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HomeMy WebLinkAbout0150 HOLLY POINT ROAD - Health F150 Holly Point Road- Centerville A=232—079 Commonwealth of Massachusetts 0? 3 p2 -D 7 F W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 11 150 Holly Point Road Property Address P0- Robert Carpenter I Owner Owner's Name - information is required for every Centerville Ma 02632 2-5-18 page. CityLrown State Zip Code Date of Inspection I�rp t l4-icy Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab: 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation ay Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number, License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-5-18 Inspector's Signature ... Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes,conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of'17 t/v�� VS Commonwealth:of Massachusetts w Title 5: Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p M e 150 Holly.Point Road Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. Clty/7own State Zip Code, Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D.or E/always complete all of Section D A) System Passes ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below:. Comments: System was in working order at time of inspection. B) System Conditionally Passes: E One or:more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,.as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal.and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. El ❑ N Ej ND (Explain.below);. t5ins..3/.13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of.17 Commonwealth.of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments w s 150 Holly Point Road Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational..System will pass with Board of Health approval if pumps/alarms.are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): El broken pipe(s).are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ _ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further.Evaluation is Required by the Board of Health: El Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass Unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ _:.Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. t5ins,.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 150 Holly Point Road Property Address Robert Carpenter Owner Owner's Name information is required for eve Centerville Ma 02632 2-5-18 ry page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well:.: . ❑ The system has a septic tank and SAS and the SAS is.less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to:this form. 3. Other.: D) System Failure Criteria Applicable to All Systems: p. 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 O ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less -than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth.&Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 150 Holly Point Road Property Address Robert Carpenter Owner Owner's Name information is required for:every Centerville Ma 02632 2-5-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® Any,portion of a cesspool or privy is within a Zone 1 of a public well. El ® Any portion of a cesspool'or privy Is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. Ej The system fails. I have determined that one or more of the above failure .. ® criteria exist as described in 310 CMR 15.303;therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems; you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well If you have answered "yes to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M _ 150 Holly.Point Road Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® : ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the.baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(Actual) 3 DESIGN flow based on 310 CMR 15.203 (for example: 1.10 gpd x#of bedrooms): 549 t5ins•3/13 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 150 Holly.Point Road Property Address 71 Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate.sewage system? (Include laundry system inspection 0 Yes 0 No information in this report.) Laundry system inspected? . ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016-33,000gallons 2017-21,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No. Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 150 Holly Point Road Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Owner- last pumped 4 years ago Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth.&Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 150 Holly.Point Road Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. Cityrrown State Zip Code Date of Inspection D. System.Information (cont.) Approximate age of all components,.date installed (if known)and source of information: 1979 per plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3, Depth below grade: feet Material of construction: - cast iron ®.40 PVC: ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 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 Dimensions: 1000 gallons Sludge depth: 4„ t5ins•3/.13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 150 Holly.Point Road Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 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 32 Scum thickness 2 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" Measured 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. 4 Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to.bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 150 Holly Point Road Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 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 plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day .Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 150 Holly.Point Road. Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box:is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.)` D.-.box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up or carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of.17 I Commonwealth of Massachusetts W Title 5. Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments .150 Holly.Point Road yV Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits -number: (1) 6'x6' 0 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ Innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Pit had 1' of standing water with a stain line '/2 way up from the bottom. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert. Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 150 Holly Point Road Property Address Robert Carpenter Owner Owner's Name information is Centerville Ma 02632 2-5-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions - Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 N Commonwealth of Massachusetts W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 - 150 Holly Point Road. Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand_sketch in the area below . ❑ drawing attached separately Garage DRIVEWAY O J 0 1 r - Ej] (DF AC-12' BC-22' AD-19'. BD-25' AE-211" BE-29' rr AF 287' BF-24' f I t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth.of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 150 Holly Point Road Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma _02632 2-5-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GW @ 12' feeee t 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: 11-97 Date ❑ Observed site e(abutting'property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) _. _❑ _ .Accessed.USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 150 Holly.Point Road Property Address Robert Carpenter Owner Owner's Name information is required for every Centerville Ma 02632 2-5-18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A; B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 17 of 17 Commonwealth of Massachusetts Title M. . Forte Subsurface Sewage:[NispospI.System Form-Not for Voluntary Assessments 150 Holly Point Rd Property Address Judy Goodman Owner Owner's Name Information isCenterville MA 02632 11/27/13 required for every C Rown State Zip Code Date of Inspection page. Inspection results must be submitted.on this torn.Inspection forms may not be aSered in any way.Please see completeness checklist at the end of the form. I fom ` A. General lnfomation on the computer, use only the tab 1. Inspector (� key to move your �I cursor-do not Jason Burnie use the return Name of Inspector key. Neighborhood Waste Water 1�1 Company Name 350.Main St Company Address W.Yarmouth AAA 02673 City/Town State Zip Code 508-775-2820 85011 Telephone Number License Number B. Certif canon I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, gate 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" 15.w of Tithe 5(310 CHAR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/27/13 Inspector's Sig Date Ther syste inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP:The original should.be sent.to the system owner and copies sent to the buyer, if applicable;and the approving authofity. ****This report only describes conditions at tie tune of inspectim and under the conditions°of use at that time.T iMpect!lon.does not address.116W a system will.perEorm in ft ftftre under Um same or dilibreat conditions of use. t5ins•3M 3 TWO 5 Oificwl S Waage Dieposal,System•Page 1 of 17 . Commonwealth of Massachusetts. T 5 Official r �Ctic Farm Since Sewage.Disposal System Form-Not for Voluntary Assessments 150 Hotly Point Rd Property Address Judy Goodman Owner Owner's Marne information is Centerville MA 02632 11/27/13 required for every cityrrow n state Zip Code Date of inspection page. B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/aiwalrs complete all of Section D A) System Passes: ® 1 have not found'any information which indicates that any of the failure criteria described in 310 CMR.16.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was found to be in good working.order upon inspection.The tank, d-box and teach pit are in the grass just off the driveway.They are H-10 and should not be driven over. There is a garage door that in order to access you will drive over the components. See as-built on page 15. B) System Conditionally Passes: one or more system components as described in the"Conditional Pass"section,need to be replaced or repaired.The system, upon coffin of the replacement of repair,as approved by the Board of.Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following Statements.If"not determined," please explain. The septic tank is metal and over 20 years otd"or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfittration 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): 3l13 Title 5 D hspeCbW Fomr.St"SlOce Sewage DWp"Sy�m'Page 2 of 17 T ` I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 150 Holly Point Rd Property Address Judy Goodman Owner Owner's Name iequiretion is Centerville MA 02632 11/27/13 required for every page- Cityfrown State ZipCode Bate offnspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.):. ❑ 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,Boafd of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑. N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the enviraonment. 1. System will pass unless Board of Health determines in accordance with 310 CIMR 15.30341 Kb).that the sys e its not.funcl ninginamannerwitich.w.1ly Proodpublichealth, 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 vegetat+ed wetland or a salt marsh tks•3113 Title 5 MO.hepection Fam:SuGmrfaoe Sewage Dam System•Pugs 3 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form SWMU# ace Sewage Disposal System Form.-Not for Voluntary Assessments 150 Holiy Point Rd Property Address Judy Goodman - Owner. owners Name information is Centerville MA 02632 11/27/13 required for every cityrrown state Zip Code Date of Inspection page. B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,N any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis; performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is.equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to Ali Systems. You must indicate"Yes"or"No"to each of the following for all inspect: Yes No ❑ ® Backup of,sewage into facility or system component due to overloaded or. clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of.the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level.in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool-is less than 6"below.invert or available volume is less than%day flow t5ins•3M3 Title 5 01f>d1.kMpeCbW Fa=Sd)=Jr ce Sewsip pisposed System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Offi W Ov� �Iq Form Subsurfac a Amage Disposal Sys .form-Not for Voluntary Ascents 150 Holly Point Rd, Property Address Judy Goodman Owner Owners Name inforequintion isred for.every Ce.nteivilk AAA 02632 . 