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0033 JAMES OTIS ROAD - Health
33 James Otis Road Centerville P A = 171 164 vcito K UPC 12543 No.53LORcoNS°��� HASTINGS.MN � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments yr 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the +I computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name rQ P.O. BOX 145 Company Address ((— CENTERVILLE MA 02632 I l� City/Town State Zip Code 508-420-4534 S14297 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 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 4/30/12 ins pecto Sig ature 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 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•09/08 Title 5 Official In 'o orm:SubsurfacefSewageDis al S stePa 1 of 17 Y 9 ' Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is CENTERVILLE required for MA 02632 4/30/12 every page. City/Town 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 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MEETS MINIMUM PASSING REQUIREMENTS TIME OF INSPECTION, SYSTEM WAS PUMPED AT TIME OF INSPECTION FOR MAINTENANCE 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", "non 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is CENTERVILLE required for MA 02632 4/30/12 every page. City/Town 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).- 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has.a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 ❑ ® 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 '/day flow t5ins-09/08 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 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. 6 /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. ❑ ® 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. ❑ ® 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is CENTERVILLE required for MA 02632 4/30/12 every page. &I /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 3 3 (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM HAS A 1000 GALLON TANK D-BOX THE ORIGINAL PIT AND A NEWER S.A.S OF CULTEC 330S Number of current residents: 7 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)): Detail: 2010---194.5 2011---192 Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT Date 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 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: DEBARROS SEPTIC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? TANK TRUCK Reason for pumping: MAINTENANCE 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•ogia8 Tide 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 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 every page. City/Town 4/30/12 State Zip Code Date of Inspecfion D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NEWER S.A.S PUT IN IN 1998 TANK AND PIT 1984 OFF AS-BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass 9 ❑ 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 GALLON Sludge depth: t5ins-09/08 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 33 JAMES OTIS Property Address RICCARDI Owner information is Owner's Name required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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 PUMPED AT TIME OF INSPECTION FOR MAINTENANCE Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 El polyethylene El 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•09108 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 33 JAMES OTIS Properly Address RICCARDI Owner owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zi Code P Date—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 9 El polyethylene El 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•09= 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 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. Ci mown State ZipCode Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0'i 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.): SOME SOLID CARRY OVER PROBABLY DUE TO LACK OF MAINTENANCE 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: NO OBSERVATION PORTS FOUND t5ins•osios Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 3CULTEC 330 ❑ 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.): 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•09/08 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 °M 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 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•09/08 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 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. CityRown 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 t5ins•09108 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 VoluntaryAssessments sessment s M 33 JAMES OTIS Property Address RICCARDI Owner information is Owner's Name required for CENTERVILLE MA 02632 4/30/12 every 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: GREATER THAN 4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked date of desig n g plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 1995 CODE Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i Y Vim\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments se''y 33 JAMES OTIS Property Address RICCARDI Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30112 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 1 TOWN OF BARNSTABLE LOCATION �4r'lE &02 SEWAGE VILLAGE_ �fTU LL C— ASSESSOR'S MAP&LOT E l t04— INSTALLER'S NAME&PHONE NO. �IG K E CO It!