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0158 HIGHLAND DRIVE - Health (3)
158 Highland Avenue Centerville ..P A 190 133 S//// �REcrcctoc te/ d zJ �2m lll! � Zi UPC 12543 Now NASTINGS,MN r TOWN OF BARNSTABLE LOCATION/ is SEWAGE# VILLAGE -.6W �' -wj ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO., �-y�� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS .3 OWNER-VA44 f4la l9141'G'F PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on i 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 LF o 0 Al ) �l 43 3 � o rom: 09/12/2017 14:04 0034 P.001/001 Town of Barnstable Regulatory Services ..� Richard V. Scali, Interim Director STAB Public Health Division .erg' ��►u+' Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: cl 1� Sewage Permit# 0 - gg Assessor's Map\Parcel V l Designer: 6 fl,. Installer: dpp.ep� Address: eo GUOL%t i Address: On 2-2 E-f 7osGyv`il�_-e Y�/rkev.%was issued a permit to install a (d Pt (installer) nn septic system at �} � C 4� t`-�y�i based on a design drawn by (address) c dated p des. I cell y 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-fequired) was inspected and the soils were found satisfactory. I certify that the system referenced above was construct a with the terms of the IAA approval letters (if applicable) t l'X M ER staller Signature) '�, R86. 1140 I _-kWignerN6 Signature (Affix Designer amp Here) PLEASE RETURN TO STABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Fonn Rev 8-14-13.doe No. �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitation for aispo8a1 6pBtem ConstCULtion Permit Application for a Permit to Construct(c.K Repair(Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot No.13$1416,yL 1411.0 0r1 V1I- Owner's Name,Address and Tel No. Assessor's Map/Parcel a— Installer's Name,Adsjress,and Tel.No.5DF^�/QD-173,9 Designer's I�amg,Address,and Tel.No. OS�P D� /l1yO �I/_—j/l�/°" 1)rpe of Building: _ Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 3 Z gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S' e Date Application Approved by ✓ Date Application Disapproved Date for the following reasofis Permit No. 00(:7 ^ Date Issued No,, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplicatlon for MispoBaf *pstem Construction Permit Application for a Permit to Construct(l.YRepair(44,"Upgrade( ) Abandon( )n a❑Complete System ❑Individual Components Location Address or Lot No./.t$N/l tiL w17D Or/V� 'Owner's.Name,A'fldiess;'Ad Tel.No. E - Assessor's Map/Parcel/ d_ 3 3G/=n/����� _ _/'- , s Installer's Name,Address,and Tel.No.5O -�'QD-9'73 8 I)esigriery's Name,Address,and Tel.No. Joseph O� (5�rry / Type of Building: _ ._.J Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 gpd Design flow provided -3! 2 gpd �t Plan Date , Number of sheets Revision Date Title s Size of Septic Tank Type of S.A.S. Description of Soil s Mature of Repairs orAlterah�ons(Answer when applicable) /Sr r�/�lp/" /l.�J�/ rU 1/Afl Date last inspected: t Agreement: k 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. /r Ab � A `�!v Date Application Approved Date / r Application Disapprov Datefor the following reaso s Permit No. 70 Date Issued---------------------------------------------------------------------------------------------------------------------------------------- /20 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,,that the On-site Sewage Disposal system Constructed( ) Repaired( /-4-• Upgraded Abandoned( )by ✓a 12.e 914,!I' eV 5 r / , at 5��--�i �A /1//% l"—YI/&jias been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - . dated II Installer. a":g Designer_may%7//r #bedrooms _� Approved design flow 3- P gpd The issuance of this permit all n t be construed as a guarantee that the system ilffftmct]ion DateInspecto r -------- -------------------------------------------------- -------- No. GEl 2B Fee /�vo THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS M[sposal &potem Construction Permit Permission is hereby granted to Construct( ) Repair( �4- Upgrade( 4— Abandon( ) System located at 1//� 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:Co structi n must be completed within three years of the date of this permit. Date 7�TM 1�7 Approved by i � 90-133 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 158 Highland SDr ' Property Address Norman Barrett III _ Owner Owner's Name information is f -ti: . required for every Centerville Ma 02632 1/30/19 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information / /3E4 on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane rab Company Address Cotuit Ma 02635 City/Town State Zip Code ��. 