The URL can be used to link to this page

Home My WebLink About0018 INDIAN TRAIL - Health 18 INDIAN TRAIL Centerville A = 210 — 017 I �u Ili i V { u • Town of Barnstable Barnstable °pIMF T°�y OknericaCity Regulatory Services Department I m I: na ASIS.LE, 1 n Public Health Division 9 ws. � 2007 039. rFa MPt 200 Main Street,Hyannis MA 02601 Thomas F.Geiler,Director Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL # 7011 0470 0001 4525 5617 February 2, 2012 Mr Kent Smedley 15 Haywood Ave South Yarmouth, MA 02664 RE; 18 Indian Trail ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 18 Indian Trail, Centerville,MA, was last inspected on 12/28/2011,by J.C.Ellis Design Co.,Inc. a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system" Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: D-Box needs.replacement. You are ordered to repair or replace the septic system within two (2) year from the date you receive this notification.. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. PER ORDER OF THE BOARD'OF HEALTH =asMcKean, R.S. CHO • Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\Town of Barnstable.doc Postal r�cCERTIFIED lVlWitT,.,—kECEIPT (Domestic Mail e Coverage . . . Lr7 . For delivery information visit our website at n Ln N OFFICIAL USE Postage $ ^. a Certified Fee Postm $' Return Receipt Fee (� C3 (Endorsement Required) I Ills 3 �012 ea p Re' Mcted DelNery Fee lti (Endomemem Required) M Total Postage&Fees $ USpS C3 Mr. Kent Smedley 15 Haywood Ave. South Yarmouth, MA 02664 t Certified Mail Provides: • A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders. ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. ■ Certified Mail is notavailable for anyclass of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt maybe requested to provide proof of delivery.To obtain Retum Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or ma7rk the mailpiece with the endorsement"RestrictedDeiivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt Is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present It when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 i SENDER: COMPLETE THIS SECTION COMPLETF,,THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A.signature item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse A, ❑Addressee ryo that we can return the card to you. B. Recei d b Tinted Na e) C. Date of Delivery 0 Attach this-card to the back of the mailpiece, or on the front if space permits. a D. Is delivery address i erent felt �1? ❑Yes 1..Article Addressed to: r If YES,enter de ry addr4belo ❑No Mr. Kent Smedley 15_Haywood Ave. ��^ South Yarmouth, MA 02664 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered 0!Return Receipt-for M_erchandise j .0 Insured Mail ❑C.O.D. _ 4. P tstricted Delivery?(Ex M'fipel yes 2. Article Number $ �n 4 7 2 2 0 0:1 !4 5 2 5' 5611,' y- (Pansfer from service labeo e d�+ A l ' + `* �~ A PS Form.3811,February 2004 Domestic Return Receipt _._. .Ao2595-02-M-t54Q' I UNITED STATES POSTAL SERVICE First-Class Mail I Postage&Fees Paid I USPS Permit No.G-10 i � I • Sender: Please print your name, address, and ZIP+4 in this box • Town of Barnstable Public Health Division � 200 Main Street � t Hyannis, MA 02601 � I I l:li��„3ioi,ii3,II,�,�„ii�i:,fiFs,ii�,��,l�ii�s�,ii��,►I�lt! I, I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >Y 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is required for Barnstable(Centerville) MA 02632 December 28, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3.10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins•11/10 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 y( 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is Barnstable Centerville required for (Centerville) MA 02632 December 28, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): D-box is very deteriorated and needs replacement ❑ 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: ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is Barnstable C required for (Centerville) MA 02632 December 28, 2011 every page. Citylrown 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: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 0 ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in.cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M yy. 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is Barnstable(Centerville) MA 02632 December 28 required for , 2011 every page: Cityrrown 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: 0. ❑ ® 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 Zane 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 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- 1 0,000g pd. 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. l5ins•11110 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 t a 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is Barnstable Centerville required for (Centerville) MA 02632 December 28, 2011 every page. 