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Home My WebLink About0043 JAMES OTIS ROAD - Health 43 James Otis Road Centerville A= 171 — 165 Ju!' rx NN UPC 12534 ' Ito.2 1� 5�� i e N * JOWN OF BARNSTABLE , , LOCATION 142ta, SEWAGE # ' VILLAGE �' ASSESS R'S MAP & LOT r SPc 7r?R'S NAME&PHONE N _ 7/ �� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 3 BUILDER OR OWNER p.P/�l/hti p�/Yat.�M PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on 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 G e GZA 2 i � t ? If,11 TOWN OF BARNSTABLE / LOCATION q 3 zf $ /� SEWAGE # VILLAGE �� - /'I ��/� �i ASSESSOR'S MAP & LOT)71--/65' INSTALLER'S NAME&PHONE NO. /� f SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: OMPLIANCE DATE: `A'��' 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 g 3 13 -'3 -�� 35 L10 CA T 10 SEWAGE PERMIT NO. 47? /? r.3 VILLAGE INS A LLER'S NAME L ADDRESS D d U li D E R OR OWN ER DATE PERMIT - ISSUED DAT E COMPLIANCE ISSUED r _ ! g_ r - ,.", .J8�- � �` ,-� 3 yr 3y' � ,3 S �' 3 d 2 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �/� 43 James Otis Road u— Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 1 required for 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 forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Q Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett HIC1(e Digitally signed by Bran Hickey y Date:2021.02.2412:14a9-05.00• 2-22-2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts r- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v� 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: ■❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. 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 .doc•rev.7/26/2018 Title 5 official Inspection Form: p p Subsurface Sewage Disposal System Page 2 of 18 Po Y • 9 r t , Commonwealth of Massachusetts -- --_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t �Y 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every St page. City/Town ate Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 18 Po Y • 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ I] Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ Q The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town Satet Zip Cade Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No 0 ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows � � y a in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? 0 . ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ 0 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: El ❑ Existing information. For example,a plan at the Board of Health. ❑ O Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 r Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 425/GPD Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2020- 58,000gallons 2019-40,000gallons Sump pump? ❑ Yes ❑Q No current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts p TitleSewage 5Official Inspection Form Subsurface Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 10-22-2018 Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 1984 per plans Were sewage odors detected when arriving at the site? ❑ Yes F01 No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town Satet Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 7" Sludge depth: 2911 Distance from top of sludge to bottom of outlet tee or baffle 1" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1611 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �~ . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 1 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is required for every Centerville Ma 02632 2-22-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form rjo} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): 0" 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 i Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ir 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: (1) 6'x6' pit El leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts - -p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7' 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): The SAS was in working order at the time of inspection. Pit was 1/2 full when viewed. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t l` 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp.doc•rev.7/26/2018 Me 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately Drivewa y i Deck 0 471" -�` A2.50' 55, W-28' B3.35' O 3 . t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑� Surface water ❑■ Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 13'feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record 12-17-1984 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: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 James Otis Road Property Address Donald Capobianco Owner Owner's Name information is Centerville Ma 02632 2-22-21 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ■❑ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed&Dated and 1,2, 3, or 4 checked ❑■ C. Inspection Summary: P rY 1, 2, 3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed OR D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION � " C SEWAGE # 9(p 56, VILLAGE ASSESS R'S MAP& LOT NAME&PHONE N �,g SEPTIC TANK CAPACITY e' . LEACHING FACILITY: (type) (size) !!I NO.OF BEDROOMS BUILDER OR OWNER r j PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leac hing Facili ty (If any wells exist j 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 1(? a✓irb4 2V. 1910 -\ Comm'bNWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS > DEPA�3TMENT OF ENVIRONMENTAL PROTECTION k .e 1 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ` CERTIFICATION Property Address: Owner's Name: ' - - � /y x, Owner's Address: _. ale Date of Inspection: _ f Name of Inspect (please print) ;� c ( /�1�►`� Company Name L� > " Mailing Address: Telephone Number: 7-7/• CERTIFICATION STATEMENT I certify that I have personally inspected the sewage,disposal system at this address and that the information reported below is true, accurate and complete as;of the time of the inspection. The inspection was performed based on my training and experience in the proper f:nction.and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:- /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ils ` Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the 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 ,v. ****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. i Title 5 Inspection Form 6/15/2000 page 1 r r Page 2 of 11 is 31 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued), Property Address: Ov lw-,2 c. 06 r v _ Owner: Date of Inspection 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.'0) or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Svstem 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: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(§)or due to a broken,settled or uneven distribution box. System will pass.inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system.required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is.removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION;FORM PART A CERTIFICATION(continued) Property Address: Q' T �j Owner Date of Inspection: 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 aimanner 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 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 nitr4en and nitrate nitrogen is equal to or less than 5 ppm,:provided that no other, failure criteria are triggered. A!r.opy of the analysis must be attached to this form. , 3. Other: :p i 3 _ r ' Page 4 of I I OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property-Ad dress: 18 "9-,7QZ6 Owner: Date of Inspection: �d D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N°/ _ y Backup of sewage into faciLty 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 dis.ribution box above outlet invert due to an.overloadedor clogged SAS or cesspool Liquid depth in.cesspool is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped V 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. I , _ U Any portion of a cesspool or privy is within a Zone 1 of a.public well. _ Any portion of.a cesspool o.privy is within 50 feet of a.private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater, than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes:if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well;is free from pollution from that facility and the.presence.of ammonia nitrogen.and nitrate nitrogen is equal to or less than 5 ppra, provided that no other failure criteria are triggered. A.copy of fbe.analysis.must be attached to t7is form.] (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,the the system fails. The system.owner should contact the Board of Health to determine what gill be necessary to correct the.failt'.e. E. Large Systems: To be considered a large system the s:vstem must serve a facility with a, design flow of 10,000 gpd to 15,000 gpd• You must indicate either"ves"or"no"to each of the following: (The following criteria apply to large systerris.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 nitrzgen 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. .4 ti Page 5 of 11 JI +. 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEVi AGE DISPOSAL SYSTEM INSPECTION:FORM PART B CHECKLIST Property Address: Qtt�b` Grp: � q Owner. .OUy Date of Inspection: ` 97 Check if the following have been done. You must indicate`yes" or"no".as to each of the following: Yes o } Pumping.information was provided by the owner, occupant, o_Board of Health Were any of the system components pumped out in the previous two weeks fl� 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 V _ Was the site inspected for signs of breakout? I� Were all system components,excluding the SAS, located on site L _ Were the septic tank manhcles uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of const'iuction, dimensions, depth of liquid,depth_of sludge and depth of scum? Was the facility owner(anq occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disziosal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no "I-," information. For example,a plan at the.Board of Health. V _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)('b)] + 1 5 i la I J Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION Property Address: Owner:G>C�' Date of Inspection: J 7'� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(.design):� Number of bedrooms (actual)'D DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x 4 of bedrooms):c� Number of current residents: c;� Does residence have,a garbage grinder(yes or no): Is laundry on a separate sewage system kye or no): if yes separate inspection required] Laundry system inspected(rye�.or no): Seasonal use: (yes or no):L0 Water meter readings, if a,v, fable(last 2 years usage (gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL/t/O -, Type of establishment: Design flow(based on 310 CMR 15.203): C,pd Basis of design flow(seats/persons/sgfr,etc* Grease trap present(yes or no):._ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Tile 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records. . Source of information: Was system pumped as part of the i-spection(yes or no): C} x. If yes, volume pumped: gallons--How was quantity pumped dete�7nined? Reason for pumping: TY E OF SYSTEM eptic 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): is Appr Nirpate age o all c. onen s, date installed(if known)and source(5f information61 Were sewage odors detected when arriv-ng at the site(yes or ri ) 6 Paee 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE_DISPOSAL SYSTEM INSPECTION FORM PART C SYcTEM:INFORMATION(continued) Property Address: Owner: �, t Date of Inspection: BUILDING SEWER(locate on site plan)V Depth below grade: Materials of construction:_cast iron''_40 PVC other(explain): Distance from private water supply welJ,1�or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC' ANK. (locate on site pl In) \J� Depth below grade: /aQ, Material of construction:,. concrete_'_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ _Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of certificate) � � � Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: �j r J� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to b9i[o 'of outlet tie or baf e: L How were dimensions determine Comments (on pumping recommLdLkoit, inlet and outlet tee or baffle condition, structural integrity, liquid levels s related to outlet invert, ev• rice of leakage, Gi AW _ �fe GREASE TRAP:. locate on site plan) Depth below grade:_ Material of construction:_concrete+metal_fiberglass_polyethylene_other (explain): ? Dimensions: Scum thickness: Distance from top of scum to top of outitt tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendati,dps, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 o Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEN;1 INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propert Address ' Owner. �C Date of Inspection 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: gallor_s/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(c ondition alarm and float switches etc.): ion of I' DISTRIBUTION BOX: 1,/ (if present must be opened)(locate on site.Jplan) Depth.of liquid level above outlet invert l Comments(note if box is level and.distribution to outl�qual, any evidence of solids carryover, any evidence of akage into or out of box. e a 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.): 8 1. Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE�YAGE DISPOSAL SYSTEM INSPECTION FORM PART C S'�PSTEM INFORMATION(continued) `1 Property Address: _ r Owner: Date of Inspectio 7 Z S SOIL ABSORPTI SYSTEM (SAS): i/(locate on site plan,excavation not required). If SAS not located explain why: Type e leaching pits,number: 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, et ),: e. CESSPOOLS:(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1. Depth—top of liquid to inlet invert: "; Depth of solids layer: Depth of scum layer: Dimensions of cesspool:.. r— Materials of construction: Indication of.groundwater inflow(yes pr no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY:A16 (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, sign)$of hydraulic failure, level of ponding, condition of vegetation, etc.): �(�� C<� G C✓ L/i lk C'¢ /� ..I /A y CLOWA ? 9 :l: Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VG,LUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pro pert 'Ad pdress: ,-, Owner: Date of Inspection SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least':wo permanent.reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water;,supply enters the building. t t / o g F 10 :e a t Z Page 1 I of 1 I k OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � y Owner: P Date of Inspection: s SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water /7 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting prop erty,,'observation.hole within 150 feet of SAS) Checked with local Board of Hea th-explain: Checked with.local excavators, iistallers-(attach documentation) Accessed USGS database-explain : You must describe how you establishe j the high ground water elevation: .yi f,. �Y I I„ 1� I i !P .9 11 l 4 Permit Number: Date: Completed by: HIGH ti ROUND-WATER LEVEL COMPU-ATION Site Location: - �L Owner: . Address: Contractor. !J/ (� c Address: G ✓� C.