508-364-9587 S113522 Telephone Number License Number r 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 r 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 1/31/19 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.; t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System tem Form Not for Voluntary untarY As sessments 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. Citylrown 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. Anyfailure indicated below. criteria not evaluated are Comments: System contains a 1500 Gallon septic tank as well as a concrete distribution box and two 500 Gallon 0 chambers in stone. 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. III 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form (/<�a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 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 _ l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. Cityfrown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 158 Highland Dr u Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form ~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) P ) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d 19 Gpd 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: New system in 2017 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 Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. Cityrrown 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: 8/8/17 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3.5 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.): System is vented at the roof line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" � How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tee's in place at time of inspection t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form r !, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' 158 Highland Dr Property Address Norman Barrett III Owner Owners Name informationis required re equiruired for every e Ma 02632 1/30/19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal 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.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4'r' 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.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 liI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name required for is every Centerville required Ma 02632 1/30/19 page. Citylrown 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.): No sign of failure. System is like new I 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 158 Highland Dr �V Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form J. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is every Centerville required for eve Ma 02632 1/30/19 page. Cityrrown 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 l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 :v x?. f,» 3 a , � ;: _ i., ..s...�' ^, 1, „� ...^' .<::- ..:x:r:' �:._,. .�, ? ,l.., /j\sa• ,5 iz�'/. `ri \ +c ',c \,,, i Z — � , ?r ? r. aa. ? r W.. f x , 1,. ✓ ,1.., �;Ar. �/ �r�''2e��u. =, �i3 a°J:} `y,.,a\�to ��:;a £ �? F, Via' '# r;ri , >w R \s s. /rf a ' , c r» ,, ra r > � a ? e v u. ram`. 9 - ,\\, s3 y#- a z, ?"a a'•:.� c�m`:<' r'^'.9'.'' � 'z?�:r_/; ;:-„/. ,k' �,.�:. h ems: '\' \ � ``'w \ 'b' _' �;j< /,� 3 �✓>v-jai � ""v3'�r.:. ;;',x Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is required for every Centerville Ma 02632 1/30/19 page. Cityrrown 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: 1 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: 8/8/17 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - �� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 158 Highland Dr Property Address Norman Barrett III Owner Owner's Name information is Centerville required for every Ma 02632 1/30/19 page. Cltyrrown 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 l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Town of Barnstable. P# Department of Reguilatory Services • ' Public Health Division Date ,63Fq. ems$ 200 Main Stree4 Hyannis MA 02601 :G W ' VV J P 1 1 - Date Scheduled Time Fee Pd: ,foil Suitability Assessment o� Sewage Disposal ` Performed By: 4J � itnessed By: i LOCATION & GENERAL INFORMATION Location Address• Owner's Name Address soD ..V- L� Assessor's MaplPrce1: (:�lj ' I Engineer's Name _ � ,33 ,. NEW CONSTIZU00N REPAIR ' Telephone# g U 0 — 33 11 Land Use 1 1 �"1 I Slopes(%) '" Surface Stones Distances from: ripen Water Body 2,®� ft Possible Wet Area, ft Drinking Water Welf O ft Drainage Way �I 0 ft Property Line /U ft Other ft SKETCH:($treet name,dimensions of lo4 exact locations of test holes&pere tests,locate wetlands in proximity to holes) v I i 1 i i Parent material(geologic) �/ V J ►v�Sv ' I Depth to Bedrock J� Depth to Groundwater Sta tng Water in Hole "' i Weeping from Pit FACE Estimated Seasonal i11igh Groundwater Dt , �TION FOR SEASONAL HIGH WATER,TABLE Method Used: Depth Clbperved standing bs•hole:. in. Depth to sail tnottlrs: {�: Depth toiweeping from side of obs.hole: in. Oroundwatet Adjustment Index Well#__, Reading Date Index Well lcvel ! __ Adj-faCtor -- Adj.drvundWtiter L9Vel.,,,,m, PERCOLATION TEST Date Time_.