11/27/1.3 requ page. Citylrown State Zip Code Date.of lrspection B.. Certification (cunt.) Yes No ® Required.pumping more than 4 times in the lash year NOT due to clogged or obstructed pipe(s). Plumber 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 time won water analysis,.wed at a'-DEP earl filed laboratory,for fecal coliforrn bacteria it dicetea.absent and the. of ammonia n�ogen and.nittate.n' n is equal to or :than 5 ppm, provided. thhat noo> failure arts.ia are triggoW.A..copy of the;.anatysis and chain of custody.must be.attached,to 004omj. ❑ ® The system is a cesspool serving a facility with a design flow of.200G. gpd- 10,000gpd. ❑ ® The systern M.i have determined that one or more of the above failure. criteria exist as;described in 310 CMR 15 303, ire the.system faits.The system owner should:contact the Board of Health to determine what wifl ti necessary to.correct the failure.. E) large Systems: To be considered-alarge system the system must serve a fait w h a. design flow of 10,000 gpd to 15,W go. For-large systems, you..must indicate.either"yes"or"no"to each.of the foRowing, in addition to.the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary,to a surfaw 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 has.failed..The owner or operator of any large system considered a significant threat.under:Section E or failed under Section D shO upgrade.the system in accordance w 310 CAAR 15 3{34 T#te system ovatter sttoufd contact the prate regional.office of the.Department t5Ns,$n3 me e.tffiaat trgeW Form secs ser ge P*-al system^PW 6 d V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments. 150 Holly Point Rd Property Address Judy Goodman Owner Owner's Nwe information is Centerville MA 02632 11/27/13 required for every Pap. Cityrrown state Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of.the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from,owner)provided with information on the proper maintenance of subsurface sewage disposal.systems? The size and location of the.Soli!Amman Sim(SAS)on the site has been determined based on: 0 ❑ 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 CWIR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 1.10 gpd x#of bedrooms): SA54 S@ . t5irm-W13 Tde 5.of ad k%pWw Fmm&bsid—sewage Disposal System'Page 6 of 17 Commonwealth of Massachusetts Tie 5 Official I0spc�on For:m Sufturface SeWW Dom{&jsftm:Form-Not for Voluntary Assessments 150 Holly Point Rd Property Address Judy Goodman i Owner Owner's Name information is Centerville MA 02632 11/27/13 required for every page- CitYflow n State ZipCode Date of tnspecfion D. System Information . Description: The system consists of a septic tank,distribution box and a leach pit Number.of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? Yes ❑ No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): 12=44gpd11= 101gpd Detail: Sump pump? ❑ Yes Z No Last date of occupancy: Earlier 20.13Date CouuneralaUlndaistriai Rew Conditions: Type of Establishment: Design flow(based on 310 CIVIR 15203): GaRm per day(9pd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑. No Industrial waste holding tank present? ❑, Yes ❑ No Non-sanitary waste discharged to.the Title.5 system? ❑ Yes ❑ No Water meter readings, if available: tWw•3H3 Title 5 Offide kopection Form:Subwkwe Sewage D System•Page 7 of 17 Commonwealth of Massachusetts lipTitle 5 Official Inspection Form Subsufface Sewage.Dlsposat System.Forma-Not for Voluntary Assessments 150 Holly Point Rd Propetty.Address Judy Goodman owner Owner's Name information isCenterville MA 02632 11/27/13 required for every per• c4frown State Zip Code fete of Inspection D. System lnfotmation (cunt.) Last date of occupancy/use: bate Other(describe below): General Information Pumping.Records: Source of information: Per the customer pumped.within the last year. Was system pumped as part of the inspection? ❑ Yes 0 No If yes,volume pumped: gaiions 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/Altemative.technology.Attach a copy of the current.operation and maintenance.contract(tD:bel 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•313 Idle 5 0MCM l kWecjan Forte akwFace Sewage Doped System•Page 8 of 17 Commonwealth of Massachusetts Title 5 O##ic i ;j t Fora Subsurface Sewage Disposal.Sim Fori n-Not for Volurdary Assessments 150 Holly Point Rd Property Address Judy Goodman owner Owners game information is Centerville MA 02632 11/27/13 required for every page. cityaown State Zip Code Date of inspection D. System Information (cont.) Approximate age of all components, date installed(f known)and source of information: 1980 per plan on file at the Barnstable BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 208n Depth below grade: 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.): We ran a sewer camera up the line and it was ok at the time of inspection. Septic Tank(locate on site plan): Inlet Depth below grade: and outer-7 Material of construction: Z concrete ❑metal ❑'fiberglass 0 polyethylene ❑other(explain) H-10 septic tank If tank is metal, list age: YMS Is age confirmed by a Certificate of Compliance?(attach a.copy of certificate) ❑ Yes ❑ No Dimensions: 1500gal 3" Sludge depth: t5ins-3113 TWO 5 O kmp9dtion Form:&bwrfeoe se"p Disposal%vtem-Psge.9 of 17 Commonwealth of Massachusetts Title 5: Official InsPection dorm Subsurface Sewage Disposal Sit Form-Not for Voluntary Assessments 1,50 Holly Point Rd Property Address Judy Goodman Owner Owner's Name informations Centerville MA 026..32 MUM required for every Ciiy%Town State Zip Code Date of Inspection pap D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 21+ Scum thickness 0" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee,or baffle 1'+ How were dimensions determined? Tapemeasure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural:integrity, liquid levels as related to outlet invert, evidence of leakage,etc:): The tank was found to be in good condition.There'is a dunce for the tank to be driven over.and the tank is H-10. Both baffles were in place and the tank was at a normal'..level. Grease Trap(locate on site plan): Depth below grade: Material of construction: Q concrete ❑metal ❑fiberglass polyethylene. [other(explain): Dimensions: Scum thickness Distance from top;of scum to top.of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle. Date of last.pumping: Date t5ins•W Title 5 0fflool,kopeckm Farm&OPstwe Ssx :Disposal System"Page 10 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form %bwr[we Sewage Disposal System Form-Not for Voluntary Assessments 150 Holly Point Rd Property Address Judy Goodman Owner Owner's Name iequired fo is Centerville MA 02632 11/27/13 required for every page. Cityrrown state Tip Code Dabs of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gals Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑. Yes ❑ No Date of last pumping: Dam Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5kr.