current residents: 1 Does residence have a garbage grinder(yes or no): Alo Is laundn on a scharate sewage system (yes o: ncil:,vo [if yes separate inspection required] Laundry system inspected(yes or no): &L9 Seasonal use: (yes or no): _&Q Water meter readings, if available(last 2 yearsltsage(gpd)): o_t I b UO ry,�, s- Sump pump(yes or no):A T— Last date of occupancy: 6 ;e COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 syst (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: , A Was system pumped as pan of the inspection(yes or no): �S If yes, volume pumped: iouj gallons-- How was quantity pumped determined? Reason for pumping:.,, TYPE OF SYSTEM Septic tank,distribution box,soil absorption system ✓Single cesspool ,i1 J A,.4 Le, .t, o,'+. _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe):. Approximate age of all components.//date/Iinstalled(if known)and source of information: y� 70.5 - ti�w, o Al, Were sewage odors detected when arriving at the site(yes or no): Ato 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Harrison Road Owner: Centerville,MA Date of Inspection: Ellen Lindgren December 11,2002 BUILDING SEWER(locate on site plan) Depth belu�� grade: 31.,k Materials of construction: cast iron _40 PVC,lother(explain): J; 5 + c/.J fit, P(J c c,c/aao r Divanc:• fron. private water supply well or suction line: &,/,7 ' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: _(locate on site plan) Depth below grade: Material of construction: _concrete_metal_fiberglass_polye ene other(explain) If tank is metal list age:— Is age confirmed by a Certificate of nipliance(yes or no)'_(attach a copy of certificate) Dimensions: Sludge depth__ Distance from top of sludge to bottom of outlet tee or aftle: Scum thickness: Distance from top of scum to top of outlet tee aflle: _ Distance from bottom of scum to bottom of tlet tee or baffle l low were dimensions determined: Comments(on pumping- recommends 'ons, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence f leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_p ethylene_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 t or baffle: Date of last pumping: Comments(on pumping recommendations, ' et and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of le age,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Harrison Road Owner: Centerville,MA Date of Inspection: Ellen Lindgren December 11,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of ins ction)(locate on site plan) Depth below grade: Material of construction: concrete metal Fiberglass Dolyethylene other(explain): Dimensions: _ Capacity: gallons Design FloNti. gallons/day Alarm present(yes or no): Alarm level:_ Alarm in working ord (yes or no): Date of last pumping: Comments(condition of alarm and fl switches, etc.): DISTRIBUTION BOX: (if present must be opened)(I to on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to lets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMI3ER: _ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,co tion of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Harrison Road Owner: Centerville,MA Date of inspection: Ellen Lindgren December 11,2002 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. Type leaching pits. number: I - S.s 'x 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.): / L a-H!1,.� �;_� o r h) o.t .:.. o� .��,_,.__� U� S • b ( c-�=�__ �': �,— <. K;��y t; hi +��5 or d-.z �L , ti9 � ors CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) S` wN� o lt.•,, Number and configuration: Depth--top of liquid to inlet invert: y Depth of solids layer: Depth of scum layer- Dimensions of cesspool: G Materials of construction: Indication of groundwater inflow yes or no): iw Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,/etc.): .,L v`_L_GL J�Jw� �/flI^e- .c.� t_ Uh O^✓s...r la c-J_/� h.t. .. t-.i l�c-�. s_.�._ J !� A.s �Jr.�. /'o ✓ ✓t� Itille,vN PRIVY: (locate on site plan) Materials of construction: Dimensions: ----- -- Depth of solids: Comments(note condition of soil,signs of hydraulic Zure, level of ponding,condition of vegetation,etc.): 9 Page 10 of.I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Harrison Road Centerville,MA Owner: Ellen Lindgren Date of Inspection: December 11,2002 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. VW . Jy C- r w s4- 10 Page I I of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Harrison Road Owner: Centerville,MA Date of Inspection: Ellen Lindgren December 11,2002 SITE EXAM Slope Surface water ✓ Check cellar ✓ Shallow wells Estimated depth to ground water 23•.3 feet Adjusted high ground water elevation/7.Sfeet Please indicate(check)all methods used to determine the high ground %cater elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: _ 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: —__.