`jt' 5JR1/�`( Dic SEPTIC TANK CAPAI')`TY 14U D COA 6 LEACHING FACIIM. (type)ft"47 6xi6t&V. Q►T'(Si�} NO.OF BEDROOMS Z� «-�3Dw {`�' -X'k I&" ICAR � ALS . to'yt3e BUELDER OR OWNER 1 e C UULg9 r A� PERMITDATE:_•}_19 /t49g 1N5 10 DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leachhin�Fagili �- I Feet Private Water Supply Well and Leaching Facility wills exist 5 �._ L l FAQ�' on site or within 200 feet of leaching facility) 616 b�VSWt'Z 14-' �/4 Feet Edge of Wedand and Leaching Facility(If any wetlands exist — f within 300 feet of leachin facili�} ��� Feet Furnished by ��Y �a 'A~ �• JTa�tld"_ -14 t ,¢-*JW',dV 4 or lava w/3,� 0 3d. i http://www.town.bamstable.ma.us/Assessing/RMdisplay.asp?mappar=171164&seq=1 4/30/2012 Commonwealth of Massachusetts2 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information XPY- /A Important: When filling out 1. Property Information: /� �,/ �`c �i4ezt/6To4 8G� forms on computer, u ��AVUZ nl /iV��, e- "T li/C��� i computer,use only the tab key Property Address � to move your � /✓ /UL�Lc it� ��c�f,91 L�CC AY IIC cursor-do not Owner's / use the return key. C5,) Owner's Address <� t--lC- /'Lys DZG32 City/Town State Zip Code Date of Inspection: Date 2. Inspector: (�L✓�ae� y STe Iti/c- � Name of Inspector t� r Company Name Company Address s, ; 59 City/Town State fCo—de r- ��— 8e3e-36/ Telephone 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 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 P❑, Nee u er Ev ti by he Local Approving Authority Insp s 19nature 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 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. t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 33 rs Property Address Z- City/Town � State Zip Code Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 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: $"TC7'? f�hiCT/�S/l t/S ��2u?v/LAcc 4•v� 17/IJ}i'/L�C'�c c P/z0,✓F-2�y 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with 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. ND Explain: t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form H B. Certification (cont.) 3 3 1 4w»s d-ris 2v Property Address z— City/Town State Zip Code Pccc Owner's Name Date of Inspection jB) System Conditionally Passes (cont.): ❑ bservation of sewage backup or break out or high static water level in the distribution box due to oken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass' spection if(with approval of Board of Health): ❑ brok pipe(s) are replaced ❑ obstruction - removed ❑ distribution box i eveled or replaced ND Explain: ❑ The system required pumping more than 4 times a ear due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Bo of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Eva n is Required by the Board of Health: N/6- ❑ Conditions exist which re ' further evaluation by the Board of Health in order to determine if the system is failing to protect pu ' ealth, safety or the environment. 1. System will pass unless Board of Hea etermines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning i anner 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 m t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form - Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M B. Certification (cont.) Property Address �'c=vTCh-t/i c c E� ✓jy� DZ6 3'L City/Town State Zip Code /} 7-n�/�(cci¢2ol Owner's Name Date of Inspection Nl C) Further Evaluation is Required by the Board of Health (cont.): 4 2. Sys m will fail unless the Board of Health (and Public Water Supplier, if any) determin s that the system is functioning in a manner that protects the public health, safety and vironment: ❑ The Sys m has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet o a surface water supply or tributary to a surface water supply. ❑ The system has septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic to k and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S 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 a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitroge nd nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggere . copy of the analysis must be attached to this form. 3. Other: t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 a Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) y d M Ro Property Address , /��Z(//fL C� /��f OZG Z City/Town State ZipCode ,Y�k?rd tl �ic(114Q9/ Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool NA ,{, Liquid depth in cesspool is less than 6" below invert or available volume is less El (yJ than '/z day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 7w 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. ❑,)14 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. ❑ N/t 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.] ❑ , � l' The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. Yes No ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4 