•3/13 Title 5 OftW hupeckm Form SWn ufaoe Sewage Disposal system•Page 11 of 17 Commonwealth of Massachusetts Tiffs 5 Official Inspection Fora Subsurface Sewage Disposal System Form,-Not for Voluntary.Assessments 150 Holly Point Rd Property Address Judy Goodman Owner Owner's Flame information required for every Centerville MA 02632 11/27/13 Pap. C4rrown State Zip Code- Date of lnspecWn D. System Information (cunt.) DMdbutkm Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was found to be at a normal level upon inspection.The cover is 2'6"deep.The box is H-10 and there is a chance the box can be driven over due to where the garage door is. Pump Chamber(locate on site plan): Pumps in working order: ❑. Yes ❑ No Alarms in working order: ❑ Yes El 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. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: SAS was Dated. t5lns•3M3 Time 5 Otbeki Inspection Fam.%bufaoa sewage Disposal system•Pop 12 of 17 Commonwealth of Massachusetts Tiffs 5 Official: Inspection Form Subsufface sewage Disposal Stem Form-Not for Voluntary Assessments 150 Holly Point Rd ice.Addrew Judy Goodman Owner Ownees Name requir c!Ib is Centerville MA 02632 11/27/13 required for every Citylrovim page. State Zip Code Die of trsspecdon D. System Information (cant.) Type: 1-6x4 with 4'of ® leaching pits number: stone ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil; signs,of hydraulic failure, level of ponding, damp.soil,condition of vegetation,etc.): The pit was found to have I'of standing water in it at the time:of inn.The.coveris:2'6"deep. The pit is H-10 and there is the chance fl could:be driven over.I also used a 1 W measure to verify the distance of at least 100'from surface water,and it was ok. 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 fto•3i13 TWe 5 Offnal bispec*m Form:S surface Sewage DWposat System•page 13 ai 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 150 Holly Point Rd Property Address Judy Goodman Owner Owner's Name information is Centerville MA 02632 11/27/13 required for every page. cityrro nt State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins,3113 Title 5 official kq)ed=Form:&ftwfaoe Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form sulnu ace Suewne Dbpoat System F0.0n-Not for Voluntary Assessments 150 Hotly Point Rd Property Address Judy Goodman Owner Owners Now information required for e Centerville AAA 02632 11127/13 very. cityrrown per- State.. Code Dafie:ofinspedion D. System Information (cont.) Stretch Of Sewage Disposal System: Provide a view.of the sewage disposat 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 _ LL Jr r 7 GARAGE N y r & K �A vu9 'M ► CIArnr j 1,ks „ta y c DR CE M F A —C: la' $-c ` AD! ►6 � 7 �.5 , E: y- t5irs•3M3 TNe5: :6�.F—3uba ft-S-MW.Dis Sd;Syskn:-. Rap 15 of 17 _ _ 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa$e Disposal System Form-Not for Voluntary.Assessments 150 Holly Point Rd Property Address Judy Goodman Owner Owner's Name information is required for every Centerville MA 02632 11/27/13 page. cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: Check Slope ® Surface water ® Check cellar ® Shallow wells E 12'+ per test hole on.plan dated 1980 Estimated depth to high ground water: 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: 1880 on file at the Barnstable BOH 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: SDW-252 Zone B water level 46.8 1.4x12= 1'5"adjustment You must describe how you established the high ground water elevation: A test hole done on plan dated 1980 show a test hole done to 12 and no.water was found. From grade to the bottom of the SAS you have a Ltotal depth of T. This gives you a proven 5':seperation between the bottom of the SAS.and to where groundwater is known not to be. Before filing this Inspection.Report,please see Report Completeness Checklist on next page. t5ins-3/13 Tdis 5 Of W kUpeCbcn Fmm&bsurface Sewage owposal System-Page is or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsur Sewage Disposal System form-Not for voluntary Assessments 150 Holly Point Rd Property Address Judy Goodman Owner Owner's Name inkrmabon a for Centerville AAA 02632 11/27/13 required for every page- t;,iEy/roam 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 0 System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•W3 rAle 5 of el.kspectiOn Form Slbsafaca Sewage Disposal System•Pap 17 of 17 350 MAIN STREET TEL: (855)775-2820 WEST YARMOUTH, MA 02673 FAX: (508)778-9628 Septic Service Pumping 508-775-2820 Installation Neighbor 1 TO: Don Desmarais Barnstable BOH Don, Here is the updated page for 150 Holly Point Rd, Centerville.The update is as follows.The number of bedrooms I had listed originally was 2.This was due to the plan that I followed for the design calculations.This change was made because the realtor for the listing was asking for it to be changed due to the permit you have on file.The original plan has the design flow at 2 bedrooms with 549gpd for the SAS.The permit for the house has it listed at 3 bedrooms with a daily flow of 220gpd. Per you're approval I have made this change to use the permit calculations for the number of bedrooms(3)and the plan calculations for the gallons per day for the SAS (549).This is reflected in the new page#6 for the Title 5 report for 150 Holly Point Rd, Centerville 4 Respectfully submitted, on Burnie Lead Title 5 Inspector Neighborhood Waste Water Services E-2 re b ..e.