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 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): 330 t5ins-11110 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 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is )(required for Barnstable Centerville MA 02632 December 28, 2011 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2011 -88 gpd, 2010-25 gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currently occupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary-Assessments 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is required for Barnstable (Centerville) MA 02632 December 28 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 3 years ago per owner 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-11110 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 M 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is.required for Barnstable (Centerville) MA 02632 December 28, 2011 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,,date installed(if known)and source of information: 1994- BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Satisfactroy condition Septic Tank(locate on site plan): Depth below grade: 0.8 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 411 Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is required for Barnstable(Centerville) MA 02632 December 28 2011 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 30" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank in satisfactory condition Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yy� 18 Indian Trail M Property Address Kent Smedley Owner Owner's Name information is required for Barnstable (Centerville)ille MA 02632 December 28, 2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'f 18 Indian Trail Property Address Kent Smedley Owner Owners Name information is )(required for Barnstable Centerville MA 02632 December 28, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0.1 Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in poor deteriorated condition -needs to be replaced -no longer holding liquid to outlet invert level. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•11/10 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 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is required for Barnstable (Centerville) MA 02632 December 28 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leach pit is in satisfactory condition - 18"of liquid in bottom of pit Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Indian Trail Property Address Kent Smedley Owner Owners Name information is Barnstable(Centerville) MA 02632 December 28 2011 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: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is Barnstable (Centerville) MA 02632 December 28 2011 required for , every page. Cityrrown 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 w A(?P w 2 3 2 a' IZ. 3o.s' 2.7' —t~�4u-c37' S3t t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yy< 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is )(required for Barnstable Centerville MA 02632 December 28, 2011 every page. Citylrown 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: 41+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS topographic and groundwater contour maps You must describe how you established the high ground water elevation: USGS groundwater contour maps and topographic maps indicate groundwater to be 20'+ below ground surface Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is required for Barnstable Centerville MA 02632 December 28, 2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ❑ System information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 �- � i � � ' Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Indian Trail Property Address Kent Smedley Owner Owner's Name information is required for Barnstable (Centerville) MA 02632 December 28, 2011 every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted-on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out I l forms on the computer,use 1. Inspector: 111"`ll' I I only the tab key VV to move your Jason C. Ellis cursor-do not Name of Inspector use the return key. J.C. Ellis Design Co., Inc. Company Name P.O. Box 2152 Company Address Brewster MA 02631 Bd11 City/Town State Zip Code 508-385-2228 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the _- information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on rifle sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15-.U0 of, Title 5(310 CMR 15.000). The system: , ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs t rt valuuiio,. the Local Approving Authority , 1-J I. td December 28, 2011 ectoes i a Date The system ins "submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sawa I Disposal System•Page 1 of 17 TOWN OF BARNSTABLE (� r 7- LOCATION SEWAGE # �� I VILLAGE ASSESSOR'S MAP Q LOTVAO —tl// INSTALLER'S NAME & PHONE SEPTIC TANK CAPACITY LEACHING FACILITYA ype) (sue) ` NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR O NE \ DATE PERMIT ISSUED: > DATE COMPLIANCE ISSUED: 155— " VARIANCE GRANTED: Yes No ROL rJ 2` F :753 i �. TOWN OF BARNSTABLE LOCATION V SEWAGE # �� 1 VILLAGE( ASSESSOR'S MAP & LOTVAO -OZ7 INSTALLER'S NAME & PHONE NO.7'V)P55\MChi0 . SEPTIC TANK CAPACITY / LEACHING FACILITYAtype) (size) qAC NO. OF BEDROOMSPRIVATE WELL OR UBLIC WATER BUILDER OR O NE X DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 155�— ,•;/' VARIANCE GRANTED: Yes No i F J✓ 3 ` l f No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zippl cation for Disposal *pstrm ConelTurtion Permit Application for a Permit to Construct( ) Repair()6 Upgrade( ) Abandon( ) ❑Complete System W Individual Components Location Address or Lot No. g To-of ANrtQA 14- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ;;t C7 ®/7 WOOD 4 vc- 50674 VA Installer's Name,Address,and Tel.No. .5108-Sf77 —8877 Designer's Name,Address,and Tel.No. do4oc--!a6 PKcSe5 C.F.C. 3 Type of Building: Dwelling No.of Bedrooms Lot Size a ��f4C>zt—S sq.k. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) P 1..--/'AA3 C D Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H Signed Date Application Approved by IL Date jl� _ _/3 Application Disapproved by Date for the following reasons Permit No. C Date Issued —(3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYicationjor Misposar *pstem Construction Permit Application for a Permit to Construct( ) Repair()() Upgrade( ) Abandon( ) ❑Complete System V Individual Components Location Address or Lot No. b T p-0IA 1-raA I L_ Owner's Name,Address,and Tel.No. ��T�Zt U 1 S Cv't'T' � KEtJt 5u-t VAssessor's Map/Parcel a b (S1-F t,v o ✓E S 4 Installer's Name,Address,and Tel.No. S-08-q7 7 —$8 77 Designer's Name,Address,and T 1.No. Type of Building: Dwelling No.of Bedrooms " ' Lot Size sq-ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures , , Design Flow(min.required) gpd ,Design flow provided gpd Plan Date Number of sheets Revision Date Title t Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He. Signed c Date Application Approved by 7 Date t Application Disapproved by Date 1 for the following reasonsrit - Permit No. 0 o / Date Issued 5 [ ------------------------------------------------- ----------------------- ----------------------------------------------------------- Th E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(4 Upgraded( ) Abandoned( )by CAPEI-.JMc— CXJ7aelfl/t 1_S at I R 1A C� y � has been constructed in accordance - r with the provisions of Title 5 and the for Disposal System Construction Permit No. �°i 3 ? dated S Installer A rOmf�� U6 Designer #bedrooms /�l Approved design flow�/ gpd The issuance of this, e t:shall not be construed as a guarantee that the system will functionas designed l Date Inspector Ins P ---------------------------------- ---------------------------------------— `------------------------------------------------------- No. 0_0 — g Fee + L� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal .pstem Construction permit Permission is hereby granted to Construct( ) Repair(K) Upgrade( ) Abandon( ) ! System located at_ �'lJ b ) �[ i �lJ rt��.✓/C� .0 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit-- Date 3 Approved by THE COMMONWEALTH OF MASSACHUSETTS " OARD OF HEALTH TOWN OF BARNSTABLE Allpfiration for i pa!3al ork,i Tomitrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal Syst — �. Location \ddress `� ^ (60 . .---or. Lot No. ` 'C Owner dr .—`.... ............................. W .� ----------------•.... �a 'm � �.. :..�'YI � Installer ddress UType of Building V Size Lot............................Sq. feet ,. , Dwelling—No. of Bedrooms................ ..........................Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ............................... . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitv------------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.........._.............................. ,� Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 ----•-•-•-------------------•------•--------••--•-------•--•---••••••---------......--•-•-•-•-...---................................ ...... .----------- •...... xDescription of Soil........................................................................................................................................................................ U --------------------------------------------------- •---------------------------------------------------------------------------------------------------------------- ------------------------------.-•---- W ----- --- ------------- V N ture of Repairs or A ions—Answer w en a plicable._.__lQ> _Q__.._ L—. '�.... '................ l 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 Co is has bee d by the board of health. Sign ------ 4! .�. ..... ... .. .... Application Approved By / .....�...... Application Disapproved for the following re s ns- ........._....._......._.......__....__..._--------------- --- ........ .... ........................ .. ........................................ Permit No. ......... Issued ....................._............................ ..�.. Dare THE COMMONWEALTH OF MASSACHUSETTS ,BOARD OF HEALTH TOWN OF BARNSTABLE &�r iftraie of Compliance is To CERAI' That the InJdividual Sewage Disposal System constructed ( ) or Repaired ( S, -------------------------------------------------------- n,��ller M has been installed in accordance with the�provisions']of TITLE I f T e State Code as described in the application for Disposal Works Construction Permit No. .......... .... dated .._........ _......�,vironmental THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B C NSTRU D AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. ? '.... t pl... "' � � ... Inspectors" - ------- -------- ---------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No._.......... FEE..�:-- ....... r �\. �s#uan Permission is hereby granted �\ - -._._._ .................................................... to Construct (,-)_or Repair ( J,�-an-Ln liyidual Sewage Disposal System at No...... - .......... ........................---- ••••-• ---•._i..••.. - / ....!....•-- I �3__._��-cam t�ray...� 'R._�� --- ------ ----------- Street / � / as shown on the application for Disposal Works Construction Permit No. ___ �ted._.___ .-_/_ ,._/_...!.-....___. PP P , ..�Z ............... '.._ .T-y Board r / Iq of Health DATE....... 1 t -----------------•••••-•-•--.._.__..._.- FORM 36508 HOBBS 6 WARREN-INC..PUBLISHERS r No..-•----•--....._..---•• '� /� _ � `� Fps...............-.......... .... THE COMMONWEALTH OF MASSACHUSETTS 130ARD OF HEALTH TOWN OF BARNSTABLE .� lirtttilan f nr Uiinpwml Workii Cnnnitrnr#tnn rrrnttt Application is hereby made for a Permit to Construct or Repair ( an Individual Sewage Disposal System at-- a --- - •--- .................................................... Location-Address or Lot No. Owner A dr�s ..................... . .......... W Installer Address UType of Building � Size Lot___________________________S q. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.---.._-_---_-_---_-_--.---- Showers ( ) — Cafeteria ( ) dOther 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. ft. Z Other Distribution box ( ) Dosing k_(- ) aPercolation Test Results Performed by------------'--.------- � =------------------------------------ Date........................................ Test Pit No. I................minutes per inch Deph t of Test Pit__�`'':�::_,___Depth to ground water........................ L%4 Test Pit No. 2................minutes per inch D nth Test Pit._._-_-----_____-_-- Depth to ground water........................ --------------------------------------------------- ........................................................................................................ ODescription of Soil-----------------------•-------••---•----•......•--••-•-----.j.....---------------------------------------------------- .............................................. V ------------------- •--------------------- •--------------•----------------------~---` ----f-----------------•••--------•------------------...----------•-•------------------------•------------------ a r UN ture of Repairs or Al3er ions—Answer w en applicable.-_-_�_C ( �_____ _ —_ ._... ._ . ................ c ...........�.+-�---------------V1-- ----�T_Q..Q9.......................................... -------•---------------•----------------• Agreement: The undersigned agrees to install the afo-red�cribed 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 Com is t has beeia-ssa d by the board of health. iSigned .. --' '--------. .. '"...- ..... ..... ................ .... ..' Application Approved By _��- r% � .. p......1 i '-ter ........ �0 `7 -- LYare Application Disapproved for the following reasons: .... ....... __._..............._........_...........------...........------- ............... .......... ...... ............................................. Date PermitNo. �........ .............. Issued ---------------------------------------------......... . Dare I /d,ill `-_0_,/ No. . -d•..�.. Finis THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH Appliration -fur Uiiipoiial Workii Towitrurtion Prrnit Application is hereby made for a Permit to Construct (�or Re air ( ) an Individual Sewage Disposal System at: ' -....� ... .. ....................Y_ . . .... . � l cation-A re s or Lot No. ..aY^ O r Address W nstaller Address Q Type of Buildf Size Lo ---------------------------Sq. feet U Dwelling-K No. of Bedrooms-----`- -------------------------------Expansion Attic (I-) -2i Garbage Grinder ( ) C14 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures _ _._.._.__ --------------------------=-------------------------------------------------------------------------------------------------------------- W Design Flow.................�f .............gallons per person per day. Total daily flow............. ''---- --_gallons. 