M B. Certification (cont.) Property Address t/ City/Town State 2 Zip Code Owner's Name Date of Inspection E) ,Large Systems: To be considered a large system the system must serve a facility with a desi flow of 10,000 gpd to 15,000 gpd. For large stems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in ton D. YES NO ❑ ❑ the system ithin 400 feet of a surface drinking water supply ❑ ❑ the system is within 2 t of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen itive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a p 'c water supply well If you have answered"yes"to any question in Section E the system is cons) efeda significant threat, or answered "yes" in Section D above the large system has failed. The owner or oper�t f any large system considered a significant threat under Section E or failed under Section D shall upgra e system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist -�U ✓��r-s errs �R� Property Address Cityrrown State Zip Code �C�✓i�/ �'��u�cp/ //- 3 U Owner's Name Date of Inspection 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)] t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information Property Address a�+/rE2 Cityfrown State Zip Code IA71 C q e V1 0 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Od No Laundry system inspected? ❑ Yes ❑ No 011 Seasonal use? ❑ Yes No Water meter readings, if available (last 2 ye s usage (gpd)): Sump pump? 414z �U 2 El Yes No Last date of occupancy: �dJ�r•u� Z40 V z°67� Date Commercial/Industrial Flow Conditions: �/ Type o� tablishment: Design flow(base on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats p s/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: Last date of occupancy/use: Date Other(describe): t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments G„M Subsurface Sewage Disposal System Form D. System Information (cont.) --�5 379ttl�s Ors Property Address ��/TG7Ll/iG�G � �ZG 3z City/Town State Zip Code /(/zZv >�t/ Owner's Name Date of Inspection General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: ''�'ga /gallons How was quantity pumped determined? �< Reason for pumping: yG /s 3 Type of System: // / l 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Ly� 0-/1,X P.T 19VA /-i Y-e? -Wa14'c5- Were sewage odors detected when arriving at the site? ❑ Yes No t5insp.doc.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form G M Sy' D. System Information (cont.) Property Address �/lcLc &4 az�3Z City/Town State Zip Code Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): )�, Taut/ A4 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): �f1X5 � Septic Tank(locate on site plan): V Depth below grade: /(QDutl e� feet 2 hui (-- i, bi I � 1� Material of construction: 4,9g OCP0L 10//o''aoUc UP concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) C�kwf /,v la�� S�f-9 Pcr If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) ------------------------------------------ ---------------------------- -------------------------------------------------- Dimensions:/&,00 Sludge depth: 2% Distance from top of sludge to bottom of outlet tee or baffle Scum thickness �7 rr Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle bo�r� -f �ddOC� How were dimensions determined? t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �N D. System Information (cont.) 3,3 Jq,,2� Or(5 Fo Property Address Cityrrown State Zip Code �'// (5eiu, 191 11-30 -07 Owners Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels a§related to outle invert, evidence f lea ge etc.): Grease Trap(locate on site plan): Depth elow grade: feet Material of c struction: El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or e Distance from bottom of scum to bottom of outlet tee or le Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle c ition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/ Tig ding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglas ❑ polyethylene ❑ other(explain): t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form - Not for Voluntary Assessments Subsurface Sewage Disposal System.Form D. System Information (cont.) jj ✓,- _f Property Address �. cc City/Town State Zip Code Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimens' s: 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 Distribution Box (if present must be opened) (locate on site plan):✓W-3 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 o/P�eaka a into or ut of bQx elc.); / / e/?:,e 3 by 1,P 1 41, -r/oU AV uvet/ lea/tz' 'ts 5�V-0 Ole 4'V-'t1 r locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes o t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) Property Address �7✓G�7z-t/!G!� ��-, O2�32 City/Town State Zip Code �/c�n�✓ �ccia�o� //-.3d -o� Owners Name Date of Inspection Comments chamber, condition of pumps and appurtenances, etc.): Mk Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 4-5 Type: A-c 4 I achi g pit ���/ -� ��/ number: �N� fte% � YZ C�' fJ✓�`�a K�9Ptictiers GtJ =e number: N� / 1�i Q Zi�o� ( ✓' A ll ❑ leaching galleries �( number: ,¢ P�/u ❑ 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.): t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM D. System Information (cont.) 33 -z?r4X1--r Property Address Itle— ego, City/Town State Zip Code 1/-30- o 9 Owner's Name Date of Inspection */- Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Numbe d configuration Depth—top of liqul o inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, con ' ion of vegetation, etc.): Privy (locate n site plan): Materials of construction. Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of po condition of vegetation, etc.): t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M D. System Information (cont.) 33 J,;�AieT marls "gp Property Address �n/Vaw////lam % oZG�Z City/Town State Zip Code /1W�04/ �/c c�9 Raj // 3v o�z Owner's Name Date of Inspection z�, Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. R Locate where public water supply enters the building. /a7 IF-6 4 2 �v 'Z g-Z /S/ S/, 33 -3 4�sze- 19-3 pole li x VL I i oti B-j�4,01514 I0 6 Gra 4 Z s.T: «sfi/��y 3 -3 24 U o q& 30 1p t5in .doc.doc•03/2006 Title 5 Offici Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth,of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form LAM D. System Information (cont.) 3'3`1 Al 'C=s Ores /(.g Property Address City/Town State Zip Code Owner's Name Date of Inspection Site Exam: Slope / a 7b 2- Surface water Check.cellar �Ry Shallow wells TvswA1A✓y-nb►2- �eV1//ct �I/y�Gi�Qa4,WW � J'7Z- Estimated depth to ground water: > Zb ' ,-/-W f r '> `/ , 4//'� c� K �r I Please indicate all methods used to determine the high ground water elevation: ,� 1�� �hz�tb,?►� [ 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: 41-Y f,e `Z�7U., Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 i Town of Barnstable �pF tHE Tp� yP�ti� Regulatory Services anxrrsrnarE Thomas F. Geiler, Director 6MAS9. 1mr Public Health .Division ATFD��p Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. ~ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTffiENT OF ENVIRONMENTAL PROTECTION David&Mason,&S,Certified Title V Inspector,508-833-2177 MAP PARCE4 ; 16 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:33 James Otis Road,Centerville,MA Owner's Name:Paul MacDonald Owner's Address:Same Date of Inspection:April 27,2004 Name of Inspector: (please print)David B.Mason Company Name:—4 Glacier Path East Sandwich,MA 02537 Telephone Number: 508-833-2177 CERTIFICATION STATEMENT 1 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 aril a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: . Passes _Conditionally Passes Needs Furt�<2her Evaluation by the Local Approving jAuthityFails Inspector's Signat re: Date: 0The system inspector shall submit a copy is inspection report to the Approving Aut orityof 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. Notes and Comments: System as inspected appears to have operated based on occupancy level. Septic tank should be pumped as a matter of maintenance. Increase in occupancy may casue hydraulic failure.The information as identified represents only the condition of the system on May 7,2004 at 2:00 PM. ""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. f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:33 James Otis Road,Centerville,MA Owner:Paul MacDonald Date of Inspection:April 27,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: R 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. _ Answer yes,no or not determined(Y,N,ND)in the for the following statements.If`Snot 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 ifthe 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS t Page 3 of 11 PART A CERTIFICATION(continued) Property Address:33 James Otis Road,Centerville,MA Owner:Paul MacDonald Date of Inspection:April 27,2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form. 3. Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 4 of 11 CERTIFICATION(continued) Property Address:33 James Otis Road,Centterville,MA Owner:Paul MacDonald Date of Inspection: April 27,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool NA_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. —X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`eyes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well if you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:33 James Otis Road,Centerville,MA Owner:Paul MacDonald Date of Inspection:April 27,2004 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ _X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X — Were as built plans of the system obtained and examined?(If they were not available note as N/A) X_ _ Was the facility or dwelling inspected for signs of sewage back up? X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS,located on site?