— I � a Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 150 Holly Point Rd Property Address Judy Goodman Owner Owner's Name information is required for every Centerville MA 02632 11/27/13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No E ❑ 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) E ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper,maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): SAS@ 54549gpd l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 L°M W t6�tl V10 SEWAGE PERMIT NO. o7.3a 0'j' _ VILLAGE V ST LL R'S N ME i AOOWESS /J OR OWNER C.ocoYlll�n� OAT E P AMIT ISSY E16 OAT E COMPLIANCE ISSUEO� v M 6'yJ o �S G •A lDh �8 z ASSESSORS MAP NO U3 22. � 2'L PARCEL Na` No. ....f��....... r • Fim.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ Town ................OF..........Ba.rnstable � Appliration -for Ui,ipwial Workii Towitrnrtinn Prrntit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: 150 Holly Point Road, Centerville - --•--••-----------------------------•----•---------.............---•-------------------........... ..................................................._...........---............................... Location.Address or Lot No. _21rrs-•...Halsn__.R.a -_MqC-7..an ----- . . .... 15.0---H0.1r1�y...ointL...Rd........0 en t€-r-ullb�e Owner AnftiZ C n 36 Wequaquet Lane. Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..--Three Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building RE s 1deT1C®- No. of persons._tKQ................. Showers (1 — Cafeteria ( ) dOther fixtures ----------------------------------------•-••--•------- ....................... W Design Flow................................. gallons per person per day. Total daily flow...----Z.O---GPD-_-----_----------._gallons. 10�0 WSeptic Tank—Liquid capaci ____________galions Length................ Width................ Diameter................ Deptlt..______.___... x Disposal Trench—No- --------------------- Width-------------------- Total Length-------- _ Total leaching area....................sq. ft. Seepage Pit No.1000-------- Diameter--'^-----/.� ..., Depth below inlet......)_.!........ T tal lea ping area..--._ _.sq. ft. Z Other Distribution box ( ) Dosingtank ( ) - } W4,T , Percolation Test Results Performed by.0-0.... --- V ---CIO... ...................... Date....��''�_ _'. �I.__.__..._.. Test Pit No. 1._.�_ Z_--minutes per inch Depth of 1'e .. Depth to ground water...____----..--.-_-..._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-.--.---_-__-.---_---. --........ ! ................... �{. Descr>prio f S 1 ezt ..." _l-- �' -- - .... % � . U ---r � � �' �/ F't '.._ .. ....._. L(/�,,s '2 -- ---- w --------------- x ------------------------------------- ----------------------------------------------------=----•------•--••--•---- a ......•-- --- ----- U Nature of Repa rs /Alterations—An er when licabl �l P .r :. _ .. - .. - • - - --•--• l a Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Zned--- ---- .......... Date Application Approved BY -- --- • - - -T------------- Date Application Disapproved for the following reasons---------------------------------------------------------- -----------------------------._...-------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date -.2� —�-I PermitNo......................................................... Issued---------------------------.._..----..................... Date No......................... rFsa ............... $•' THE COMMONWEALTH OF MASS:A'CHUSETTS , t BOARD-,,.OF 'HEALTH s S 07 .f. OF..... .. Appliratinn -for Rirniitt1 Works Tanstrnrtinn Vrxntit 1• Application is hereby''made for`a Permit to Construct <( ) or Repair ( ) an,Individual.; Sewage Disposal System at ocation-Ad- _s - s 1 ;:�=----?yl� —........ •--- %J�''cD`r N . Owner . ��ft � � 1 ...... • �Add1dd ss a ressr.----Installer ?� �. d Type of Building , ..1 Size Lot----------------------------Sq. feet U Dwelling—No of Bedroom's``-__7 ------ -- --------Expansion Attic ( ) Garbage Grinder ( ) a ,Other_ Type V BuildinX.t"/4_11X4_L No. of persons Y_4_4-.-W___-----_--_ Showers (t — Cafeteria ( ) �3 "Outer KttirEs -•--------------------•--------------•- µ " ..... •---- -•----•---••------•-------- ----•---------••------- W Design' Flow------------ ,.1 ........... ........gallons per person pei days Totai'daily flow------------ o - PD `:gallon~ Ri Septic Tank=Liquid capacity/0!�4__gallons Length---------------- Width_ ---.. . .... Diameter_---. .-. _-- Depth---_..--------- Disposal Trench—No. .................... Width.................... Total Length _-_ Total leaching area........ -----------sq. ft. Seepage Pit No../A��.___..'"I)Emeter..�._../- .._ Depth below inlet__.___ t__._____Total lea ping area-- •--___.-sq. ft. Z Other=I)i'stribution box ( ) " Dosing tank -' ,Percolation Test Results- Performed by ___,. ... ' ti__�.___. ...._.. Le.... kw.'t. .T.. . .Test Pit No. 1--Z-%-..--minutes per inch Depth of "ayesXiit.................... Depth to ground water........................ Test Pit No. 2................minutes,Per inch Depth of Test Pit.---:------.._..... Depth,to ground water--_-.- _-.--.---_-__.. Id`1•.. T 1 - ---• . --- ------- - -- --G. ----------- Description f S '1+ Q-__ _ � � ,� --- -------- -----------------=-------------------- - --- •. - --- x` �4 --------- ------- tJ Nature of P.ep rs o`Alterations—An er wherl;a hcabl �.._ E�+r +t�` :... --- ' ---------- Agreement: - The}:,undersigned agrees to install tfie,�aforedescribed Individual Sewage.Disposal System in accordance with the roisions of Article XI of the.State Sanitary Code—The undersigned further agrees not to lace the system in . P Y g g P Y operation until a.Certificate of'Comp1, ce has been issued by the board of health. ._ S, ed -- .r x.a l t a---------------- ------------------ Date Application Approved By---'- -.- - `, ...... Date Application Disapproved.f or the following reasons: ..................... ________......____...._____________._.._._..............._...............__ -;' . Date Permit.No. -------- ........ -------- Issued........................................................ . Date r. 7HE COMMONWEALTH OF MASSACHUS'ETTS i BOARD OF HEALTH y' r �.CC��rrft�irntr of f�nm�fittnrr THIS IS T9 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired b ' y ................................................ ... ----•- --------- ----- r Installer y has been instaleWinaccord.mce with the provisions of AptrorchXl of The tate Sanitary Code as describe describea in theOF a -,a•-1..7 ----- application for Disposal Works-C nstructlon Permit Ni dated t THE JSSUANCE OF THIS 'CERTIFICATE SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. s is DATE--- ..... `�' -----------------------•-• ...