1:4 Septic Tank—Liquid capacity------------gallons Length------------_- Width__............ Diameter----............ Depth_-_._--._..---- xDisposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area.___---._--_._.___-_Sq. ft. Seepage Pit No.................... Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------ --------------------------------- --------------------- -------- Date------------------•-------------------- a Test Pit No. i----------------minutes per inch Depth of Test Pit_.-__-_--_-_--__--- Depth to ground water..-.__-..___.---_.-._-_. LT, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--._-.-._-_--_-.___---_ a •-----------•- -- ------ 0 - ------------ Descriptionof Soil---------------------------------- --- ------------------------------------------ x W ----------------------- ---- -------------•----------•--------------------••-------------------------------------_------------ -•--- --- - U Nature of Repairs or Alterations—Answer w appli ble.___. --. _ ._.--------------------------------------------------------------------------- .__ . s Agreement: 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 jealt.' r agrees not to place the system in operation until a Certificate of Compliance has bee i ued the ar of hS�gned . --- ....... ............. Application Approved By...... f� � 73 Application Disapproved for the following reasons:..................................... -------------•-•-------------------------Date _------------ •------------------------------------------------------------ -----------------------•-••---------•------------------------•----•.....------------ - / Permit No.......... Issued 1 s Date No...60....7 THE COMMONWEALTH OF MASSACHUSETTS EOARD F HEALTH ------.OF..... „� �� . .........4 / f Appliration -fur Btopuiitti Worko Totulrnrtiun Permit Application is herby made for a Permit to Construct (�or Re air ( ) an Individual Sewage Disposal Sys at . ..................... . ........ ............................................... cation.A rcSs / or Lot No. O r Address . ------- W %., nstaller Address d Type of''Buildi Size Lot/---------------------------Sq. feet U Dwelling NO, of.Bedrooms....'`^- :.....:..........................Expansion Attic (4') : Garbage Grinder ( ) pa, Other—Type of Building ____________ ___________ No. of per sons-----.---------------------- 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. 3 Seepage Pit No..................... Diameter-------------------- Depth below inlet_____:____________:-Total leaching area-..-.__-___.-___sq. ft. 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..-------------._-..___. �Tq Test Pit No. 2________________minutes per inch; Depth of Test Pit----------------------- Depth to'ground water---------------- --------------------------------------------- -----.-•-•- Description of Soil - �, �'` .a '.. ...� O / V ------------------------- --- ---- - -- ----- -- W .................. -- --- ----- --- --- U Nature of Repairs or Alterations-Answer w appli bl -------- - :�• ,, ....-•---••---- ----------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article Xh of the State Sanitary Code— The undersigned furth r' iagrees not to place the system in operation until a Certificate of Compliance has been ue the of healt Signed: = .-- -=--- ........................ ................................ Application Approved By-- -- �i �1 _40f+..D_.'�` .... `Date Application Disapproved for the following reasons:........................:............ -----.----- --_-------------------------------•------------------- •-----•----••--•--•------•--•---•--•-•-•------------- ----------------- Date PermitNo......................................................... Issued...................... ...................i.............. Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF,,, HEALT . . — Tntifirate of f 1IM111tFtnrr l HIS IS TO CE IFY, That the Individual Sewage Disposal System constructed 4::� or Repaired ( ) ."'."- ------------------------- by * f� t' lert F-- t F"='� f/ ------ a laaslic ton for DisposalosalcWorkseCon Construction Permit No�rticle X of T� State S��tedv..Code a�es�iUed in the with the P PP P THE ISSUANCE OF TEAS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE TIiAT THE SYSTEM WILL FUNCTION SATISFACTORY. ` DATE................................................................................. Inspector-----------------------------`..................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALT ,�1�w-/ ^�7► /� 4 ................O F Q, +'' �, !C✓ *, r dam' ................... N --t of. ------ ;.: .FEE_; i..... ............ . . �i��u ttl urk,� n,�trttrti>att��rrtntt�. Permissio7 is hereby grant * ! ------------------•------•------------ •--•------•••. to Cons ConsUjufA r R atr . a� iviclua ewa e Di osal S m at No'.- ----- Street , as shown on the application for Dis 'sal Works Co truction P it N . _ .___ Dated_ s�r� Board of Health DATE �� - -t-I I-------------------------- -- -�---- FORM 1255 HOBBS & WARR INC. UBLISHERS -