—.• Observation I Time at 9" Bole# t 1 n nj. Time at G" Depth of Pere —{ -=— I O 0 Time(9"-60) Start Pre-soak Time.@ �Ln — End Pre-soak G2h , Rate Min/inch Site Suitability Assessment: Site Passed Site Failed; Additional Testing Needed(YIN) Original:,Public I3e'alth Division Observation Hole Data To Be Completed on Back,y ---- ou must first notify the ***If percolaAion test is to be condrscted within 100' of wetland, Barnstable C64servation Division at least one (1) week prior to beginning. I DEEP OBSERVATION HOLE LOG Hole# Other Depth:from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) (Munsell) Mottling (Sons stenc %Gravel)tructure,Stones, lders. A4 WITIA14 -35.,, A an �� s A 3S11 112'' G a 2 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nsis enc % el a'►� `' , Goan is s Amc 2.s DEEP OBSERVATION HOLE LOG Hole# 186 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. o Gravel DEEP OBSERVATION HOLE LOG Hole# fj Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones.Boulders. Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No`' Yes _ Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perv'o faterial exist,in all areas observed throughout the area proposed for the soil absorption system? • If not,what is the depth of naturally occurring pevvious material? Certification p, I certify that on (date)I have passed the soil evaluator examination approved by the Department o viro mental Protection and that the above-analysis was performed by me consistent with the required traini ,expert's "and experience described in 3:10 CMR 15.0 7. Signature Date 1 Q:\.SEPTIC\PERCFORM.DOC TOVINYOF BARNST'ABLE ':t.0 ATIGN IS /G/r/�/Q ' 3R SEWAGE # • 'v''11-�.AGE e ZNT ASSESSOR'S MAP & LOT 174" 33 �IA�sP�47-oeS s Q n O�• Ria�WS NAME&PHONE NO. �U l N C U ' SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR WNER "A" ,5d£Z714A, /d•oZ O el► PERMITDATE: CONHHdAN@E DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet LFurnished by Q DATE: _ 12./1 1 /96 PROPERTY ADDRESS: 158 Highland Drive Centerville,Mass . 02632 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 61x8l block cesspool. 2. 1-1000 gallon precast leach pit. Packed in stone. Based on my Ingr-action, I certify the following conditions: 1 . This is not a titlb five septic sy_stem. 2.. The- sewage'system' is in proper working order at the present time. 3 . Cesspool acts .as a septic tank. Contains solids in place. The leaching pit is used as a overflow. Water from cesspool. SIGNATUR": Name:_J_P Macomber Jr________ Company:* ompany J. P_Macomber & Son- -Inc . Address:_ _gg______ Centqrvi11e LMass__02632 Phone: _50,g.,, 5_3338..... • 1 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Ceupools-Leachf lelds Pumped ` Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 773-3338 775-6Al2 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of nnAlronmental Protection Trudy Coxe tlscrecary David B.Struhs U.Go..r Convrrlsabnsr e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Addles&: 158 Highland Drive Centerville,MA Addroa& of owner. 1040 Ridge Road Date otInspeotion 12/11 /96 (If of Oakfield Maine Name of Inipector Joseph P.Macomber Jr. 0%763 Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate aad complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-sits sewage disposal systems. The system: �Paases Conditionally Passes — Needs Further Evaluation By the Local Approving Authority Fails r��C Inspector's Signature: ( Date: System The Iaspecto s submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 go or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner wd copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check& B, C, or D: Al 9Y9 PASSES: I have riot found any information which indicates that the m violates an of the system y failure criteria as defined in 910 CUR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: __Zone or more system components used to `be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instance&. If"not determined',explain why not) The septic tank is metal, cra:ked, structurally unsound, shows substantial infiltration or ezflltration,.or tank failure is immin°nt. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by tL. Board of Health. (revised 11/03/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617) 556-1049 • Telephone (617)292.5500 �� Primed on Ruy W Paper ` S f, r •\J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropertyAddresx 158 Highland Drive Centerville ,Mass . Owner. Gina Clark Date of Inspeotlom 1 2/1 1 /9 6 B)SYSTEM CONDITIONALLY PASSES(continued) 4AeL. Sswap backup or breakout or ho static water level observed in the distribution boa is duo to broken or obstructed pipe(,) or duo to a broken,settled or uneven distribution boz. The system will pass inspection if(with approval of the Board of Health): ' broken pipes)are replaced obstruction is removed distribution bos is levelled or replaced The system required pumpinY more than four times a year duo to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is ramoved Cl 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 f.ailins to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: O Cesspool or privy is within 60 foot of a surface water Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENTS The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surfacs water supply. . G' The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. TU The system has a septic tank and soil absorption system and is within 60 feet of a private water supply wall. 4X The system has a septic tank and soil absorption system and is less than 100 feet but 60 feet or more from a private avatar supply well,ualw a well water analysis for coliform bacteria and volatile organic compounds indicates that the wall is &" from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 pp,. 9) OTHEfi System- has one cesspool acting As a septic tank with A 1000 gallon precast pit acting a ovarflnw- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Addr.ea&- 158 Highland Drive Centerville ,Mass . Owner. Gina Clark Date of Inspection: 1 2/1 1 /9 6 D) SYSTEM FAILS: • I have determined that the system violates Or.or more of the following failure criteria as defined in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to oorsect the failure. Ab Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool. 4b 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 th•'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 Is"than 1/2 day flow. Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. dJD Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. /W Any portion of a cesspool or privy is within a Zone I of a public well. /0 Any portion of a ossspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analysed to be acceptable,attach copy of well water aaalyais for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design Dow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: / 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) The owner or operator of any such system shall bring the system and facility into full oompliana with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Plea"consult the local regional office of the Department for further information.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddr.w 158 Highland Drive Centerville ,Mass . Owner: Gina Claik Date of Inspection: 1 2/1 1 /9 6 e Check if the following have been done: ` /Pumping information was requested of the owner,occupant,and Board of Health. _�_/Nons of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection• ZAs built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. �Ths system does not receive non-sanitary or industrial waste flow ,��The site was inspected for signs of breakout. ZAll.sy.tem components,acluding the Soil Absorption System, have been located on the site. NDtJ�The`sew tank maaholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. v The site and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. , The facility owner(and occupants, if different fiom owner)were provided with information on the proper maintenance of Sub.. Surfaoe Disposal System. (revised 11/03/95) 4 SUBSUIU'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION property AJcl+��,. 