(INCLUDING THE SAS) _X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,!depth of liquid,depth of sludge and depth of scum? mX� — Was the facility owner(and occupants if different from owner)provided with information on the proper aintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X_ _ Existing information.For example,a plan at the Board of Health. X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)13 10 CUR 15.302(3)(b)) Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:33 James Otis Road,Centerville,MA Owner: Paul MacDonald Date of Inspection:April 27,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3_ Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330gpd Number of current residents:,2 Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): 2003;66,000 2002;73,000 Sump pump(yes or no):No Last date of occupancy:(current) COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Property owner Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping:Per owner system was pumped 4/25103. TYPE OF SYSTEM _X_ 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) _Tight tank —Attach a copy of the DEP approval Other(describe):With pump chamber Approximate age of all components,date installed(if known)and source of information:6/4/84 as-built card Were sewage odors detected when arriving at the site(yes or no):NO OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:33 James Otis Road,Centerville,MA Owner:Paul MacDonald Date of Inspection:April 27,2004 BUILDING SEWER(locate on site plan) Depth below grade:Approximate;34 Inches Materials of construction:_cast iron X_40 PVC_other(explain): Distance from private water supply well or suction line: NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage. SEPTIC TANK: N.A.(locate on site plan) Depth below grade:24" Riser is 8 inches below grade Material of construction:X_concrete_metal_fiberglass`polyethylene ,other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:Typical 1000 gst 8'6"L,416"H,51811W Sludge depth:5 inches Distance from top of sludge to bottom of outlet tee or baffle:24" Scum thickness:4" Distance from top of scum to top of outlet tee or baffle: 16" Distance from bottom of scum to bottom of outlet tee or baffle: 14" .How were dimensions determined:actual measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)No evidence of leakage. Septic Tank requires maintenance pumping. Outlet tee in good condition. Tank is H101oaded.Appears to be slight plumbing leak due to continual flow. GREASE TRAP: N.A. Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of l l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:33 James Otis Road,Centerville,MA Owner:Paul MacDonald Date of Inspection:April 27,2004 TIGHT or HOLDING TANK: N.A._(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass____polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_YES (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even with outlet pipes. One outlet pipe had a flow leveler. 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.): Box is level. There is evidence of solid carry over. Box is not leaking,but shows evidence of decay. Box is 32 inches below grade. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 01ST01VTLM IMTTTl171LK•T7l17►T i + Page 9 of 11 Property Address:33 James Otis Road,Centerville,MA Owner:Paul MacDonald Date of Inspection:April 27,2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X_leaching pits,number: 16'X6' _X_leaching chambers,number:(3)Cultecs _leaching galleries,number: leaching trenches,number,length: _leaching fields,number,dimensions_ overflow cesspool,number: innovativelalternative system TypeJname of technology. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc)-No indication of staining,no ponding or damp soil. Approximately 10 inches of effective leaching available in pit and 8 inces of effluent in c ultecs. Utilized camera to observe. CESSPOOLS: NA_(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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N.A._(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address:33 James Otis Road,Centerville,Ma Owner:Paul MacDonald Date of Inspection:April 27,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. �1 JAI1 2� / T Page 11 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 166 Sandy Valley Road,Marstons MB ,MA Owner:Wyett Date of Inspection:May 2,2004 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water 20_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: X_Observed site(abutting property/observation hole within 150 feet of SAS) X_Checked with local Board of Health-explain:Recent Test Holes Existing_enQineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography does not indicate ground water to be within 5 feet of bottom of leaching facility. e Home: Departments. Assessors Division: Property Assessment Search Results 33 JAMES OTIS ATNI Owner: Property Sketch Legend MACDONALD,PAUL B&MICHELE Map/Parcel/Parcel Extension - 171 /164/ Mailing Address MACDONALD,PAUL B&MICHELE 33 JAMES OTIS RD CENTERVILLE,MA.02632 2004 Assessed Values: Appraised Value Assessed Value- Building Value: $142.200 $142,200 Extra Features: $2,700 $2,700 Outbuildings: $0 $0 Land Value: $135,700 $135,700 Interactive Property Map: p mQuires Plug in: ti �'; Totals:$280,600 $280,600 I have visited the maps before '. . Show Me The Map Rpril2001 photos available Sales History: Owner: Sale Date Book/Page: Sale Price: MACDONALD, PAUL B&MICHELE 6/15/1984 4160/165 $78,000 SMALL,A E 2806/62 $0 SMALL,ALAN E TRS 6601/228 $0 2004 Tax Information: Tax Rates: (per$1,000 of valuation) Town Tax $1,854.77 Town Fire District Rates Other Rates 6.61 M Barnstable 2.01 Land Bank 3%of Town Tax C.O.M.M.FD Tax $308.66 C.O.M.M. 1.10 Cotuit 1.52 Land Bank Tax $55.64 Hyannis 2.03 http://www.town.bamstable.ma.us/t.../displayparce103.asp?mappar=171164&SearchBy=Addres 5/13/04 West Barnstable 1.36 Total: $2,219.07 Due to rounding differences these values may vary Land and Building Information Land Building Lot Size(Acres) 0.35 Year Built 1984 Appraised Value$ 135,700 Living Area 1712 Assessed Value $ 135,700 Replacement Cost$158,005 Depreciation 10 Building Value 142,200 Construction Details Style Ranch Interior Floors Hardwood Model Residential Interior Walls Drywall Grade Average Plus Heat Fuel Gas Stories 1 Story Heat Type Hot Water Exterior Walls Wood ShingleVinyl Siding AC Type None Roof Structure Gable/Hip Bedrooms 3 Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms 2 Bathrooms Total Rooms 6 Rooms Extra Building Features - Code Description Units/SO ft Appraised Value Assessed Value FPL1 Fireplace 1 $2,700 $2,700 Property Sketch Legend BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTO Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TOS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/t.../displayparce103.asp?mappar=171164&SearchBy=Addres 5/13/04 --ems C3t�s.,�_.�SBWACIE0 Jy-3Yj LOCATION 33 - y ILLr lASSPUMS MA AO i . • sc< jSC tn � YeSk INSTALLER'S NAME&PHONE NO. rii SEPTIC TANK CAPACITY 14 + _. LEACKNO FACUXN; (type) -- NO.OF BEDROOMS_ BftDBR OR OWNffit' P IITDA'ISt�' :C•S.Bf . COURJANCE DATA: 6�y Separation Distanco Betwooa ft _ 1189mumi Adjusted owpmj�iretw Table and BOOM of Lgaalting Fsciliry - Pdvam Wim Well and Leaoblog Fiilitp'Of any wft exist on dtc or withw Z t of ieae ft facuk)i• Faac Bdp of Wgtlaltd and Lefiddn Facility(It MY wetlands exist Few wid"300 fW of leciUtY) •� Fumished by 4 s . v No. y Fee 5'd THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pplication for �Bigpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Ow er's Name,Address arLd Tel No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. .711 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 gallons per day. Calculated daily flow gallons. 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) 3p 1 s ' S•mne_- -�// Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed ,,..i. Date Application Approved by Date Application Disapproved for the o lowi g reasons Permit No. — Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for Mi!5pogaY-*pgtem Congtruction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Ow er's Name,Address d Tel No. ssessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.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 gallons per day. Calculated daily flow gallons. 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) 42 44-�r5"--y—S, r, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. , Signed Date PP . A ' lication•A roved b'PP Y- Date /-a•�� �1 � Application Disapproved for the Rlowilii reasons Permit No. - Date Issued - -------------------------------- - ------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( pgraded( ) Abandoned( )by ���e & y� at 3 M �'�„ �.� P-L C e,,.r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - dated Installer l� e \ i �d�.�."' Designer The issuance of this permit shall not be construed as a guarantee.that the system will function as designed. Date Inspectors ——————————————————————————————————————— No. 6 _ Fee `¢ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mwigpogal *p!5tem C n5truction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at 33 R JL e_,7 Tr r ei,l-- and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: j '? 78, Approved by w r 3 3 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 1 1 z-z g=`s` ,concerning the property located at 33 ©- �e �<< meets all of the following criteria: t/• There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed to •* There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will n9l be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) _ B)Observed Groundwater Table Elevation(according to Health Division well map) S SIGNED `� ct•.r��� -�— DATE: f ,27 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert rr�� T TOWN OF BA.RRN�STABLE ,/ -/ LOCATION -✓3 J 4�e5 �r7 f-�a�7 SEWAGE #1N��r7 lAA VILLAGE C � TCI2 V I L L C- ASSESSO(R''S MAP & LOT < <�¢ INSTALLER'S NAME&PHONE NO. �'IGI�EY �o�'ST' 664 5JIZVt5 ( plc, SEPTIC TANK CAPACITY i� a►e �+cc, rvt=F v��+hi LEACHING FACILITY: (type) `�"'`� �t^� Q�T(sjze) `"o" ce'-4'` 5 t*'I NO.OF BEDROOMS �1.4tr �'Sr A�d4a 3a'� zAK I P W�aSty :%S to -A30, BUILDER OR OWNER �NSt�tlo PERMTTDATE: -1.9$s+Zt946 LRAO&T-DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leacphin�Facili D / Feet Private Water Supply Well and Leaching Facility (If anan wClls eexxist ►Jv 1/ FqQ�- on site or within 200 feet of leaching facility) C'�"'(�°Vs lark t4- ^J/4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �/ ^�A' Feet Furnished by ` ,0C." Z+O �7,0 57a�✓(� �A�s Ors Fw 4 3 40"d'*6-_? lq.