—.__.1L_.?. �__S �srW 4.t lr r..�.c✓' l�u- .../..�c .:rrN I i 44 fiQ 14,. 4•f 4 W da,'}c.� t.c✓..-1 c�,t •'�.c �j.+..� o_.0 �h S �ac..l�j'�r�. / B- 3 ' J, ` This report has been prepared and the system inspected as of the date of inspection. This report is not a warranty or guarantee that the system will function properly In the future. There have been no warranties or guarantees,either expressed,written or implied, relating to the system,the inspection and/or this report. 11 ' TOWN OF BARNSTABLE LOC:.ATION 2-- �� 69 - SEWAGE # VILLAGE Gc V. ASSESSOR'S MAP & LOT�2 °I '7�'� Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS A4-d,,A BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 71 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 �W%W, > 171111- Z �� ,Z�a �.� � p 1 �� ,� Y� I S .� r /y�N� -5 3-Sl LOCATION ,' 5EW&64E PERMIT UO. ILLAGE -C�z!�'C� 4- —A, — — — W�S-TILLER 5 U&PRE � ADDRESS ,L�s L�� c'®tea •�,G-� .�.vlj .�oy �� — — BUILDER 'S Q &MF- ADDRESS D47E PER ISSUED DATE COKAPLI &MCE ISSUEC) : ��. ;` _ 7 + y �� Y , V ii a ' ��' � �ry� � � F No...........u� Fiz$......E�t 9.2...... THE COMMONWEALTH OF MASSACHUSETTS"� BOARD OF HEALTH 1 .OF. . .arns.table ........................................... Town ... ... .. .8 Applirattun -fur 43t,ivumt Workii Ton,itrurtimn Vrruit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: 72 Harrison Road - - ----- --------------------------•----•--••---------------------• --------•------•----------•----•-•-----------------------......----•-------•-•---........-•-••--- Location-Address or Lot No. ........E�---�.----Lind.gren-----....--•.................................... ••----.....c�.tex.ville.--...•--•--•-•--•-•-----------------•------•--- Owner Address W Joseph P. Macomber &...Son.,.... nc:.... Centerville Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------------------_--.-----.. .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons..--.-----.................- Showers ( ) — Cafeteria ( ) Q' Other 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 leaclii ig area------------------sq. ft. �e - /r a 7 z Other Distribution box ( ) Dosing tank ( ) D.d^ � aPercolation Test Results Performed by........................................................... .... Date-.--..--.--.-.-.--.--.-.--._..--..-.__.. a Test Pit No. 1................ininutes per inch Depth of Test Pit......-------------- Depth to ground water------------------------ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.......--........... Depth to ground water...-.-.---.--.._.--.-__. 9 ------------------ ---------------------------------------=+---------------------------•-••-----...........----...------------------------------------------ O Soil Sand & Gravel — Description of -------------------------------------------------• ---------------- -------------------------, ------ -- ----------- �c� �' v ------- ------------ W Nature of Repairs or Alterations—Answer when a---licable----..1.-1J_ . -it_----------- ----- ------------------ - ��-..gallon-..�.�.t-------------------------------------- .. -------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- 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 bee ssued by the bard?ohe lth. Signed.. .... � Date ApplicationApproved By............................•-----•----•••--•---•••----•-----------•-----------•----------------_ ......................----------------. Date Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------•---- -----••--------------------------------------------------------------------------•--•--•-•--•------------I----------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date No.------ �� Fa$....... z�JO..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH gown_.... . .........oF......R ..r,.n. s.tr. F................................................... A.VVI atiun -fur 43iupuuttl Workg (onstrurtiou Vrruiit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: ..._.___.72...Harr .son Road o.a--------------------------------•--•----_----- -----------•-••--•---•••-•--------••--••-----•- .......................................... -Address or Lot No. F - LndyPn..... Cc�ntrzr3-11Q Owner .7Psen!;-_ P.___Macomber & Son, Inc . Centerville Address ........ ......•.. ...........•--... -•--------------••---•--••--............................... -----................................ Installer Address UType of Building Size Lot-...........................Sq. feet �-I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ----------------------------------------•------------------ -----•-----------------------•---•-------...._..------•-•--------------------.