158 Highland Drive Centerville,Mass . Owner, Gina Clark Date of lnape+utiwi.: 1 2/11 /96 FLOW CONDITIONS RESI D ENTIAL• J Design aow: ya o )ow Number of bedrooms: Number of cumnt residanu:—O- Carbadv grinder (yea or no):_ , Laundry coanectied to ryrum (yea or no): lx Season-.al us+ (yw or no)• Tr`j Wawr r rva4uv, if a' ble: Zp �OCr/.ipAu iwAiz -VS 1 q-- Last date of occ-upancy: COMMERCLAL NDUSTRIAL- Type of wubLuhnient: Dwa gz Dow:_,Vgnllons/day Crease tnp pntsent: (yw or no)" Lcdustrial Waste Holding Tank present: (yes or no)-&—/¢ Non•aaaitary wasw discharged to the Title S eystem: ryes or no)_ Wawr motor reading, if available: dJ* Last dau of owupancy: 0TIIER (Describe) AM _ Last date of omupancy: 4),4 GENERAL INFORMATION PUMPING VORDS d aoty{ce o�ir}fonration: Sysum pumped as part of inspection. Vu or uo)d4 V yes, volume ptunpad: —.1,-11�� -��J''u,u Reason for pumping dill' TYPE OF SYSTEM Septic uu.k/dirtributiou boz/soil absorption system Aia Overflow ce.:spwl A Q Privy Shared ryvum (yes or no) (if yes, arts h prvviow ' pection records, ' any) Other (al plt in) J T 1 s L4 APP 0 MA AGE of" componeau, dau u:.+ W (if lu+own) and source of information: Are Soware odors r..nurcxl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. • • SYSTEM INFORMATION (continued) Property Address: 158 Highland Drive Centerville ,Mass . Owner: Gina Clark Date of Inspection: 12/11 /96 SEPTIC TANK:1de4V_ . (locate on site plan) Depth below grade:_42.61 Material of constructiorl.KJ4 concrete _metal _FRP —other(explain) Dimensions:_ 4JA Sludge depth; V)9 Distance from top of sludge to bottom of outlet tee or baffle:,•.&/_ Scum thickness:_ Distance from top of scum to top of outlet tee or baffler_ Distance from bottom of scum to bottom of outlet tee or baffle._ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle-. depth of liquid IPvel in relation to outlet invert, structural rity, evidence of leakage, etc.) Septic tank is not presen GREASE TRAP. 4aVe. (locate on site plan) Depth below grade:rt/± Material of consinirtion;A/A.oncrete _metal _FRP —other(explain) AIA Dimensions• N14 Scum thickness:.�;19 ,• Distance from top v It scum to top of outlet tee or baffle:_4)A Distance from bottom n( crum to honnm of outlet tee or baftte-AA Comments: (recommendation for pumping, condin. of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, et rease rap is not present 4 (revised 0/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMSATION (oontinued) PtopO1r.h,,ddr,ss; 158 Highland Drive Centerville ,Mass . Owner. Gina Clark Date of Insp"tions 12/11 /9 6 TIGHT OR HOLDING TANK,&/O.f/e- (locate on site plan) • Depth below grsds:.&d MaD•rial of coastrUcdoa-fJ?9o=vte_metal_FRP_other(emplaia) - 44 ZVA Dimansions: A).4 Capacity Amilons Design flow: onalday Alarm level: commaats: (-711—gp of inlet tey,ooadit}oaof alarm and float sw not etc.) 1 or o Ing an 8 are nod resent. DISTRIBUTION BOXY W&— (locaw on site plan) Depth of liquid level above outlet invert: A14 Comments: (note if level sad distribution is equal, evidence of solids carryover,evidence of Isakage into or out of boz,etc.) Distribution box is not present. PUMP CHAMBM- (locate on sit•plan) Pumpe in working order-.(yes or no) Comments: (note condition of p chamber,condition of pump+and appurtanaaces,etc.) Pump Chamber is not present. (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 158 Highland Drive Centerville ,Mass . owner. Gina Clark Date of IInspeotion. 1 2/1 1 /9 6 Son.ABSORPTION SYSTEM(SAft'z (locate an eke plan,if po•srbk;excavation not required,but may be approximated by non-intrusive methods) • If not determined to be present,explain: Type: pits,munbsr:_ Lachia�chambers,numbe karhing galleries,numberr kachia trenches,number,langth: leaching fields,number,dimensions: overflow oesspool,number. (note oo n of }l,signs of failure,level of of ve n,etcJ e rum ran o ins scar ,;aeo signs o� l dradu��ic Faliftre Ail Ve e a ion is norma ._1r over of the—ZitshoulcLbe raise 1 cover is 'Areseritly 31811 below grade. Install co• --ars .- CESSPOOLA. (loeau on site plan) Number and configuration: 1 Depth-top of liquid to inlet invartjbOW Depth of solids layer. P_ Depth of scum layer:-- 4r_le� Dimensions of cesspool lo ' C MatariaL of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Cesspool not pumped 311 of water i A the cesspool. The overflow leach pit is dry. Comments:(note conditign of soil,signs of 1ja failure,level of pga�iag, ndi ' of etc.) Medium sand to fine saiid;` '�o signs ofI rinyyc�°raut'�nic` aizre or ponding. yeae a ion is norms . PRIVY:dj�.fle (locate on site plan) M.tarials of construction: Dimensions: /LW Depth of solids: V,4 Cammants:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,-etc.) .l Privy is not present. (revised 11/03/95)• g SUBS-URFACE--SEWAGE---DISPOSAL-.