-. Inspector THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH OF... ....... ........ N *. �t.• / fr'.. �.......... - FEE.__ _ .............. Mlipatittl 1Un k,q Tongtrurtion Vamit Permission is hereby.granted_,,-, - ------------------•--------------.-.' --------.----------------- ............... to Con stru ( ) or Repair an Individual Sewage Disposal S em �;7 at No. s At • .............. t j as shown on the application for Disposal Works Construction Permit 4- 3 -._ Dated_.. --_-_.__-_.4. t _ � h -. DATE................................................................................ FORM 1255 HOBBS & WA'RREN. INC.. PUBLISHERS � 1 G' f � I 4�\ V r l a I 0CA N SEtvA6E PERMITS'4 & q®. IL LA6E I 0 N s LL Q's i OR ®Wq ER D ' ® ATE 1� SIT ISsu E ------------ DATE COMPLIANCE ISSUED Dif No........ FEB THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN -. _._.-.... OF......WNSTABLE.................................................... �} VILLAGE OF CENTERVIL . ppliration for M.5pagal ork i Tontrurtion ramit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: HOLLY POINT ROAD ......LOT---�$ .- 16 - •---- ............ Lo do A ess or Lot No. Helen -�.�Ic ane .150..HQ1.1y....Faant...Road,.C.erLterui.lae.,Ma.02632 Owner Address a ........... .....•.— ....... .`.................................................... .............................. ...--•-•-..._...........---------•-------•. Installer Address QType of Building Size Lot-_-.- 4.,701..__...Sq. feet Dwelling X No. of Bedrooms.........2--------------------------------Expansion Attic ( ) Garbage Grinder fjo) P4 Other—Type of Building ............................ No. of persons.......2-11------------- Showers ( ) — Cafeteria ( ) A4 Other fixtures .------••---••••........--•-••......-•--- Design Flow......11.0..............................gallons per gin per day. Total daily flow........22-0.._..__......___......._.._g.a ll ot.n s. r1 WSeptic Tank X Liquid ca acity1000.gallons Length._. .I ... Width-----4 .2.0biameter................ Depth..5.t.4 r.....x Disposal Trench—No..................... Width_..-i-.......-_-__.. Total Length_..............._. Total leaching area....................sq. ft. Seepage Pit No..............1.... Diameter-----10_-.-----. Depth below inlet...6............. Total leaching area..2.67........sq. ft. Z Other Distribution box (X ) Dosing,tank ) '-' Percolation Test Results Performed by---t�..F. hit ng___________________________ Date.NOV.28_,-197�_..--. ,aa Test Pit No. 1.---?........_minutes per inch Depth of Test Pit .................. Depth to ground water-._10.1.......... Test Pit No. 2.....2........minutes per inch Depth of Test Pit......51.......... Depth to ground water----none---ancoun. -----------------------•-•-•---•-----•••---••••-----• •-------••••-----•--•---------•.............__..................--------................----• ems, O Description of Soil....II l'..-W-o0d...1Acf.t71�V—3-'-;g1�}15a�.�-T-- .grayel.,.__.._-$-$. --_-feo2_,--_$, - 2-medium..white•-'_saand, No water...en�sz� � . �. � �, W -- -------- -------- .-... --•-----��;Ga�="""' -•-•- -•----..._0. RENWICK UNature of Repairs or Alterations—Answer when applicable._......................�2,�f--- -.----.-_-----------.._ a. _ B . // 4APMAN w --------•-------------------•---•--...............-•---••---•----•-•--••-.......---•--------•---••--•--••-••-•••--••-----......-----•--•----•--•---•-......----•----•------•-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor the provisions of'TT 5 of the State Sanitary Code— The undersigned further agrees not to place the sy operation until a Certificate of Compliance has been issued by the board of health. Si ed Date ec:� Application Approved By...... .•-- . ... •••• ..................... ... _.'..�.". f Date Application Disapproved for the following reasons:................................... .................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF" HEALTH .............. . �...OF............ ..... ...6�G !'�..t.......................................... �rrtif iratr of Tomptianrr 1 THI TO RTIFY, That the Individual Sewage Disposal System constructed or Repaired (� by ----------------- F ` rna- �/ ------------.. has been installed in accordance with the provisions 5 of Th St e Sanitary Code as described in the application for Disposal Works Construction Permit _ _-_.-_�--F. :..__-. da.ted.._.� ..'_(v..". -�/.e-------------- THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 g F HEALTH , �Y � _.�i No...............1..._..._. FEE.11�4.... or fiton�� ion rraati� ; Permission is hereby granted._— .. = =---•---•--•-------------------------------------------------------------------•-••--......-•----------...... to Construct ) or Ryit ( Individual Sewage Disposal System at No. .._•• . r- G Street as shown on the application for Disposal Works Construction Pe No.._ .t _.. .... ed..../Z.-_�3-.'.�1�s......... ,,. .................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No........7V".... Fps...... ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T ..._:............_........OF......$AI�N3.ULF...---------------------------..................... VILLAGE OF. ppliration fur 6ENTERVILLET iipuia1 orks Tongtru.rtion Prrmit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: ..........................HOLLY POINT ROAD ..._.LOT--�$_...... C._.BI<6............................................... Helen t: -Cieane............................. ._.F.91n.t_Roati_,Oenterville MaX2632 •- Owner Address --••--•-•---------------------•---------•-__ Installer Address UType of Building Size Lot_:__2Q:s_7Q1.......Sq. feet Dwelling X No. of Bedrooms......... .................................Expansion Attic ( ) Garbage Grinder 140 ) Other—T e of Building No. of persons....... "4_--_••______- Showers — Cafeteria Otherfixtures -------------------------------------------------------------_------- -------------------------.------------------------•---------------•---------- W Design Flow_____ gallons e er d'a Total dailyflow--------220............................gallons. WSeptic TankX-Liquid capacitvlQQQ.gallons Length.