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0025 HELMSMAN DRIVE - Health
5 Heim.sman Driv% Centerville A= 194—079 S M E A D No.H163OR UPC 10259 smead.com • Made to USA �c% jim). No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH,DIVISION - TOWN OF RARNSTABLE, MASSACHUSETTS Yes ftpfitation for Zisposal 6pstent Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(0<) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2S 1 6.f,6-MAC 0l1, Owner's Name,Address,and Tel.No. CC✓rf&I tf mmw "07fA/INl Assessor's Map/Parcel 9 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 5 ''A� l�cc�v+r1►NS DAN A f s1fAK,+A_W Type of Building: Dwelling No.of Bedrooms S Lot Size 22,879 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) SSO gpd Design flow provided S7S 3 gpd Plan Date 110)Zi Number of sheets I Revision Date Ad A Title .5)!C_RA V Size of Septic Tank /Sw Type of S.A.S. (111 W tit, Description of Soil Sl`�r (�9 t✓ Nature of Repairs or Alterations(Answer when applicable) jsw 4 y7 i V—J c, 4� S�tS Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea . gned Date �" -a Application Approved by Date Application Disapproved by Date for the following reasons Permit No. R_ Date Issued ----------------------------------------------- TOWN OF BARNSTABLE LOCATION Z5160. ^� t1f?-. SEWAGE# 20;1- 11 a VILLAGE G 11/1 ULE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE.NO. :'Tii,_ ., 7n11�►Ste,'Y3Z�aP SEPTIC TANK CAPACITY t d10 V" r0� LEACHING FACILITY: (type O (size) NO.OF BEDROOMS 5 OWNERS - PERMIT DATE: COMPLIANCE DATE: Separation Distance Between.the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feett 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)/� �+nr� � � Feet FURNISHED BY E)l9AJ A 6- 3++.f yLf I 3 g2 3s,s 4 32 31 1, s 2J Tl I 1 94 / /4)� No. Fee Ido_� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC H"LTUDIVISION - TOWN,0_17 BARNSTABLE, MASSACHUSETTS Yes y 2ppfication for At'sposial *pstem Construction 3dermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual C mponents Location Address or Lot No. 2S Owner's Name,Address,and Tel.No. e�~v�ct�,itle Mrs j_7 �,� �� Assessor's Map/Parcel !o,F f?ej ✓"' Installer's Name,Address,and Tel.No. _ Designer's Name,Address,and Tel.No. Lo VV(AVY..-IJA.J, t)A!V a f4 jjtvPn+ 4_ J SG1 i` i i y� 3 ' i- r( Type of Building: Dwelling No.of Bedrooms Lot Size .74. �7) sq.ft. Garbage Grinder( )' Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets l Revision Date nil A ' Title 5)i c 1-,tA v ' Size of Septic Tank l SLY!,, Type of S.A.S. 1)l7U7 c.,a C t t C Description of Soil 5 t i t,, Nature of Repairs or Alterations(Answer when applicable) A SA-3 i Date last inspected: " Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed i Date '/,y� ' Application Approved by }�`�-✓ "'"'" Date / Application Disapproved by / Date f for the following reasons ti Permit No. , Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS V�� �` f !� . : � �' Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) I Upgraded(� ) Abandoned( )by !?C 'N AA0 ('X(-A X./A-7,1-0/ `f - -at -- 5 r'/f-1 r`+SMi1.� 171 has been constructed in accordance with,the provisions of Title 5 and the for Disposal System Construction Permit N po"- ✓—/q dated Installer Designer #bedrooms -5 Approved design flows gpd y, The issuance of this permit shall no be construed as a guarantee that the system wi-l1 funs--as d�e is geeed. Date (�/j ��.� Inspector '..._ ^No -; .•> � Ow �. . Fee �- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstrm Construrtion Vermit Permission is hereby granted to Construct( ) Repair( ) Upgrade Abandon( ) System located at 2S y/I ZM.SM ns 1>i i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date c�✓- /C ( Approved b•y�""� _ �,, Town of Balrnstable Inspectional Services : Public Health Division sRrrerasMIMAM Thomas McKean, Director 0 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Cerification Form Date: I �0� Sewage Permit## - �A Assessor's Map\Parcel 41 ,WC ON— Designer: ID Installer.- W Address: ��b CU Address: On tZ t5 ►'�a as issued a permit to install a dat H (installer) septic system at based on a design drawn by (address) _Doo� �� dated1 �. (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the to rms of the IAA,;aapproval letters (if applicable) IN OF/ygs�'ir DAVID �y (Install s ignat re) B. CAMASON rn v No.1066 64ST6- eslg 's Signature) PLEASE RETURN TO BARNSTABLE PUB:. 