-E-YBTEM---INSPECTION--F-0RM--- ----- -- PART B --_-- --.-_- .__-.. _-_. --.B.YSTEM.._INFORMATION....continue.d-._..._..._ SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties to t two permanent references-. landmarks or_ benchmarks locate all wells I 'thin i`k _. ---- ------- --- ------- —------ ---- — ---- Center l-le Oste lle Marstons Mills Wate Cow y . - - — -- 428� 691 \ • • F1 r r _....._ _ .. d �-�_ y 4- -DEPTH -TOr-ZROURDWATER ----------------- ���—�.�� {d --- ....- ------ - �161 + depth to groundwater r+ckthod of determination or approximation: cast . it` 8-_ 1;/ Per ft _ -76—3cJ5 No water encounte ed _121 :Svg m ins tallad .:by on Tne. _ Sbyy 3r�1 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the i ' •,on of Water Pollution Control `]•/T•1'{T rRI'i71"�TT' t1f.—wR•l.lewTrtRa7R.!•R.tlnlrlttw►ItrRlRwlrlffeTw7i 1's��r1I.T .TT'rtT�1r�T�...--.r•.,` I SU[iSU[tFAC TOWN OF Barnstable BOARD OF HEALTH + R SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION `� F.^•T^LT". •.'1—�.IIT.�.�T�1rm'R.rrl T1r14TfT1'T.'IT.T�'1"i111•R��717.1Cr�TTfgRwffR111T1R'llrf f�T .� -TYPI OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 158 Highland Drive Centerville ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # OWNER' S NAME Gina Clark PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Sr. COMPANY NAME J.P.Macomber & SisW Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State tip COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: X) XXXXXXXX"System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public hea1Lh or the environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature ' Date 12/12/96 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEAL'I'll. * If the inspection FAILED, the owner or•Ihoperator shall u pgrade ' tho system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 16 , 305 . partd .doc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION W� v OEM 5�6 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 4" 2 TITLE 5 tiFy�� Der OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 190 PAR 133 Property Address: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner's Name: ROOT,LINDA Owner's Address: 15 GREAT HILL ROAD SANDWICH,MA 02563 Date of Inspection OCTOBER 24,2002 Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ./ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall suYmnitapy 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ""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. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT,LINDA Date of Inspection: OCTOBER 24,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ./ I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT,LINDA Date of Inspection: OCTOBER 24,2002 C. Further Evaluation is Required by the Board of Health: N/A _ 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT,LINDA Date of Inspection: OCTOBER 24,2002 D. System Failure Criteria applicable to all systems: N/A 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 N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pit is less than 6"below invert or available volume is less than'/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supplyi ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No 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 11 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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT,LINDA Date of Inspection: OCTOBER 24,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping infonnation 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 nonnal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? N/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? ✓ Were the manholes uncovered,opened,and the interior inspected for the condition of 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 infonnation on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No N/a Existing infonnation. For example,a plan at the Board of Health. ✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 J Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT,LINDA Date of Inspection: OCTOBER 24,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2000 244,000/200145,000/2002 43,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 800 gallons—How was quantity pumped determined? Reason for pumping: PART OF INSPECTION TYPE OF SYSTEM ✓ Soil absorption system ✓ 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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT,LINDA Date of Inspection: OCTOBER 24,2002 BUILDING SEWER(locate on site