__� � . Width----4!201Diameter-_------•--_•._• Depth-5 t 6tt x Disposal Trench—No..................... Width.....1............... Total Length...... f Total leaching area....................sq. ft. Seepage Pit No-•--___-.--.--1____ Diameter-:__ Q-_......_. Depth below inlet__.�______________ Total leaching area_?6�........sq. ft. z Oth. (X. ) ) er Distribution box Dosin tankrr,,��,,,,,, Percolation Test Results Performed by.. r'__! u ..................................:.... Date.Nw.� $.:19 __._... 0_1 0.4 Test Pit No. .... .._......minutes per inch Depth of Test Pit.................... Depth to ground water_._10 t.......:. -.- (s, Test Pit No. 2.....2...._'._minutes per inch Depth of Test Pit.....5.._.......... Depth to ground water...11CIZIP...f31r1.Gp'l n 0 Description"of Soil... _�_t----kt�k6d_l�2�m �.t--V -•subsoil,...3•!- 8.-".MZ diil� ..oar-ae_ rx'�v.�? .x. F3-- f'ec _ - medlar wt. a. :an fat eC >eicx y� W cn --------------------------------------------------------------------------------------------------------------------------- ------ --- !'�'-- U Nature of Repairs or Alterations—Answer when applicable-------------------------- ___S_j -7_ ..-. - u__ _P_HAP.MiAN.. y ..•-•--•-•--••-------•-------•-•••--•--------------•----••••-•-••-••--••-•••••••••••..._.............--•••-•••------------------------•-----••••...---•..........•--••-•... 1 a No: 27654 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acc @tlAiv' the provisions of I.i 5 of the State Sanitary Code— The undersigned further agrees not to place the sy n operation until,�Certificate of Compliance has been.issued by the board of health. Sigdo.. ............................................................... r'-- �a......--.-y--•--- te Application Approved By..... _...:....._. ... •-•• . Date Application Disapproved for the following reasons-------------------------------------------------------------•-----------------------............--._...•-•-_..._ " ..----...--•----------------------•-----•-•---------------••---•--------•-------------...._..-------•-------------------•-----•------------------------------•-------•------------------------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH • .............. ...1o .OF............. ... 1- '1!,. . ............................................ (Irrtif iratr of Tomptianrr THIS TO C RTIFY, That the Individual Sewage Disposal System constructed ( r Repaired by.......... ..... ____ .._..- '. /t�, ; at..... .................................... has been installed in accordance with the provisions of TI ' > of he tat Sanitary Code as c�escr�l in the application for Disposal Works Construction Permit No... .... ......�_ ...r .... da.ted.--.._-/� �...._. ____-______:.- THE ISSUANCE OF THIS CERTIFICATE SHALL OT BE CONSTRUE® AS A,GUARANTEE THAT THE SYSTEM WICL FUNCTION SATISFACTORY. w DATE............................................................................ Inspector— -. - . • -- ...--•-•---•--•-•-...........•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7` 7 . ............. .T- 4e—- ..OF.............. ............... . :... ........... No. FEE... ............... Dinpusa1 or �onntrution unlit Permission-is hereby granted_ n..—_. to Construct ( '. ) or Re a•r ( ndividual Sewage"Disposal System . atNo.....`'.....' ..:Ct�..--- ...............................V�- •-- r Street as shown on the application for Disposal Works Construction Per No _____ d..... ................................. ............ .. f 'Board of Health DATE.---••-------------'•'--------...--•-•--------------•••••............--••--••-•- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ' LOCUS; MAP NOTES: LEGEND ELEVATION DATUM ASSIGNED. PLAN REF: f 20239 C (4) SEPTIC SHOWN PER OWNER RECORD. CERT REF: 189134 � ` ¢ ASSESSOR'S MAP: k 232/079 EXISTING CONTOUR 100 ZONING: �RD-1 SPOT ELEVATION (SLAB) x=109•7' : • SETBACKS: 30 -10 -10 BURIED GAS LINE � - SO' FLOOD ZONE: =C & B BURIED ELECTRIC LINE E— o eUFF PANEL NUMBER: 250001 0005 C TELEPHONE POLE fft: o _ , DATED: 18/19/1985 PERCENTAGE OF LOT COVERAGE m LOT AREA 21427t S.F. O ' 1 EXISTING STRUCTURES 12.1% _ " EXISTING PAVEMENT 11.2% o Y ��o� LOT 59 TOTAL COVERAGE 23.4% �` �� 6 04 �� PROPOSED 6.2% 4 k . ry - - E- - - _ N t \ 11 _ _-�-_ _ - - - - - - SLAB - - -EVA TIO 150— —_ un . _____ __——_— LOT 58 _______ _ ___ _______ 21427t S.F. o DECK — ix P PROPOSED C� BREEZEWAY .. '\0.49 ACRES f BEARSE POND _ — — — — — _' 24' TO BE ON � Lam/ O _ — — — -- _ — — _ SONOTUBES NCO AG PLOT PLAN OF LAND ., PAVED ; , - 110 -w f o o f ` — — — DRIVEWAY LOCATED AT: -- - `. -L_ °� 40 �"D p• W 150 HOLLY POINT ROAD00 CEN TER VI LLE, MA _ �L o ' \ 1 PRO,P`OSED­QARAGE PREPARED FOR: �� - 1 172 ROBERT CARPENTER SHED _- APRIL 25, 2014 ®®®a ., M �p� " REV: � � � �.,-�� �,,,��- "�,. � ,+ . � ��.-� 7 :' � �® ��N�r r�t;:ss�� REV: 00 o. ` . ✓" _V REV: i 1 O YANKEE LAND SURVEY CO INC. �' � ' _ _ e - ----a.. _. y' �Hi✓^ JUG 119 ROUTE 149 LOT 57 � . w zo GRAPHIC SCALE � � N 76 os MARSTONS MILLS, MA m 6 Q4 ,, _ TEL: (508)428-0055 FAX: (508)420-5553 780 P yankeesurvey@comcast.net www.yankeesurvey.net 1 inch = 20 ft O SHEET 1 OF 1 JOB#: 55008 JM • ,A - fSOI L L06 q 87 4 ' /I Y."PEA9TONE _ LOAM S FILL 12 MAX 40 T.DIS I° --� 1000 BOX I;.o•;0 000 GAL. ° �- lo'MIN. GAL. RECAST OR c E` 24" SEPTIC BLOCK I•;: • I MIN _� 3 Z I I --- � TANK I,�..•,,° ° , . I --+ �� a.p, T • 6' I , E E PA G E •. . I c" PIT�---�� I' �'d8; ' ° 20' MIN. ------ +f°: �- - - - - - - - d._I L�.j O 1 FOUNDATION loo , I/ + Ave •O I 2 WASHED STONE I "eWA.sa •_' f 411 ELEVATION SKETCH PERC. RATE ��z__2 d �•�, v _ . SCALE I = 4 TEST BY TOWN INJh'tl, I VK BACKHOE OPERATOR TEST MADE ON / E M f _ ELEVATION SCHEDULE I l I. INV. AT FOUNDATION 2. INV. INTO SEPTIC TANK 3. 1 NV. OUT OF SEPTIC TANK = ` -7 7 4. INV. INTO DISTRIBUTION BOX = � j �. .:� j✓ �' f ) - 5. INV. OUT OF DISTRIBUTION BOX = � � 6. INV. INTO SEEPAGE PIT = 4 7. BOTTOM OF PIT = &1• Zo , I ��. ,/ / j r / .. i 1 „_. '. : •.; CA.4 .. ir�,r'"1 �,�1'%.v,,.--._+ x '_) �,•... 'l iJj�,. 4•t. > :�.I;L I �- �;,- ,. - ► � % s . ...�,�.,, _ ,ate . c x „ , � . i.`, _• ; ; It I � 4 _ }- f I vk N.- 2 I .f .... .._— fie.Y c.4 -- ..._._..- - �b?[O/...... r�._..�,.._._y_ T;-- _.--.. t r • .._.... /Y i� ` Ar Nov Ile ` I f ii _ . _ __ _._ -- $o I L �.OS . to 1 [. FEAST UK •LOAM • Flll••• I4•YAR ''1•�J � �f ,• � �, I s .so fir• �� t� .'j W 1�f�•� .:�. .>w DIST. I,•,;;• , . o I 84. L ?S —� 4 C.I. . •. 