1 E OF COMPLIANCE WILL NOT BE ISSUEL __ _ _ ,,..i�i P ND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEAE'TH DIVISION. THANK YOU. NtoaM ptAHEALTHISEWER connecASEPTICOesigner Certification Form Rev 8-14-13.DOC h r .--�� _.� �, �..._ 6/17/2021 Mail-Dan Speakman-Outlook Sent from my Who�n�� ri fY . III[ � R Ai 01 e https://outlook.live.com/mail/O/inbox/id/AQMkADAwATEOYjYwLWMxMQAyLW E4NDctMDACLTAwCgBGAAADSpiOdiNumUG 1 a8MmmMaBXwcAvwL7... 2/2 Town of Barnstable Inspectional Services Department BA y 'OrFa► MASS. Public Health Division 639. 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 8272 December 15, 2020 STEARNS, MARK B 25 HELMSMAN DRIVE CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 25 Helmsman Drive, Centerville, MA was inspected on 11/10/2020 by Troy Williams, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septicsystem h w h "p pshowed ed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: I • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\25 Helmsman Drive Centerville.doc Commonwealth of Massachusetts ,F Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P-79 Property Address — — --- Mark Stearns Owner Owner's Name —— — information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 31 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P-79 Property Address Mark Stearns_ Owner Owner's Name information is 25 Helmsman Drive, Centerville MA 02632 _November 10, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A_ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form _ Ie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P - 79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was found with water level just below inlet invert with staining above inlet. Leaching does not have a minimum 1/2 day flow that is reguired by Barnstable regulations. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth —top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` 25 Helmsman Drive, Centerville M - 194 P - 79 Property Address Mark Stearns Owner Owner's Name information is 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 -6'X6' pit with1' of stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P - 79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive Centerville MA 02632 November 10, 2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found in working order. D-box is located under cement driveway with no access. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 25 Helmsman Drive, Centerville M - 194 P- 79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: N/Afeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �xip Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P - 79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive Centerville MA 02632 November 10, 2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 8'with riser to 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: 5'X9'X6' 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 2' 8" Scum thickness thin layer 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 16" How were dimensions determined? probe/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.): Inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P-79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Tank, d-box and leaching were installed on 6/4/86 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 5'+ 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.): Lines were found clear at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P-79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive Centerville MA 02632 November 10 2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: N/A Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe below): N/A 3. Pumping Records: Source of information: No pumping info available. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Iz Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u, 25 Helmsman Drive, Centerville M - 194 P - 79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: N/A Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No 68,000 gals. = Water meter readings, if available (last 2 years usage (gpd)): 11865,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts l�l� Title 5 Official Inspection Form I;s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P- 79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �u- 25 Helmsman Drive, Centerville M - 194 P -79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ❑ Liquid depth in cesspool is less than 6 below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P - 79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P - 79 Property Address Mark Stearns Owner Owner's Name information is 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of•Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P-79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes:. , ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts 9� Title 5 Official Inspection Form Ito Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P - 79 Property Address Mark Stearns Owner Owner's Name information is 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 required for every 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. III Important:when A. Inspector Informationfilling out out forms on the computer, use only the tab Troy Williams key to move your Name of Inspector cursor-do not Troy Williams Septic Inspections use the return Company Name key. 19 Hummel Drive 4:1 Company Address South Dennis MA 02660 City/Town State Zip Code (508) 385 - 1300 S1682 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails SNovember 10, 2020 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins .doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 P P 9 P Y 9 Town of Barnstable a BARNYfAHLE, b q A Inspectional Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone I to a public well ❑ A portion of the cesspool is located within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) /Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P -79 Property Address Mark Stearns Owner Owner's Name information is 25 Helmsman Drive Centerville MA 02632 November 10 2020 required for every � , page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form pie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Helmsman Drive, Centerville M - 194 P -79 Property Address Mark Stearns Owner Owner's Name information is required for every 25 Helmsman Drive, Centerville MA 02632 November 10, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 17.0+ 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 maps estimate groundwater at over 20'. Bottom of leaching at 16.0'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 S I W A G MIT WO, ? 3 0 N INSTALLER'S HA04E A ADDAE55 a• Z.E t7/c/40 X1DS A 8 OWNER DATE PEER MIT ISSUED 3 — �� DATE COMPLIAHCE ISSUED i it 1 3 I' ,i Coo c,-4G 3 ` STOw,C 0 CA SL W AG �t417 k1o. �,LLAG L : N IMSTA IIAER'S NAME S A DAfSSIQ �_� FA SAT =� E IT l5SUED DATE CnMPLIANCE t53UED L � � 31' . I U� i 8 No. 4oq P.O. Boy�34 �— . ." Hyannis, Massachusetts 02601 Fes$ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH O OF..... .... Appliration for 11ispasal Worko Tomitrnr#ion 1hrmit Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System at .. - :� .... - ---------------------------------------- �yy ocation- dress r t No . ......................... ... . ........................... s ner ss ... Installer Address (�sue�s d Type of Building Size Lot.AA__�.;.I,?.Sq. feet Dwelling—No. of Bedrooms..........1j............................Expansion Attic s Garbage Grinder 9/42 aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other, tures -------------- ---------------------------------------------------------------------- -------------/�r ....... W Design Flow.:............0....................-_.gallons per person per day. Total daily flow......,�„7.. ............................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing t Percolation Test Results Performed by..._. _.._ _ .. Date___.�`J..:.�_��_�.[f_. _.... a ....°� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil_..p_":'Lf,_. -x :_ _.. c, W UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------_.................................. ..----.....-•--•---........-•-•------------------------------------------•-----------------------------------•---...-----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'ITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in ope t til Cert*ficate of Co pliance has been issued by the board of h 1th.P Si ned.------ -(�a9 g � 'l ------------- •-----. . ••----._..... Jute Application Approved By.........._ L. tale ..--•--... Date ----•------ Application Disapproved for th f o owing reasons----------------•--------------------.....--------------•---------.------------------------------------------.7 -----------------------------•------------------------------.....-----------------------•--.........----•---•----------........------------------------------------------------------------------....•-- Date Permit No.....� °-'9"®� ._ Issued_ �,,Ej. QS ------- .. - Date s No...