plan): ./ Depth below grade: 15" Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): N/A Depth below grade: Material of construction: Concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to the bottom of outlet tee or baffle: 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP(located on site plan) N/A Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 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: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT,LINDA Date of Inspection: OCTOBER 24,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 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: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT,LINDA Date of Inspection: OCTOBER 24,2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type J leaching pits,number: I leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER 3' BELOW GRADE.6"WATER IN PIT. WALLS CLEAN. MAIN CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Depth—top of liquid to inlet invert: 6" Depth of solids layer: 4" Depth of scum layer: 2" Dimensions of cesspool: N/A Materials of construction: BLOCK Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): MAIN POOL BLOCK WITH COVER AT 20".NO INLET TEE,OUTLET TEE.POOL AT WORKING LEVEL. NO SIGN OF OVERLOADING. POOL PUMPED AFTER INSPECTION. PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 ACT: Page 9 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT,LINDA Date of Inspection: OCTOBER 24,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I� gAQ i O ya' l s� , o Title 5 Inspection Fornt 6/15/2000 10 Page 1 I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 158 HIGHLAND DRIVE CENTERVILLE,MA 02632 Owner: ROOT, LINDA Date of Inspection: OCTOBER 24,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 40+ feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS) V 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: G.I.S. r - yot IIoi M Title 5 Inspection Form 6/15/2000 11 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 to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) Nam, Fill in please: APPLICANT'S YOUR NAME: C S BUSINESS YOUR HOME ADDRESS: ' TELEPHONE # Home Telephone Number i oFp_ 3�1_ NAME OF NEW BUSINESS Zo ti TYPE OF BUSINESS `IS THIS A HOME OCCUPATION? YES .k,_NO Have you been given approval from the building division? YES NO ADDRESS OF BUSINESS MAP/PARCEL NUMBER__ �n — j 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. I. BUILDING COMMISSIONER'S OFFICE .This individual has been informed of any permit requirements that pertain to this type of business. COMMENTS: Authorized Signature**. 2. BOARD OF HEALTH"Sign This individual hrmi A ements th t pertain to this type of.business. =-;- MUST COMPLY WITH ALL 4A7ARDOUS MATERIALS REGULATIONS- 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: r ` � / �l?/ �� TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 4AA12oti �PA[tiTltiG BUSINESS LOCATION: /qd' &6aZ4±1n 00 /'�,r,/��721!G/ �� ��� ,�, INVENTORY MAILING ADDRESS: 0 ao— - /,14 3 TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: GGlCL EMERGENCY CONTACT TELEPHONE NUMBER: 5 3yS-3 �7 3 MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials 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) Misc. 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) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. 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 Misc. 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 (inc. carbon tetrachloride) NEW USED Any other products with ".poison" labels Paint & varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor & furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): 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 COC&TION : 5E\N&64 PERMIT MO. s IWSTNLLER S U&ME ADDRES-S BUILDERS Q &"F- �. b DDRESS DATE PERMIT ISSUED � � — — — DATE COMPLI WACE ISSUED : 3 S 0 33 33 3s ° 3, LEGEND a _ ? C NTERVILLE PROPOSED CONTOUR ° ® PROPOSED SPOT GRADE / SITE s� r 9cF —— 98 —— EXISTING CONTOUR °951 + 96.52 EXISTING SPOT GRADE W-- EXISTING WATER SERVICE TEST PIT \ eooF of SCALE: 1"=20' 59. pq�eMFNr � 1 i i 7 LOCUS MAP LOCUS INFORMATION PLAN REF: 123—F TITLE REF: C167628 -60 PARCEL ID: MAP 190 PAR. 133 FLOOD ZONE: "X" COMMUNITY PANEL: 25001CO561J DATED:07/16/14 SEPTIC SYSTEM REPAIR PLAN �� /�G / LOCATED AT: 20 f� �; c / 158 HIGHLAND DRIVE E CENTERVILLE, MA V 1�—� PREPARED FOR I NORMAN F. BARRETT ' I 1 PROP I- 0G SEPTIC TAG + 63.0 I I � \1 f � AUGUST 8, 2017 I I �• or O r73;C AR E M. tirp M l O T 37 %Q� AY / AREb = 15620 sf+— C�� / I 'y LAND CoPRt PLAN XX123—F 1 0 72 N�At��'� e C_r 0 J 0 ASSP 6AP1 90 PCL 133 — - % ,. o 61 TP-1 BENCH MARK PAINT SPOT ON MEYER & SONS, INC. 770, ( Op. P-2 BULKHEAD CORNER P.O. BOX 981 ,L 62.