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HomeMy WebLinkAbout0115 HOLLY POINT ROAD - Health 115 Holly Point Road iJ Centerville P A 252 123 s NoP.. 23�R '`�srr�`� HASTINGS,MN a Commonwealth of Massachusetts aka -1 3 CO PY Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Holly Point Road _ . Property Address Ira Nagel_ .4 Owner Owner's Name — .6 information is 4`; required for every y Centerville"✓ MA 02632 Jul 13, 2017 "°' page. City/Town State Zip Code Date of Inspection L Jai 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 A. General Information �I-i�- �a433 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick T Sullivan use the return Name of Inspector key. Ready ooter Excavting Company Name PO Box 89 _ r Company Address 1 Forestdale MA 02644 M City/Town State Zip Code 508-888-6055 SI 12843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that thm- information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority /—~ July 14, 2017 _ Inspector's Signature Date 1 he 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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. '***This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Z004�tos t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.. 115 Holly Point Road Property Address Ira Nagel Owner Owner's Name information is required for every Centerville MA 02632 ,July 13, 2017 page. City/Town State Zip Code Date of Inspection B. Certification (cant.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as descr "ed in the"Conditional Pass" section need to be replaced or repaired. The system, upon c mpletion 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. 7 The septic tank is metal and over 20/years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltr ion or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is reaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will passnspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that th tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Holly Point Road Property Address Ira __— Owner Owner's Name information is Centerville MA 02632 Jul 13, 2017 required for every _ — — page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of alth): ❑ broken pipe(s) are/ed ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is rem ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is eplaced ❑ 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 /E] Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed / ❑ Y ❑ N ❑ ND (Explain below): -- --- .. . C) Further Evaluation is Req.u/ired 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 .Irotect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins.doc.rev.6116 'rifle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Holly Point Road rroperty Address Ira Nagel _ Owner Owner's Name information is Centerville MA 02632 Jul 13 2017 required for every _ _/� , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a s rface water supply. ❑ The system has a septic tank and SAS and th SAS is within a Zone 1 of a public water supply. [] The system has a septic tank and SAS an the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS a I 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 wa/-�ranalysis, performed at a DEP certified laboratory. for feca; coliform bacteria indicates absent nd 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: ;) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Holly Point Road rroperty Address Ira Nagel Owner Owner's Name information is Centerville MA 02632 July 13, 2017 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 3 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. =or large systems, you must indicate either"yes" or no"to each of the following, in addition to the questions in Section D. j Yes No / ❑ ❑ the system is within -00 feet of a surface drinking water supply ❑ ❑ the system is whin 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is/(ocated in a nitrogen sensitive area (Interim Wellhead Protection Area— IW jA) or a mapped Zone 11 of a public water supply well i if you have answered "yes" tany question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance w)th 310 CMR 15.304. The system owner should contact the appropriate regional office of the D,6partment. i t5ins.doc•rev.6116 / Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachuse tts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Holly Point Road Property Address Ira Nagel Owner Owner's Name information is Centerville MA 02632 July 13, 2017 required for every State Zip Code Date of Inspection page. CitylTown %,hecklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No 0 ❑ 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? El ® Have large volmes of water been introduced to the system recently or as part of this inspection? ® El Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD t5ins doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 P Y rY y 115 Holly Point Road _ �iupeiiy Address Ira Nagel Owner Owner's Name information is required for every Centerville MA 02632 July 13, 2017 — page. CityfTown