�-4 6n��N l�_� �►�9Z cp 3 33o c,ji+Qcs p 1 p�r TOWN OF BARNSTABLE Q LOCATION 33 , cs t�ctis �-Z SEWAGE # 8Y—3Y� VILLAGE LAE' a-6s A 14ey1 '. ASSESSOR'S MAP & LOT 17 1 J�� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITYuV LEACHING FACILITY: (type) tec ; (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE ,;'.l 45--S_ErY COY«1 PLIANCE DATE: tY Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility' (If any wells exist on site or within 200 feet of leaching facility)'; Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet r Furnished by r C4�1 y� Ct �q o 12 9 TOWN OF BARNSTABLE LOCATION 33 -�ar.��s ��s Q"Z- SEWAGE # 8Y.--•3Y� VA .AGE Lot 1�� _ASSESSOR'S MAP & LOT17l INSTALLER'S NAME&PHONE NO. JAI SEPTIC TANK CAPACM I�uc;U LEACHIN 'G FACILM: (type) C C. S (size) /C 30 X Z NO,:OF BEDROOMS BUILDER OR OWNER PERMITDATE! ', 45 -1—8Y COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on-site or within 200 feet of leaching facility) Feet Edge:of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) , Feet Furnished by S b Lin r' TOWN OF BARNSTABLE 9$ EZ LOCATION 4-Z SEWAGE # 8Y- 3YS VI LACE Loc ASSESSOR'S MAP& LOT 17 1 INSTALLER'S NAME&PHONE NO. i1, It g f as r SEPTIC TANK CAPACITY 1 (DU U �iT LEACHING FACILITY: '(type) tC. 3 (size) /C i NO.:OF BEDROOMS i i BUILDER OR OWNER = PERMTTDATE! '. 45 -3-BY COIAPLIANCE DATE: -V'kY Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist od site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 'j0. L � o b� �h �"t ;! No. ..... s' i FI�s.. .............. THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH f..fin...........OF.... ............................................ Appliratiun for Diipnuttl Workii Ton rur#inn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal st at: D . . -••• ... .....---... ocation-Ad re ............................................ .............. ....................�!...�i ,g Owner Address a ----------------------- ......-----...--------------. .Pi c. ...... Installer Address r^ Type of Building Size Lot_._f . ' Sq. feet Dwelling—No. of Bedrooms......... .............................Expansion Attic (�Q Garbage Grinder (,A),10 p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fi tures ............... d W Design Flow........... ... .. . .............gallons per person per day. Total daily flow............... ..............gallons. WSeptic Tank—Liquid capacityf -' allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .. ................. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-__1 O`+ .. Diameter......... ...... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by...............................=.......................................... Date...............................:........ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ...............................................................•............................................................................................. 0 Description of Soil........................................................................................................................................................................ x U ...-•--•••.........•----••--------•---•••-•--•••-•---•-----•-••................••-----•-........-•-------...--•------•----------•---......-•----•----••--•••--•-•----•-•--.................-•------•--••. w --------------------------------------------------------------------------------------------------------------------------•----...------....---------------------------------------------...._.0....... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------------•-----....-•••...................... Agreei nt 1 undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with t pr visions of'SIT 5 e State Sanitary Code—The undersigned rtlier agrees not to place the system in � per ion C at Compliance has been Jim Aby rd iealth. L �4� Ap ' ati Approve .,.-•--- ---•---•••-•••--•..................................................•---........... e Date lication Disapprove r t following reasons:.....•.......................................................................................................... -•............................•--'--------•-•--•---'-••••'--•---------•---....---------••-................. Date PermitNo......................................................... Issued........................................................ Date FEB THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... Appliratiun for Diiipas al Work.5 Tontrurtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sysiem at:/ ...................................... ••----•.....--•-•-••...._._.................. ................ -Location-Address t or Lot No. f ...................... ...............( i..........................................................t -- �� :'� (_ fi d �.Z 1 Owner Address ................... .......................................... tf ............ Installer `"x Address - U Type of Building Size Lot....°`� z:Z. :._':Sq. feet Dwelling—No. of Bedrooms......... ..............................Expansion Attic (.+'�y)`"r�'a Garbage Grinder aOther—Type of Building ............................ Vo. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures-------------------------------------•----------------------------- -•---•------.......--------•---......... � Septic Tank—Liquid apacitu-%'.'.'rgallons p Length P ._....._........ Width..._........... Diameter................. C.