•2 6 3. 1 4 PLAN # US�S DATUM ASSUMED EAST SANDWICH, MA. 02537 PH: (508)360-3311 SCALE: 1 in = 20 ft '+ ,2.5 FAX: (774)413-9468 0 20 40 meyerandsonstitle5©gmail.com I _ 0 10 20 40 SHEET- 1.. OF 2 J 1894 f 4 d TOP NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS I FOUNDATELEION "IN VBRING ALL COVERS TO WITH 3 OF FINISH GRADE (Existing) FINISHED GRADE (62.20) :f = 63.21 �. �F.G.EL: 63.0 �, F.G.EL- 62.50 F.G. EL: 6. 50 MAINTAIN 2% MIN SLOPE OVER LEACHING AREA iR a D I F.G.EL: 60.10 2" OF 3/8" DOUBLE WASHED _ I STONE OR FILTER FABRIC 3/4" 1-1/2" DOUBLE WASHED STONE A 6" 4" SCH 40 PVC T7- 101 6 MIN. ®13E30 ®®®® ff 1% ®®®®®®®®®®® A' TEE'S ARE TO BE 14 INV.58.63 ( ) 4" SCH 40 PVC 2 EFF. DEPTH ®®®®®E3---- INV.58.83 .58.43 4' 2 X 8.5' 4' GAS 'PROPOSED DB-3 EXISTING OUTLET BAFFLE INV. 59.38 .. ,, . ..... . .. DISTRIBUTION BOX EFFECTIVE LENGTH = 25' INV. 59.08 { (1-120) INV. ELEV.= 58.20 PROPOSED 1 ,500 GALLON SEPTIC TANK + f GAS BAFFLE TO BE INSTALLED ON ���`� 0s9 BREAKOUT OUTLET TEE AS MANUFACTURED BY TUF-TITE, ZABEL, OR EQUAL DAR N ELEV.= 59.20 ME ) TOP CONC. ELEV.= 59.20 INV. ELEV.= 58.20 �E3 ®® ®®® NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING �fG/ 0 ®®®®®®® ' PIPE INVERTS PRIOR TO CONSTRUCTION -14NIw0l + E3El3®®®® 2) TANK AND D-BOX SHALL BE SET LEVEL AND BOTTOM EL.= 56.20 3.75' 5 FT. 3.75' TRUE TO GRADE ON A MECHANICALLY COMPACTED SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN I SEPARATION 5.00 FT. EFFECTIVE WIDTH = 12.5' 310 CMR 15.221(2) SEPTIC SYSTEM PROFILE 3) INSTALL INLET & OUTLET TEES W/ I BOTTOM OF TESTHOLE EL: 51 .20 _ SOIL ABSORPTION SYSTEM (SECTION) GAS BAFFLE AS REQUIRED (500 GALLON LEACH CHAMBER) GENERAL NOTES: SOIL LOGS f� : 15 y DESIGN CRITERIA 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL } NUMBER OF BEDROOMS: 3 BEDROOOM BOARD OF HEALTH AND THE DESIGN ENGINEER. DATE: AUGUST 8, 2017 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE SOIL EVALUATOR: DARREN 'MEYER, R.S., CSE #1614 DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS. WITNESS: DON DESMARAIS, BARNSTABLE HEALTH DEPT. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFlLLED PRIOR 1 DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE FI� GARBAGE GRINDER: NO (not designed for garbage grinder) DESIGN ENGINEER. Tr"-� Depth I Elev. TP-2 Depth 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 62.20 0" 62.30 0" SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE PROPOSED 1,500 GAL. SEPTIC TANK FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN A A ENGINEER BEFORE CONSTRUCTION CONTINUES. LOAMY SAND I LOAMY SAND LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 61.45 1OYR4/1 g" .48 10YR 4/1 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF - B 61 B 10" USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS W/ 4' THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF LOAMY SAND LOAMY SAND HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 59.28 1OYR 5/8 35" 1 59.48 10YR 5/8 34" STONE ON ENDS & 3.75 STONE ON SIDES: 25 L x 12.5 W x 2,D 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. C I C 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED BOTTOM AREA: 25 x 12.5= 312.5 SF TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. + MEDIUM p� TEST MEDIUM SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE SAND t THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 2.5Y 6/6 0'EL 57.30 2.5Y 6/6 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D CONSTRUCTION. 10. EXISTING CESSPOOL TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION I. 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY 51.20 132" ' AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 51.30 132" PROPOSED SEPTIC SYSTEM UPGRADE PLAN 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 1 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. PERC RATE <2 MIN/IN. ('Cl" HORIZON) 158 HIGHLAND DRIVE, CENTERVILLE, MA No cRouNDWATER'oesERVEO Prepared for: Barrett 15. ALL PIPING TO BE 4" SCH 40 01/8"/FT (UNLESS SPECIFIED) Design and.Site Plan by: SCALE DRAWN DATE I, Darren M. Meyer, R.S.:CSE. hereby certify that i am currently approved-by MADEP'pursuant to 310 CMR 15.017 _ r MEYER-&SONS,INC. N.T.S. DMM 08/08/1 T " to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO Box981 requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October, 1999. EASTSANDWICH,MA02537 CHECKED SHEET NO. 50&,W--290 D M M 2 of 2