State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes 0 No Water meter readings, if available (last 2 years usage (gpd)): 2016= 131 GPD 2017- 111 GPD Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: Current Date Commercial/industrial Flow Condibom - Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day 19Paj Basis of design flow(seats/persons/sq. ., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pre nt? ❑ Yes ❑ No Non-sanitary waste discharge to the Title 5 system? ❑ Yes ❑ No Water meter readings, if av ilable; — i t5ins.doc•rev.6116 P P Y Title 5 Official inspection form:Subsurface Sewage Disposal System•Page 7 of 77 f Commonwealth of Massachusetts = Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments N 115 Holly Point Road Property Address Ira Na el Owner Owner's Name information is Centerville MA 02632 July 13, 2017 required for every — page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date __-- Other(describe below): General Information Pumping Records: Source of information: Owners records: Pumped 2015 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined'` _..-..----._._._--_.__-----_----_.-_--__._ Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Holly Point Road Property Address Ira Na el — — Owner Owner's Name information is Centerville Y MA 02632 Jul 13, 2017 required for every _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank installed in the'90s. D-box and leach field installed 08/08/2001. Certificate of Compliance on file at Health Dept Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 32" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/Afeet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan)-. 2 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 10.5'x 5.5' x 5' Dimensions: Sludge depth: t5ins.doc•rev.6116 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 115 Holly Point Road _ Property Address Ira Nagel Owner Owner's Name information is Centerville MA 02632 Jul 13 2017 required for every — —�—� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 14" How were dimensions determined? Tape measure and dip tube. 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 in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Tank does not need to be pumped at this time. _ Grease Trap (locate on site plan): Depth below grade: / feet Material of construction: ❑ concrete ❑ metal /El fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum o top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping Date t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Holly Point Road =roperty Address Ira Nagel Owner Owner's Name information is Centerville MA' 02632 July 13, 2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site playa): Depth below grade: Material of construction: ❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): Dimensions Capacity: gallorts Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm in working order: (] Yes ❑ Alarm level: 9 No Date of last pumping: Date Comments (condition of alarm and float switches, etc.). Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Holly Point Road Property Address Ira Nagel Owner Owner's Name information is required for every Centerville MA 02632 Jul 13 2017 - _- - - page Citylrown State Zip Code Date of Inspection D. System Information (cost.)-_ _. -- _ Distribution Box(if present must be opened) (locate on site plan): q Depth of liquid level above outlet invert 0„ - Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, two outlets. Speed levelers in place. Very light solids carryover. No sign of past high water stainingover outlet inverts. Riser brings cover within 6" of grade. PumpChamber locate on site Ian): ( P Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump c/ber, dition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Holly Point Road Property Address Ira Nagel Owner Owner's Name information is required for every Centerville MA 02632 Jul 13, 2017 -y page. City[Town State Zip Code Date of Inspection u. System information (cont.) - Type: ❑ leaching pits number: — ® leaching chambers number: 3- 500 gal ea. w/ stone. ❑ 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 vegetation, etc.): Camera used to inspect and locate chambers. No standing liquid in chamber at time of inspection. High water staining 6" from base. No sign of past hydraulic failure. esst)ools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet inve ` — --- —"- — - Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction -- Indication of groundwater in ow El Yes ❑ No t5ins.doc•rev.6/16 Lille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Molly Point Road rropercy Aaaress Ira Nagel Owner Owner's Name information is Centerville MA 02632 Jul 13, 2017 required for every _Y page. Cityrrown State Zip Code Date of Inspection 0. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials at construction: --------------- ---_ _ ._-----------. ___._----- _-- Dimensions Depth of solids. Comments (note condition of soil, /nshydraulic failure, level of ponding, condition of vegetation, etc.): 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N 115 Holly Point Road �I vpel'iy/ddi CJJ Ira Nagel Owner Owner's Name information Is Centerville MA 02632 Jul 13, 2017 required for every —Y— -- page. Cityrrown State Zip Code Date of Inspection S,stem Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below [_! drawing attached separately I -- ----- ---—L----- I I � i I �O O I I l i I l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Holly Point Road Ira Nagel Owner Owner's Name "llull""`lull Centerville MA 02632 Jul 13, 2017 required for every _�/ page. City/Town State Zip Code Date of Inspection Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 6.3 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: 06/21/2001 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: maps.mass.g is.state.ma.us/oliver.php n,i must describe how VOL] established the hiah around water elevation: Ground water form (2001) shows ground water elv= 36.5. Base of SAS at elv=42.8. Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Holly Point Road__ ?roperty Address Ira Nagel Owner Owner's Name information is required for every Centerville MA 02632 Jul 13, 2017 _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f 6 ?�- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS s DEPARTMENT OF ENVIRONMENTAL PROTECTION ♦ �aI`+ MAP PARCEL ; 1 Z"3 LOT TITLE 5 i;IFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION FRECEIVED Property Address: 115 Holly Point Road Centerville MA 02632 N 2 9 2004 Owner';i Name: Steven Porter Owner'::Address: 41 Babbling Brook Road Centerville MA 02632 TOW HEALTH DEFN OF BA DEPTABLE T. Date of Inspection: January 21,2004 Name u1'Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing;Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certif- chat I have personally inspected the sewage disposal system at this address and that the information reported below i s true,accurate and complete as of the time of the inspection. The inspection was performed based o %+++tt t t tflll1'�� training ;uad.experience in the proper function and maintenance of on site sewage disposal systems.I am `LH�OFIIJgss,� approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Z�.• .� RIC X_ Passes = = Conditionally Passes of ti Needs Further Evaluation by the Local Approving Authority Fails FSINSPEG Inspeel.-or's Signature: C ---s Date: `1/21/04_ 11itII ►+�� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)m-i hin 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or=p eater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.Th;original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authoril y. Notes anJ Comments: System in good condition. Recommend removing garbage grinder.System not designed for grinder use. ****Tlii;�report only describes conditions at the time of inspection and under the conditions of use at that time.Th is 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 page 1 i Page 2 3 f 11 4'IFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 115 Holly Point Road,Centerville Owner: Steven Porter Date of Inspection:January 21,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy.-;rem Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Sy;lem Conditionally Passes: C'ne 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 ties,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 a complying septic tank as approved by the Board of Health. *A met 31 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 exf 1;dn: 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 exrhLin: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass ins p action if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND exf lain: Page 3 J 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 115 Holly Point Road,Centerville Owner; Steven Porter Date of Inspection: January 21,2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failine to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption,system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "'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 ff.ilure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 A 1 I I'IFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 115 Holly Point Road,Centerville Owner: Steven Porter Date of Inspection: January 21,2004 D. Symem Failure Criteria applicable to all systems: You mtiat 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 _Y— Discharge or ponding of effluent to the surface.of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 3; Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow —Y— 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. _Y— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. h: Any portion of a cesspool or privy is within a Zone 1 of a public well. h_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _h_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution'from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] —No—.,'Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You mils t 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in`section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. A Page 5 of 11 (IFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 115 Holly Point Road,Centerville Owner: Steven Porter Date of Inspection: January 21,2004 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ _ Pumping information was provided by the owner,occupant,or Board of Health 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? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ __ Was the facility or dwelling inspected for signs of sewage back up? _X_ ___ Was the site inspected for signs of break out ? _X _ Were all system components,excluding the SAS, located on site? _X_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ' _X ___ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ __ Existing information. For example,a plan at the Board of Health. X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 if I I 1-1FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 115 Holly Point Road,Centerville Owner: Steven Porter Date of [nspection: January 21,2004 FLOW CONDITIONS RESIDhNTIAL Numbe-of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIG N flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms):440 Numbe-of current residents: 0 Does residence have a garbage grinder(yes or no): Yes Is laun0-y on a separate sewage system(yes or no): No [if yes separate inspection required] Laundr f system inspected(yes or no): Seasonal use:(yes or no): No Water m-ter readings,if available(last 2 years usage(gpd)): 2002—60,000 gal.2003—66,000 gal.=172 gpd. Sump pump(yes or no): No Last da::e of occupancy: Summer 2003 COMM ERCIALANDUSTRIAL Type of establishment: Design f.ow(based on 310 CMR 15.203): gpd Basis or 9esign flow(seats/persons/sgft,etc.): Grease b ap 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 rrn:ter readings,if available: Last dare of occupancy/use: OTHE g(describe): GENERAL INFORMATION Pumphig Records: None Source o'L information: - Was sy.-m pumped as part of the inspection(yes or no): No If yes,vc lume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Se piic tank,distribution box,soil absorption system _Sing cesspool _Ov.-rflow cesspool _Pri vy _Shan.A 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 obtain i from system owner) TiE,hr.tank _Attach a copy of the DEP approval _Otlie•(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date:8/8/01 Were semage odors detected when arriving at the site(yes or no): No Page 7 :,f 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 115 Holly Point Road,Centerville Owner: Steven Porter Date of Inspection: January 21,2004 BUILDING SEWER: X (locate on site plan) Depth below grade: 1' Materiel:;of construction:_X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: 25' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC- TANK: X (locate on site plan) Depth tie low grade: 18" Material of construction:—X—concrete_metal!fiberglass_polyethylene _othur(explain) If tank s metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 10.5' long x 5.8'wide—1500 gal. Sludge d.-pth: 9" Distance from top of sludge to bottom of outlet tee or baffle:24" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as relatucl to outlet invert,evidence of leakage,etc.): fees intact and clear,recommend Dumping. Liquid level at bottom of outlet pipe GREASE TRAP: No (locate on site plan) Depth be low grade:_ Material )f construction:_concrete_metal_fiberglass_polyethylene_other (explain) Dimens ions: 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 if st 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.): i Page 8 :-f 1 l +;IFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 115 Holly Point Road,Centerville Owner:Steven Porter Date of [nspection: January 21,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass__polyethylene__other(explain): Dimen,ions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of 1 ist pumping: Comments(condition of alarm and float switches,etc.): DISTRI113UTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comme n is(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage i ito or out of box,etc.): Box set level,no high stains or solids carryover. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms it working order(yes or no): Comme rrs(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 -A 1 I ()FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 115 Holly Point Road,Centerville Owner: Steven Porter Date of Inspection: January 21,2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: X_le<ching chambers,number: Three 500 gal Drywelis. leaching galleries,number: lea.,,hing trenches,number, length: lea,.hing 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.): No signs of saturation or breakout. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Numbe•and configuration: Depth--top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimen,ions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation, etc.): PRIVY: No (locate on site plan) Materials of construction: Dimens io ns: Depth of:,olids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page H,of 1 I 0FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 115 Holly Point Road,Centerville Owner: Steven Porter Date of Inspection: January 21,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide i sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchir irks.Locate all wells within 100 feet.Locate where public water supply enters the building. Holly Point Road w�s 44 IlS 43 � O Ty �_ _� f • Page 11 of 11 +JFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: 115 Hotly Point Road,Centerville Owner: Steven Porter Date o1'Inspection: January 21,2004 SITE EXAM Slope None Surface water None Check o:ilar Dry Shallow wells None Estimated depth to ground water: More than 10 feet Please irdicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: .Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain: Checked water information in file. C ro:cked with local excavators, installers-(attach documentation) Aa:essed USGS database-explain: You must describe how you established the high ground water elevation: Information on file based on NGVD shows 11.3 feet to groundwater. Bottom of SAS not more than 5 feet below grade. TOWN OF BA/RNSTABLE LOCATION I/7�T�//�/ �l�'7� SEWAGE # VILLAGE G ���1�� ASSESSOR'S MAP & LOT2,5_2 `�?J INSTALLER'S NAME&PHONE NO. ✓�UJ SEPTIC TANK CAPACITY MOO 4106 L ACHING FACILITY: (type) J-00 C L - (size) /O'S1 yQ'.42" NO. OF BEDROOMS Y BUILDER O OWNE PERMITDATE: COMPLIANCE DATE: ���' Z"01 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility)- �^ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by cz 4.1 3 y' � / t 00 � ► i0 I No. !�v I�7 Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ��es Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZipplicatiOn for Mtopogal *, pztem Co gtructiOn Permit Application for a Permit to Construct( )Repair( )Upgrade(�bandon( ) ❑Complete System 21It ividual Components Location Address or Lot No. />�"� �1,�/,/ 04r/, , Owner's Name,Address and Tel.No. e Assessor's Map/Parcel !J /G'v j /^/i1/�e `�t/_- f ly Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7ZZ -e2e Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(10 Other Type of Building 2 L� G'e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title 14 Size of Septic Tank ® ,O s Type of S.A.S. J/ Description of Sod 3 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 Certifi- cate of Compliance has been issued b ;hif It / / Signed Date 6`ai// Application Approved by Date 6 z Z A Application Disapproved for the following reasons Permit No. Date Issued I >E���6?;�:'s .1 -5'a �,.- `sue'*.�'�Z.-fir- �- ":�,�- �- s •" � ( �}.�� -yam+^. `✓ 'c;., F-R`}M ,.'' "" 7 `h'L6fl R j �f"" N g j e F 'iyt rraCri T9WN OF BARNSTABLE ' y LOCATION //f/ �lk'T SEWAGE # VILLAGE .G /'�s�l�e ASSESSOR'S MAP &LOTZ INSTALLER'S NAME&PHONE NO: ��� J /`� SEPTIC TANK CAPACITY" s06 mL . LEACENG FACILITY: (type) (size) NO.-OF y v BUILDER O OWNE c c� .. s PERMITDATE. �' .. COMPLIANCE DATE. Z / Separation Distance Between the.' t Maximum Adjusted Groundwater Table and Bottom of.L eactung FaciLty Feet Private Water Supply Well.a 77777 nd Leaching Facility '(If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 30 feec'of leaching facility) Feet y15 l .. ... Furnished by _ - I r mar Q11, v: 3y' ,t K. w } O O F7 f M ... No. / _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ` Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Application for Migaar *pgtem Cougtructtou Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System, 216 vidual Components a�Location Address or Lot No. /`/ r1�i9,� Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's?Name,Address and Tel.No. t Type of Building: Dwelling No.of Bedrooms V A Lot Size sq. ft. Garbage Grinder(10 Other Type of Building /�e�fr f No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons;per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 4j`%yll%'o Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees o 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 Certifi- cate of Compliance has been issued b his oar f Halt J------ Signed Date IV//2/// Application Approved by Date IoAr Z 0 Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS 3 BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CER IFY,that t e On-site Sewage Dis osal System Constructed( )Repaired (' )Upgraded(E/) Abandoned( )by �l''� at has been constructed in accordance with the provisions of Title�5 and the for Disposal System Construction Permit No.'2,&/—IJ/3 dated 6—2 2—U Installer Designer The issuance of this pe t s�aall of a construed as a guarantee that the syste fund'° esigned. 51 Date 0 ©I Inspector C No. c"ir/ /—y�J ——-----—--—— Z- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Ifi6poof *pgtem Cow0ruction Permit Permission is herebyranted to Construct Re air )Upgrade de Abandon g ,c� (/ ) ,P�,/ ( ) Pg //( ) ( ) System located at Z),7— /1 7/1,/ �`/c�er i,7 G eylrAt/i//e and as described in the above Application for Disposal System Construction Permit. The applicant recognizes 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 rmit.