� dons. Design Flow..........:................................ allons per person per day. Total daily flow............... _____ - -- Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit ... Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P -----------------------------------•----•--•--•------•-----•------......--------.........-----............................................................... 0 Description of Soil....................................................................................................................................................................... x U -----•--••----------••--•-•-----•----•-----•••-....•-••--•--••.................................•-••-••••-----•••-•---•----------•••-••••------•-•-----•-•--------•-•._.......--•------••-----•---•-••--- w VNature of Repairs or Alterations—Answer when applicable............................................................................................... -•--------------------------•---------•--•-----•-••--•-•---•-•-•---...--•-•----...........-----...........------•-----------...._...----•-•-•---...----.....................-•••-••------------......... Agrejen,.int undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with t psions of'I 1 �f 5 e State Sanitary Code—The undersigned ,further agrees not to place the system in per lion .$ ' �Ce cat Compliance has been issued by the board of health. f/ J ... gned................ ................................. / f . .. ( to A pl' do Approve .J .....-- .-•--- • Date lication Disapproved ,or t f ollowing reasons---------------------•---•-----------•---...-------------------••-•-••-•--•-----......••--- ---...••----.....-- •-•••••----------------------------•-----.....-•••--•••--•-•-•--•-------...-----••-•-•-•••-•-......•----•..•-•----•---.......••--••--•-•----•----...••-••-•--•----•-•••-----••--••-•----•-•--•••......... Date PermitNo......................................................... Issued....................................................... Date e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF..................................................................................... Trrtifiratr of Tomphanrr TF 1 O CERTIFY, That the Individual Sewage Disposal System constructed ( �orepaired ( ) by.......�.-.✓ ..-•--------------------/it1ii .. •---.... -------------•--•--•------.......--•---................------.......--- at '.r .:.-• ------------- has been installed in accordance provisions of TIT LP. 5 of ate Sanitary Code as described in the application for Disposal Works Construction Permit No.__-___._, . .................. dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIJON/SATISFACTORY. f� DATE.......................< / fd ei.....-----•-------•---.......... Inspector......f--'-=-1,1411.1.............................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................................................................................... C No -•......••.....1..._ FEE........................ Muyu,srku Tontrttrtion "unlit Permission is ranted --------- ------------•-- ••. _-....................................................... to Construct ( art i.-i al wage Disposal (v at .. ................... ......... ....t ..... `'C rc......... -------• , No. •- Street as shown on the application for Disposal orks Construction Permit No..._ :,eg ........ Dated.......................................... / ................... ........ .......-•-• ........................................................... ��~~ Board of Health DATE---------•---J-`-f FORM 1255 A. M. SULKIN, INC., BOSTON 51"6LC- FAMILY - :3 BcoRootA {.10 'GARBAGE �jR.INDE2 � p/aIL,Y F�'oW = IIG�X 3 = 33oGPI? SEPTIC. TANK = 33OXr5o% : ,49�;6.P. P boa vv z U51✓ l000 o15Po5nL PI-r U5E I000 GAL. 5 1 DI=WALL A2C/a = ►5o S.F t✓Xi' l5o 5.r-. X 2.5 = 3? 5 G.?o A(;.," �oP BOTTOM A;.EA= • 10 6.F, r 0 -I OT A 1- O E S1 GN = ,4 2-5 G.P D. -QQ -ToTAL DA 1 L�,( FLOW z 330 G.PP V, 74-LiP ��Z PE2.GoLA-r1o4 RATE - 1"IN ZMIN OP-LC=55 71, H. � OF .� Mqf� +1 DAVID D!� jj (3AX!"L"F{ , ' o C. THULIN m li N4.�•.t1,3 I i= No. 29976 �n 5L•v 1 fb co �o,O 4o J%. A �F IIvIL �o _. i N� S U F:=' <<r F s16NA L EH � A Alf e;�. I ;G% �vi-q ��. SL Top FWD= LF' lZ-IL.S3 ^ ' �l l000 lN�• pIST. INd. �G4L' poy, _ .aEPTIC. ' I Doo iN� �4, TANK ' SA�J•>�f Lc EA.0 S� io acu PIT INY. INr�Y. �73•�- '' I / WASUGD 67011E 41 I CESZTII^IED PL07 PL-A.I.J 1 ; , is i` P I L1= L o C AT I o N NO SCALE 5cALC-- E 4•Z�-� v WATWZ- i �' CERT��Y TNaT 'TN��ovl�Darlo�.l SuowN PL-Ar, REFE2GNGE I KEREo►.t COMPL*(6 WITVA -THE S I PELIN I AWP SETQe.GK 26Qv12EMENT� oG -C1��- � r � � 3 L D C p. E D W I T FI I W T 14'& G l-O o D P Lb,I W R- L I� PATE -Z�-B�- Gt BAxTEQ.r- 1.1`(E INC. !i REG i�T F-26.D'I.A1.1 D s u 1?.v EYoes i "TI11S PL or C3t\5r=r-" o►d AN OSTE2VILLE 1u,5-rZUME►,11- SUQVti=Y � -TNE 01=F5E75 5uouL%D II Not DE USEDTb pETE (t!^11.1� LoT - INES APPLICA, -IT l ALAill�j LO'CAT10N 3� SEWAGE PERMIT NO. . Lot 265 James Otis Rd. 84-345 'VILLAGE Centerville INSTALLER'S NAME i ADDRESS k6berV81111 Our Co. I c. Great Western Rd. North Harwich 0 U I L 0 E R OR OWNER Alan Small �o DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r 6t-4.-�2. o<. < r1 \ 1