1 n.E ��E Q a 1000 BOX I;•o•;; 1000 GAL. . n o • �r IorMIN. GAL. is ,•; PRECAST OR . • : o{- 24 6 sir ` Si�Ail: r j �OCV-, ) ,�"o � I/ SEPTIC 1� BLOCK ;( MIN �4y 8 3•Z Bc o � TANK 6' 1 '• ' . : I *I f I s` dam. SEEPAGE GE � :. . i s ,ua f� �'�d2.s � � L-, "• /4 Qr+l�d • , • I 20 MIN. --�1 ., , �. . d.•I Lp.I •6J. 79• Z FOUNDATION I 1 % " WASHED STONE �E ! ELEVATION SKETCH ' - 10. PERC. RATE:cA)-�a_e z .M_.• %.. L �,� /,�q P SCALE Irr= 4' TEST BY ' _ r w Ad ar. JrT ---- - SCA[F /'•20U�i'S TOWN INSPt1, I UF( — BACKHOE OPERATOR __.A 0Q1 41 5C0A.)91t; TEST MADE ON : II� 1 f h ELEVATION SCHEDULE I. INV. AT FOUNDATION - -- %� •/' _ 2. 1 N V. . INTO SEPTIC TANK 3. 1 NV OUT OF SEPTIC TANK = gT 7 ,I! ( _ /' — 4. INV. INTO DISTRIBUTION BOX 4 ' tJ,L�• �� / ! / E��1 _ J 5. INV. OUT OF DISTRIBUTION BOX 1 111 / �� � �� 6. INV. INTO SEEPAGE PIT 7. 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I � - i 1 4- �z ; I I , i -I - +_ t _­7---'--i-�- ---� � -I--I-I__---11� � � I li I ­_ .. 7 .It - ;--,- I I ___ t � - .�­_ - - I I - �t _J - , 0 t I �,­�..I I I , I-- � I I_t­ 't I : , ,-� F_ - - 7 -1 - -- _:--t - __ . I --i---l. � - i � �, �- � - � � L- ill I : , I ! ,- , �_t-,--�- I I � : __ , :- - � __ I: - - 411�4�"01, 1 � , -... I . I I : , �_ I I i 1 r- , � _1__�_4__;, .� �__ �-i---L-i. _�_ -' ;-1 F__�_t_4_4---1_1- , -.-.- i� , _ ! I I � I i I 11 � � 1-t , I -1 .- �- � � I I I I I I : . f : : I� I I I . - ,- - I � --4 I ; : I �� I i I-+-f-+-H I--- 1 1 1 -- . i , : -i 4- � I- -'- --t--i- I -_�------- -1 , : " . . - .­­_­ I I I � -. ,_. , . , I I I-!--,.,-i.., _.: - r,__, - - _!__�--_,�- � ! ; � I : __ I - -I- - - __+.__t ! I ,, , I . . . I . I I j 7 . i I I I ,-, -j- r--,-- - . I - - ------I ! -: , - � � � ! ; _1 : �, �-4-4 � - i f I �- ­� t f , 4 1 , " , - , I _ ..i . --.1 T-7---��-I-.. ­i_ ___­ I I . I I : . L : 1 , ­4_-I -�-I -1-1 I . - I I -1 j- I- [ -1�i 't, 1 , , r I - I . . I I I � I I I � --i-t �­.-�I �_A, 1 , : , � 11 : , 1 +--­_, � I I I I I I . � . t ! � I I : � - � I f ate° T No..e?.231— o FEB�....30.00 µ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iratilan for Disposal Works Tonstrnriinn Famit Application is hereby made for a Permit to Construct ( ) or Repair„`6X) an Individual Sewage`Disposal System at: Y 150 Holly Point Road Centerville � ) fit _ _e - c Location-Address or Lot No.), f_rfar Owner ; -Z' Address........................................... - T M�arnmhuy�-•.Tr- / L�...O Installer ��,1 ( � i(fAddress d Type of Building Size Lot............................Sq. feet Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.......--............--.--.. Showers ( ) — Cafeteria ( ) d - ......................................................�.............-•-•-•--••-•-•-----------•----------------...---........--•--. W Design Flow.......................Other fixtures ................gallons per person per day. Total daily flow............................................gallons. Ga $Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter-------------... Depth................ Digposal Trench—No.. ................ Width.................... Total Length.................... Total leaching area.0..................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z OthWDistribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... fZq, Test Pit No. 2................minutes per inch Depth-of-Test Pit.---..-.--.-........Depth to ground water_------.:.--------.-. W •••--....... xDescription of Soil......................... 2.!u.1......Grwmj............................................................................................................. U ------•---------=----------..-•----•--••--•-------•----------------------------•---.....---......----------•--•---------------------------..............-----------------......--------- W VNature of Repairs or Alterations—Answer when applicable........................1-15Q0---prallon_..tank....-___-.......... ---------------------------•----....------•----•-------•---------------•--•--..............-•-•----------------•--•----------------...-----.....----------------------------------•-...........--.--•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further;agrees not to place the system in operation until a Certificate of Compliance has been issued by the board"of health"' Signed ... .. . . .. /. G _ 5/11_/g'�............. I ...+� Date Application Approved BY -�a!r ---- ------- r------------------------------------------------------------------ -S-./ ,�e .......r.<.-.-'rs r Per Application Disapproved for the following reasons: ..................................................................................................................ji.....-------- f �p Dare Permit No. .7. , Issued ...............:' ..............-...-.....I....................... �.............. -"` r - IYate t THE COMMONWEALTH OF MASSACHUSETTS ` BOARD6 HEALTH TOWN OF/BARNSTABLE - k6.El r'n'tE of �LLlmyliance THIS IS TO CERTIFY, Tthe*Individual Sewage Disposal System constructed ( ) or Repaired (XX ) by.....J.P.Macomber Jr. .. ...................................................................................................................................................................................... Installer at ....150.... 01..7ru....P.O.int-...Road......Gent,.ery .l 1p.............................................................................................................................. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ... ./_?— .... dated ..,T/.,�.. l ------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUED AS A GUAR)►NTEE THAT THE SYSTEIV�WILrrL FUNCTION SATISFACTORY. DATE....../...i�-I----�U------------------------------------------------------------------ Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE -- Disposal Works Tunstrnr#ion rrrmi# Permission is hereby granted.......iT. P.,M !.� a? r? ...►Tr..............:........................................................................... to Construct ( ) or Repair)(X ) an Individual Sewage Disposal System at No.15D....N.?1�1�7..1? ?3 x1 t...?3oad...Ce_n.i-..exm.I I-.. ...•...•........................ ------...............•............. Street as shown on the application for Disposal Works Construction Permit No.!V.-r231 Dated.., j P...... :�.............................. ..........v..............--••`................................- Board o Healtl✓ DATE../4 FORM 3850E HOBBS&WARREN.INC.,PUBLISHERS