� Date: �Z Z/� Approved by e laxl d� NOTICE: This Form Is To_Be'TJ' sod.F or the Repair Of wiled Septic Systems. Only. C-E-R-i-MCATION OF SIMCH kND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(VY=OUT DESIGNED PLANS . � y certify thz,- the a-ppllc=on ror rusoesat worxs coz?s'u-ttction permit siaed'Qy me dated concerninz the Mee:s all.or the folownng cnterla:. Y Ile f�i er sr�tem s conne_ted to.3 i aZL''_IIcz1 ciiweig an;V. Ge:e 30 comaZle:cia1 Cr jC- =s ,uses,ZSocizt--; tithe ctw iTizz. 7-be SOL.is C:^�Sa"iA�as CLASS 1 and'tic_ _o.arlon rate is .` S dip-a or tqL :o _ imizu= =r 1. are r10 wet_{c^.nd5-;vicnirl 10() 7I)DOSec C'IIIIC=:S:Il =ne:�are no p:7.YIe weds Sri- .1=0 ___.of_ae r pc . 42=2 o O_ Sep S�,,IIC is a e L flow ;�_r In==—s =- Cvor C:�Z?a im'Se 7FC7osrC' `r_ IIO Cr V^aI cIlCeS.I^�^L1S�_ m^�i 3 Be boLIO .02 the pIO?Csrd 1e3C � aCl1l1LZ wT I Liot b-1C,ester l [l��l Ve=:above the aCJus-,z ,CoAIICtZi-ate 3J1- �AQ)LS't.' _---junCwat.r tab!--LIPc_ �e i IIIutCI /•method when applicable]• v tf the c o c wiL b-loch;pith.=50 im:of anty 2L vc2t -__ +e:ianC, the Doaori oI:Ile Crovcsed leaching faciiry mill not be located Less than fot'_rtcta(14) f=above the r;,a;;l;tturl adiu�°� grounciate:table elwamon, Pie=complete the following �J A) Top of Ground Sur>ace=Ic.adon(using GiS information) 3) G.-W.FicyaIICn t7 3 'tk IV—kx!'�G.W. AC!7115"u'Ilent. ✓e DLcr -NC 3 t rrN A and 3 `! 3 (Fr=hL proposed plat of syst.--n on b=kj. s 4 LOCH ION _ SEWAGE�PERMIT NO. VILLAGE I'MSTALLER'S NAME & ADDRESS U I L 0 E R OR OWNER DATE PERMIT ISSUED 2 DAT E COMPLIANCE ISSUED �Y No. 83— FIm$....�s0 00....... - _... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH T own Barnstable ............ ........ O F............................._.........------....---.._...------------------•-----------•. Appliratinn for Disposal Works Tonstrur#inn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: Stuart Meyerq Holly Point Rd, Centerville, MA 02632 .............................................................:.................................... --•-••••-••-....-•------•--••-----•-•-•------•••-•••--•------...............................---••- Location-Address or Lot No. Stuart Meyers___ _ _ _ Solly Point Rd......... Cnterville,__M .......2632--._._ .---•---•-.•.... ..................... Owner Address A & B Cessp ool Service ............................... 128 Bishops Terrace,• Hyannis l _MA__.02601_____ Installer Address i d Type of Building Size Lot------ ------------------Sq. feet 04 Dwelling—No. of Bedrooms....................3 ...................... Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons.......5.................. Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... .. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench--No..................... Width.................... Total Length......._..:......... Total leaching area....................sq. ft. Seepage Pit No---_--------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ►-' Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-_-_______-_-__-__-_:. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___•_-__-_--_---____. a •--•-•-•••-•---•••-••-------••••••----•---••--••••••••••-•-••••••••-•••-...........•---••-•.................•------.....:....••......•••--....--•---......... 0 Description of Soil................Saxid............................................................................................................................................... x W --••---•--------------------•------•--••-•••-•••••-•----•-----•-----•---•---•-----•------•---------------------•-•---•-----_.... --•-------------••••••-••-••-••--------------•------•---••-••----••... UNature of Repairs or Alterations—Answer when applicable........insta11ation...of..a...1,.QOa..gallon-,__-gam..-cast .,9t_Qn..e--packed__leaah..pit---(ave- fl.ow)-_---------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant a been issued by the bo F iea Sig • .... ... --•-••----------...�....------- -r ....51-.2/.8 ........... Date Application Approved BY '................................................... ---------------5/ -2/83--------- Date Application Disapproved for the following reasons:............................. --•-•-•--•----•--••-----•---•••••••-----------•-------•....... ......---•------ --••-•--•-----------------------------------------------------------------------------------------------..--------------------------------------------------------------------......................... Date PermitNo.....8-3---------------------------------------------- Issued..........5/.2,83--............................ Date No...83 a..... Fu$.......lo oo........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...------ --m.own""...............OF.........BarnstaBle... ._... Appliratinn for 11iipnsttl Works Towitrn.rtiun amit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System,at• - Stint 111eyers Holly Point Rd, Centerville, AAA 02632 ................_........_.............................................a........................ .......--------------------...----....------......-----------------........-----......--•---..-•-- 1' Location-Address or Lot No. _ lfey_eTr�.