�.y. Gay Notes: STEP 1 Measure depth to waxes table to nearest 1/10 ft. ... . _...._..... ........................................................... .Dat' month/day/year STEP 2 Using Water-Level -Ra Zone `ga and Index Well Map IDc_te site and determine: - -' n A ro- :o P u'.r L Inde)_.rL'eII.................... �� a O Water-level range =cane` ...... L--� w,,•; STEP 3 Using monthly report 'Current _ Water Resources..Cond=ions' l determine curre.nt.dept€t to I = - -water level for index ;%_I ................. 07k5, �7 . monthyyear fDr index well (S TEP��,y.�„ s�current depth to water level for index.wAh1 (STE0 3), and.waterlevel zone (�I—w 2a STEP 4 Using Table of Water- ere Adjustmen-s ; - _ il� determine water-level a._ju tment .............................. �/P -'- ............_........................ L `M. - - .... r).'e e- STEP o. Estimate dep th to high water y subtracting the water- level adjustment (STEP `I = from ed depth measured th [o vralter level at site (STEP 1) ........................ a r -.:.Yet: <: Ficura 13.--Reproducible corputation form. - `a .2.r..a.F .. 15 ,s � S1 zJ r Fri ............. 1 i i No. Fee THE COMMON EALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pphration for Mie;pogal *pgtetn Construction Permit Application is hereby made for a Permit to Construct( )or Repair( v<an On-site Sewage Disposal System at: Location Address or Lot No. Ow er' N Address and Tel.No. 43 STgme_s 0/_/6.^ol //� a/, Ge'v yne-PIA N3 James Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. d�Af I'll �.¢ Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(/�O Other Type of Building �Qe6�/�GrlGr� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /f D gallons per day. Calculated daily flow 3 3e9 gallons. Plan Date I Z —!7-- g'/ Number of sheets ! Revision Date Title Description of Soil r$ ze Nature of Repairs or Alterations( nswer when a plicable) T 1 y'`e zg-- eX l�l7v/O�1 1C✓O�Zj 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 th Environmental C de and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B d o Health. Signed Date 9�m Application Approved Application Disapproved for the following reasons Permit No. Z 1 �i Date Issued .12 No. Fee THE COMMO WEALTH OF MASSACHUSETTS 1 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS [ication for igpo�a[ *raem Construction Vermit Application is hereby made for a Permit to Construct( )or Repair( V<an On-site Sewage Disposal System at: Location Address or Lot No. O er' N e,Address and Tel.No. y3 Tqm es o ti 5 ro - /� Gey�✓'vi//e ��3✓yes �tls Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. der '4 GOZ11' 7; 4 vajee y ,qAr.5I-av Sri//s asfe1'v,,Ile- Type of Building: _ f Dwelling No.of Bedrooms 3 Garbage Grinder(�O Other Type of Building /IeSe No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1112 gallons per day: Calculated daily flow 334,2 gallons. Plan Date /Z —/ 7 Number of sheets / Revision Date Title Description of Soil $e tJ/'91n F Nature of Repairs or Alterations(4 nswer when applicable) 0),/ Mel 5 lie joze'l .. 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 th_q Environmental C de and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B 2A o Health. Signed Date ��o Application Approveds { Application Disapproved for the following reasons Permit No. f i' A!f Date Issued " Ir THE COMMONWEALTH OF MASSACHUSETTS 7�`/� � PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that theQ�n-site Sewage Disposal System installed( )or repaired/replaced(✓)on by 40Y&elell eee-f ' for d/i/ tas Y3 i!T S 4t1S / has been constructed in accordance/ with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Z 2�- X, Use of this system is conditioned on compliance with the provisions set forth below: 6'` No. / ^e ! / C/� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS P Miga5al *pgtem Construction Permit Permission is hereby granted to to construct( )repair an On-site Sewage System located at �1 J7 7&Ay"s 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. All construction must be completed within two years of the date below. , Date: Approved i DES/G/t/ OA 7",4 S/N6L E AA- A(IL Y 3 BE0�2oOM �Gq Zq /t/O G��BAGE 6�/NOES G.PO. 670 00 O/Sf•�2S,DL �/T�--USE /040 6'.�1L_ • Ate` ,S/OEIs/.�LG A2,—.4 = /�O S.F �� rPrr TOTAL, 1J.4/LYFLaYt/= 3-3DG•�o — F,v�• RD 57. OE.S/G•t/ EE,2cOL4T/at/.2�JTE•" /"/•(/2•N/�t/. I�LE� r ' TE✓"l i/G�..� t Sao a BDX /,v✓.F L---A-At -/,r 2 cs�L. /a'i/ ��G .SE,�nC S4 � '• ' SAuo� W-/ i I r✓,�ryEv S4'Z. .�TbNE 7-B Zo7 �G i GEeriFy Tf/.4r'T//� �v:i��,a rr,.�J,syo►.+/.t/ Lc � �� i ,�sEt�Eo� G-GL+lPLY.s k//171/ 'IWE- /�vC -:,�v,SETl�,aG,� ,2E4v/,eEMENr.S of Ti5'� ,eE6isrF,P�=O�.�✓o.SIi,L��ydP.S a��rf1J y✓/Ti5//iS/ THE .cL Go0�11!/if/. f /.f �V�T I�AjEp��v AN/r>:S1.?Z- ,CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) T �� Lo i hereby certify that the application for disposal works construction permit signed by me dated 2-/'7�4'/f-� , concerning the property located at I meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: Z /Z7/Jc — 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]. ,� ��. s� �:� �Y.r '_«tss-;.�•� 5;z;7'+�' �_";4'3r.j S''.�4 a�xi,."J �-'r��c,'r � •,�T, :•t ,-.�r ;'�.:`-e,.�Z 1_. X at�.3 .#�" ' .s r r _ c`:,