�:S= q©°3 Fss...... ��G;J THE COMMONWEALTH OF 'MASSACHUSETTS BOARD OF HEALTH � Applira#ion for Disposal Works Tonstrnrtinn lirrutit Application is hereby made for a Permit to Construct (t"or Repair ( ) an Individual Sewage Disposal Systemm at: ..r-,_,T.a..� ��....... .X,l?�:.tl�,'c=cP.!Jr?:......./_.�.'lsL�e� <'.. ... _� » Pyt�.� �.1 ✓���t'�!.. .._.. ......................... Lo ation-Address c - or Lot No• _ - Owner ddr j, -y.-- � ...:................................ ........�+� ,r�� .G.SG � C.� nstaller Address UType of Building Size Lot., ._ _._.__ S feet Dwelling—No. of Bedrooms........... .............Expansion Attic (�/�r Ga bilge Grinder (61&� aOther—Type of Building ............................ No. of persons............................ Showers ( ) — .Cafeteria ( ) d Other fixtures . W Design Flow..........././o...........:...........gallons per person per day. Total daily flow---------may J. -0.....................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by... -.. .f lt, ,�.S'_.._-._ ............. Date..._Z......_ f Test Pit No. I................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........................ W ............................................ _ ODescription of Soil..-Q=-Lt.... "' '-------,--:5-,,-,,z-.,:—--�-----------------------------------------------------------•---.......--- v �. --- /Yr •------ - • ------------------•----------•---------•--------•----------- W VNature of Repairs or Alterations—Answer when applicable............................................................................................... ...............•---...-•-------------••---•-----------•--------•-•----------•------••----•---•--------------•------------------------•-------•-•-------------------•------....----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.I 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 ~ ,.- --•---- to.: _. Application Approved B ' .....ate �� ' p Date Application Disapproved for they f o�owing reaso s:.............................................................................................................. ......•---•-------•---------•-•--••-.......---•----...-•-----•-------------•••-----•---------••--------••...................•........................................................................... Date Permit No.-----. --------•--------------- Issued-.............. `Ss' ........... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ../,/.!9. -(•••/s ......OF...... yr. ye: ✓.�.:/".................... Tnrtifiratt of Tompliaurr THIS�I�TO CERTIFY, Th _t the Individual Sewage Disposal System constructed (for Repaired ( ) J :...... �, Instal er at....... 'l- �/�✓ --------------------- has been installed in accordance with the provisions of TITLE 5 of Thetate Sanitary Code as descrid in the application for Disposal Works Construction Permit No------- ��.__..-1..____ _. dated__-.._---/._ I�., _-t ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL UN �-I0 SATISFACTORY.ISFACTORY. DATE.................. � ................................. Inspector............../��---------•----•---•-•--...----•-----•------....---•--••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 42 el No.....:5,?.S.::...4.p 9 ........OF.. FEE.... .. ... .... Disposal Works TV.11noir ion nutit Permission is hereby granted----- t�_ a.�� j ©��------- -- ------------------•----------......------•-------.....---•--------.... to Construct (L j or Re air ( ) an Individual Sewage Disposal System at N ------------- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... •---.....--••--•-•--•--•--------------------------------------------••--------•-----•-•------..._........ DATE---•-•-•-•-s .......................................... Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON j S/N6LE F.4J/L Y 3 BEO.eoOtil I /VO 45Q•2B. 4sE a�elxlOEAz OA/L Y FLO lit/ = //0 X-3 : 330 6.P.Z? ' �T/c /f - A'Pc ►5 0"o 9 SE T,Q.c/ o ,ffSE /,000 C7L. ��i io7.�o x, Q/.f�S.4L �/T•-USE /.G100 6'.G�... �`n zo' '� �" /�O X.F. x Z.j' = �' ,'�• G.P.O. p "°'Trw w� ' lei BOTTo�yA.P�d S IV � TOTAL. I�.4/LY�Lo�t/= ,3.�'O G•PO, od° � . s�'. f�E'•E'G,5 1447-/1:rlN.e41Z: / /.V G7eLE� CMG- a. r►R r r' OF lilgs�9 1 �o z �o ti� OF 4 q T 3 A � r PETER , �, �� �, SULLIVAN ZZ, $'?6 ��T. a E N0. 29733 �G RICHAR® Q `n A. .. . BAXTER H \\ Na 24046� S.'�7, K. 12 � f �T--e-0- /o<•E -11, $41 o. 2SS \ ( f1" O/Sr, 00 :•..• /�/✓., GAL. �04.8 � t�Acw Pir a lad 6 SE.or7G W/ .may. 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