-•-•--••--••-----••-•-----------------------------•--...-------- Stuartrt vl Owner Address W 1.4 ........................B ool Service _ 12L__Pishops Terrace Hyannis, MA 02601 - Installer Address Type of Building Size Ldt............................ q. feet Dwelling—No. of Bedrooms....................3......................Expansion Attic ( ) Garbage Grinder ( ) p`4 Other—Type of Building ............................ No. of persons.......5.................. Showers ( ) — Cafeteria ( ) 04 Other fixtures ---------------------------------••----••--•-•-•-•.... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--•-----...•-•-••-••---•-•--•----.....---•----•........---••-••--..•--.. Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water......................... fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ------------------------------------------------- •--------------------------------------- *..... •---- -------------- •---------------------- -........ •------- •-- O Description of Soil................. asscl----------------------------------•---•-------•-•---------------------------------------------------------------------------................. W . U Nature of Repairs or Alterations—Answer when applicable........imsta.Llation... Qf._s_.I,.Q00._f allAzl¢_.pxt�.-Cast .6tone-paekerl...l ----•---...-•-------------------------------------•------------------------..........----••---•••---•----•--••..•--•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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 rof- ealth. fi Signg ✓ G £ C __. c..'.�,[-fE_.lL l !I li/f.--! (i �� 283 ,......-------- / ate/ Application Approved By...- :� ,...,,.�, 'J � 51D?J��_3 _.... ----••...................... Date Application Disapproved for the following reasons:..................... ---------•----•................................ ...................•-- •-----........ --.....-•-•---•------•-----------------•-•-------.....---------•-•------------...._...........-------•---••.........--•...--•-•-----••••••-••--••-•--•-•-•-------------•••----••-••••---•••--•-......... Date Permit No.----U7...----•---•---.....----•------------------- Issued.---------51•-2l....----.......-------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................T.Own.............OF......Famsteble.................................................... �r�if irtt#r of f�unt�rlt�anr�e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X) by.. A & B Cesspool Service, 128 Bishops _y'errace, Hyannis, MA_ 02601 ....----•---------------------------•--•----..... at........i-lolly Point Rd., Centerville, FA OAV r - Stuart Meyers ............• . .-----••••-----•-...._••---- . ------••------•-•--•-•--••-•-•-•-•--•-••..............•---••••••. has been installed in accordance with the provisions of T jI E 5 of The State Sanitary Code. as escribed in the application for Disposal Works Construction Permit No.-�3-......zllii --r�.............. d � 2/83 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........5L V83 Inspector......................••------............•-- -----------------•--•-•---------------....-------•---••---•----.---•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 83 G Town........OF..............Farnstabl® ............................ 4 10.00 .......... ...................................... No............. ......,� FEE..$.................... �i���a��1 nrk� ��an�� uan prnti� Permission is hereby granted.....................A & B Cesspool Service ---...... • --••-•••---••-•••-•........................................................ to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at No.......... iollr.Point Rc .�.Centerville ..MA 02632 — Stuart My. ers Street /� as shown on the application for Disposal Works Construction Permit No.__83........ .. Dated........512/_Z3................... 5/ 2183 o Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON LOkCAT ION EW.A G E PE RMI NO.. VILLAGE I `NSJ,4 LLER'S AME & ADDRESS B UfLDE R OR OWNER DATE PERMIT ISSUED 0ATE COMPLIANCE ISSUED ,., � ��� 2'� i arc, No......................... ......................... " THE COMMONWEALTH OF MASSACHUSETTS BOA oD F I-I �►R G� _.......... _...... ..... Appliratinn -for 'Uh4p sal v&a Tutuitrurtion Vamil Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System ` /l� G -------- �-/--- ------------------ . .�. ...................... ---0 c n=,Address or Lot No. -... �vnor. Address W Installer Address d Type of Building Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms_________________________________ ________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures _________________________________ W Design Flow............................................gallons per person per day. Total daily flow..............................................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. it. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------- -----------------•---------..----------------•-••----•••-••••---- Date------------------------------------ Test Pit No. 1----------------minutes per inch Depth of Test Pit_----------------- Depth to ground water...