-------•--- 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 leachit g area------------......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) o.(�' �� 3� 7� aPercolation Test Results Performed by-------- -- .............................................................. Date--------------------------------------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water................-------. (s, Test Pit No. Z----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water......-..--.----. ----. tx .................... ----------------------------------------i......................................................................................... O Sand & Gravel Description of Soil - U ------------------------------------------------------------------------ /,ht2�f ------------•-------•-•---------------------•----•-----------------•----•--------------/----.... --•-•----•----•----------------------- --•-------------------------•------ V Nature of Repairs or Alterations—Answer when applicable...-.-..-_-.1.000__•ralln"___?�7_t,__________--....... _________________ --------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I 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 boalyd of] ealth. , Signed-- . � --- �- •------------- ---•--....------- Date ApplicationApproved By------------------------------------------------------------------------------------------------- Date Application Disapproved for the following reasons:--•-••-------------------------•-----•-•--•-----.......----•---••-•-•-•-•-----------•----.....-----....._•----- •---------------------•----•----...--------•-----•---•---------------•-------.---•---------------•---------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............Town...............OF.........Barns table........................................... �rrtifirutr of 0111utpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X) by---._...._Jos Ptah---P.---Macomber__&--Son Inc . * Centerva.-lle--------------------------------------------- •------ Installer at......72...Harrison__Road-._-..Centerva_lle,- Lind;7ren ------- --- ............................................................ has been installed in accordance with the provisions of :Aicle XI of The State Sanitary Code as des t d in the application for Disposal Works Construction Permit No.�_*....... .............. dated_.....-/�.-. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WIL ....... CTION TISFACTORY. DATE--------------•.-......�------ ��---.... Inspector...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7� Toc'!n........ ......of............Ba.rn.s a -IP.. ................................... No.--•--..!� 3 •--• $5.00 FEE........................ Biri:Vu,ittl urk-q Ounstrurtiutt Vrrmit Permission is hereby granted---?nSfPh---P....Ka-00mber P' Shtj.:- .......... ............................................ to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at No.----_72...Ha,r_r .S.0r ..R0. _d strc t /" -•-- as shown on the application for Disposal Works Construction r;L�it' No.__l._.- ._. d-.-.----��3� 7� . - -- _ DATE. --- I�.=�'/.-� � Board of Heal FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �7 .v`v'a`s � " 29 n 'Amu .��alf i%�2�C� i mvidmN, .63 TOWN OFFICES 397 MAIN STREET (617) 775-1120 Ex. 128-129 HYANNIS, MASS. 02601 I` Qx STIPULATION AGREEMENT I, Joseph P.- Macomber, do hereby agree to the following conditons set forth F' by the TOWN OF BARNSMBIE CONSERVATION COMMISSION and intended to regulate work at the property of E. O. Lindgren, Harrison Road, Centerville, Mass. Conditions: 1.) Project as per plan dated October 19, 1976., A - j 2.) . Approval of the plan by the Barnstable Board of Health. 3.) Notification to the Barnstable Conservation Commission ' upon completion of the work. This agreement should in no way be construed as a waving of the rights of the Barnstable Conservation Commission under G.L. Ch. 131, Sec. 40, nor under Article XXVIII of the Town of Barnstable By-laws. Should the conditions set forth herein be violated, the Commission-may exercise those rights and require ++r complete compliance with the above cited statutes. A ' Joseph P. Macomber On this 29th day of October, 1976, before me personally appeared Joseph P. r Macomber, to me known to be the person described in and who executed the foregoing instruient and acknowledged that he did same as his free act and s deed. s IT.' �s Notary Public My Commission Expires: u. _• ••'-: � .-. ,.. ,.>.�-r"�,^.�..�'` "�: �'iy. r. .-4`-��.'�irj°.r. .er.: .;.,,.t w...�.'�`.r... ..�4 .ji. - i"3 .+ .� t �^�. - kT�ta.. �,�y Harrison Ri Proposed on loachin4 Pit a 1 —_ t1,p x ox. C 3 At -72 Road (' P4 - 9 T f� 5 Jr 1 r 1 7 1. j{ s r- aico:1b, x 'rt:. 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