______-__-__-__-_---- �, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ -•------•--••------------------------------•-------•----- Descriptionof Soil -------------•••-----------•-----------------------------••--------------------------- ------•--- x U ---------------•---------------------..........................................................................n-----------------------------------------------------------------•--•----------------- W --•---------------------------------------------------•---------------.._•_-...__•-•--••---•----------••-••. ------ .......................... - UNat e of Pepairs Al��I;ations—Answer wh livable._._ _ __.... __ C1�.0.- --- _-.-----__--_------ ---- --------------------- -= _t- ent !�r ------------------- greement The undersigned agrees to install the aforedescribed Individual'Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e issued b the board of hea th - igned_ - . ---- ............. "`=! � d•---- Dat Application Approved By-- --- . ................ ----t ---- 1 7� Date Application Disapproved for the following reasons------------------ - ------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------- r Date PermitNo...................-----•-•-------•-................... a '. Issued 3•-,L .---------••7_...._..•••-•••••-- Date -eo No......................... FEs<,r�!....................... THE COMMONWEALTH OF MASSACHUSETTS _> _ SOAR F t-a ..._....o ...::....:.. ..... .. AvArtttion -for Uigvwial Morkii Tomitrurtion Vrruiit Application .is hereby'made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System ........... ------ ----- ............ ..... ..................... 0................................................... ddiess or Lot No. ......• ......... --- ------wner---- O W Address ,a ----• ------- ----- •... -- p Installer Address Q Type of Building :...> 'AtticStze Lot---- -----------------------Sq. feet.; U Dwellin g—No. of Bedrooms----------------- EYpanston ( ) I t Garbage Grinder ( ) a Other—Type of Building ---------------------------- No. of persons __ '=. werr ------------_ Shos'"(�; ) Cafeteria.( ) QOther fixtures ---- -------------------------- -fl�,-- -- Design Flow............................................gallons per person per day. Total daily flow = ern. gallons. P4 Septic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter _x- Depth Disposal Trench—No......................'Widtl _ „-._ -�ayTotal Length....._.___._...._... Total leaching 1> sq. f t. Seepage Pit No__________________•- Diameters A_n,. _..._ _-_--._'Total leac7iing aroi_ ____ _-Sq. ft. Z Other Distribution box ( ) Dosing t4nk a ..___ `....................... Date Test Results Performe by '- -- a Test Pit No. 1________________minutes per inch ----- Depth to"ground water -.-_ .___... ... f� Test Pit No. 2................minutes per inch Deptla f 1��Yt�I t Depth to ground wafer" f s--._-._-_--_- 4, r n: y . ..................•-----•••......-••---•------- D Description of Soil----------------------------------------- '" R< .... . . -="---------------------------------------------------------------------------- =-=----------------------------------------------- ------ ------------_ V Nat e of Repairs r. 1 t ions—Answer wh licable._.-_,- -- /�`!" ev. . ' = . 1 ------- greement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \1 of the State Sanitary Code— The undersigned further rees not to place the system in operation until a Certificate of Compliance has e issued b th board o hea .,._.. ...Y Application Approved B -- a �- PP PP Y :r ... l '1!� '�: -c3------------ - � e: Date Application Disapproved for the following reasons:'_____________________________________ __•-•-__-_--___-_. _;- __ -_-___-_--_______..... � 4«sue , ------------- ate Permit No................................. ssued.._.. •... ----- r Date THE'COMMONWEALTH OF MASSACHUSETTS BOARD' O HEALTH t..............OF.......... ................... W.J.prtifirttte of 011omplianir .. THI S 0 ER FJY,, That the di 'dual eVage Di osaI System constructed w( , or Repaired ( ) I r at---"--- • -- --- ---- --- ....................... •. ----•- -- •. ---- --" ........................... _... -• -- has been installed in ac rdance with the provisidfis of : 1 o The State Sanitary CQde a esc in the application for Disposal Works Construction Permit No..._______ _______________________ dated.....*3"" �"" ............ THE ISSUANCE OF THIS CERT9F164TE SHALL. NOT BE'CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... _. `_ _. Inspector f -------------------•--•------ THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH �7t .....OF.... . -.. C............................................... No. --- FEE �i��tt�tt - -� �tri�rti�a • .rr if ----- ��,,.�` � - Permission is hereby granted_.__ :. .. _ .____.___ to Constru ) o ..•R r ( Jan Indi id 1 age al e��� --- ----- -- ----------------•--- a, Street / ..77 as shown on the application for Disposal Works construction P No Dated ..................... DATE �. !/ —7 " Board of Health - == ----------------------- FORM 1255 HOBBS & WARREN• INC.. PUBLISHERS -