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HomeMy WebLinkAbout0126 JAMES OTIS ROAD - Health 126 James Otis Road Centerville,MA A= 170— 151 UPC 12534 Alp 1 ")6451 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road-Assessor's Map 1 M Parcel 151 Property Address Vito F. DiBenedetto Owner Owner's Name information is Centerville MA 02632 April 13, 2015 required for every p 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 tilling out forms A. General Information an the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Narne of Inspector key. ComTech Rapid Response Company Name 155 Geor eg�Ryder Road South Company Address Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328. 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 �- A ril 13 2015 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. *"`This report only describes conditions at the time of Inspection and under the conditions o use at that time.This inspection does not address how the system will perform in the i ture r'+ the same or different conditions of use. 15ins-3/13 Title 5 011idal Inspoctlon corm:subswtace Sawago Disposal Systom p Commonwealth of Massachusetts - �� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 126 James Otis Road-Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto Owner Owners Name information is Centerville MA 02632 April 13,2015 required for every --�._--_.--..-.-.-.—.--_— ---. p page. cityr own 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: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5,or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of systern longevity is made or implied by a passing determination. Removal of garbage grinder is recommended B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined"(Y, N, ND) for the following statements. If"not determined,"please explain, The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 151ns•3,113 11tio 5 Otticfni Inspectlon rormt Subsurtacv Sewagu❑lypo sil Sy.�tom-Pago 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ib Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road -Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto _ Owner Owner's Name _ information is required for every � Centerville MA 02632 Aril 13, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of 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 t5tna•3tt3- Titto 5 Official Inspacaon romt Sahsudaco Sawago eisposal System-Page 3 at 17 g Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 126 James Otis Road-Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto Owner Owner's Name information is Centerville MA 02632 April 13, 2015 required for every .� page. City(fown state Zip Code Date of Inspection B. Certification (cons.) 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 feel or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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 1/2 day flow 15ins•3113 Title 5 01ticlnl Inspection roan:Subsurlace&,wage Disposal System•Page 4 of t7 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road- Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto Owner Owner's Name information is Centerville MA 02632 A ril 13 2015 required for every _ P page. City(rown Stale 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. ❑ 19 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-3113 T7llo 5 Olticial In5poclion Form;Subsurtaco Sawago Disposal Syslam•Pago 5 of 17 Commonwealth of Massachusetts �r- •ya Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments h. 126 James Otis Road- Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto Owner Owner's Name information is required for every Centerville MA 02632 A ril 13, 2015 p page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3-�-— Number of bedrooms (actual): 2 - - --- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins 3l19 'title 5 Otficw InsPection roan;Subeurfaco Sowngo DlsposN System-Page 6 of 17 Commonwealth of Massachusetts .a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road -Assessor's Ma 17 p0 Parcel 151 t Proporty Address _ Vito F. DiBenedetto Owner Owner's Name M��+ information is required for©very Centerville MA 02632 _Ap nl 13, 2015 - . _ page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 299 gpd 9 ( Y 9 (gp )1� Detail: 2013: 114,000 gallons 2014: 104,000 gallons Irrigation system in use. 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-310 Tltle 5 01116 d Inspaction roan.Bubsurlaee Sawngo t)Ispoaaf Systom•page 7 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �r 126 James Otis Road-Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto __ Owner Owner's Name information is required for every Centerville MA 02632 April 13, 2015 --- page. CitylTown Stale Zip Code Date of Inspection D. System Information (coot.) Last date of occupancy/use: Date 1 Other(describe below): General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons ��� �� How was quantity pumped determined? -- Reason for pumping: --~—~- Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Tole 5 Official Inspection Form;Subsurtace Sewage Disposal System•Pape a of 17 1 Commonwealth of Massachusetts --_=_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 126 James Otis.Road - Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto Owner Owner's Name information is required for every Centerville MA 02632 _April 13, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 29 years. Original system installed 1986. Distribution box repaired in 2005. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. 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 8.5 x 5 x 6-1000 gallon Dimensions: - -- - - - Sludge depth: 4 in tSins-3113 Title 5 Olticlai Inspection Formt suosurloco Sewd90 Disposal System-Page 9 of 17 L Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road - Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto Owner Owner's Name information is Centerville MA 02632 A ril 13, 2015 required for every p� page. Cily/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? previous inspection report Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet - Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: - Scum thickness ~- - -- Distance from top of scum to top of outlet tee or baffle ------- Distance from bottom of scum to bottom of outlet tee or baffle - m - - -- Date of last pumping: Date t5ins•Wl3 lido 6 Official Inspection Form:Subsurface Sewage Disposal System•Par3e 10 of 17 s Commonwealth of Massachusetts -_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road- Assessor's Map 170 Parcel 151 Property Address Vito F. DiB.enedetto Owner Owner's Name information is Centerville MA 02632 A ril 13, 2015 required for every _ P page. City/Town State Zip Code 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 ❑ polyethylene ❑ other(explain): Dimensions: Capacity: - gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins-3.113 Tula 5 df6dal ingpoceon Forrn:Subsureco Sewage Oisl3osal System•Pago 11 of 17 Commonwealth of Massachusetts 51) y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 126 James Otis Road -Assessor's Map 170 Parcel 151 Property Address_ Vito F. DiBenedetto Owner Owner's Name _ information is Centerville MA 02632 Aril 13, 2015 required for every __ p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at 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.): Distribution box appears structurally sound with no evidence of leakage in or out. 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.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•3113 Title 5 official Inspection Form:Subsurface Sowaile Disposal System-Pago 12 of 17 Commonwealth of Massachusetts E Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road-Assessor'spMap 170 Parcel 151 _ Properly Address Vito F. DiBenedetto Owner Owner's Name information is r required for every Centerville MA 02632 April 13, 2015 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,,dimensions: ❑ overflow cesspool number: ------ — ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water, poured into the distribution box, was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down vigorously into the leach pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer ---- — — Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 157rts•3113 Title 5 011letal fnspecilon Form:Subsurface Sowago Disposal Systom•Page 13 of 17 Commonwealth of Massachusetts F < Title 5 Official Inspection Form r kxl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _ 126 James Otis Road-Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto Owner Owner's Name information is Centerville MA 02632 Aril 13, 2015 required for every p - page. City/Town Slate Zip Code Date of Inspection D. System Information (cons.) 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.): *Ins•X13 Tilla 5 01bcinl Inspoctlon Form:Suhsurfaco Sowago Disimal Syslom-Pngc 14 of 17 ' Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road- Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto Owner Owners Name information is required for every Centerville MA 02632 April 13,2015 page. CityfTown 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: Z hand-sketch in the area below ❑ drawing attached separately LEACH Piro n DISTAIBuriON BOX 2 s 1000 GALLON - SEPTIC TANK L p�0CA T§ON S 1 -OF SEPTIC COMPONENTS —DISTANCES IN DECIMAL FEET A 8 1 32 50 2 37 54 3 41 57 8 A 4 54 41 EX§S t�PNnlG DWEa LNG 0 126 NOT TO SCALE ©o _ a w ? J Cr THIS SKETCH IS a • BEST VIEWED IN ro COLOR FORMAT = Q 508 364-0894 L__ JA MES ®T§S R®A 151ns•M 3 Title 5 Official Irlspoctlon Form:3ubsurfaco Sewage Disposal Systern•Pago 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road-Assessor's Map 170 farcel 151 Property Address Vito F. DiBenedetto Owner .�.. ��"" '" "....."....�._..._. Owner's Name information is required for every Centerville MA 02632 A ril 13 2015 _..�_�__..._._. p__..„ � _ page. City/Town State Zip Code Dato of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow welts Estimated depth to high ground water: 20+ — --- foot Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1986 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: Approved design plan on file with the Board of Health shows bottom of system to be 4 feet above the bottom of a test pit in which no groundwater was observed. Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table.,_ Before filing this Inspection Report, please see Report Completeness Checklist on next page. 151ns•3/13 Tltlo 5011lclnl Inspoct➢on Conn;Sugaudaco Sewaffo Disposal 5ystom•Pape 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 126 James Otis Road-Assessor's Map 170 Parcel 151 Property Address Vito F. DiBenedetto Owner Owner's Name information is required for every Centerville MA 02632 April 13, 2015 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 GEOHYDROLOGICAL PROFILE - NOT TO SCALE z PRECAST r 'EACH PIT + " O 1C BOTTOM OF LEACHING �- PER DESIGN PLAN LEACHING IS GRO UNDWATER ND ER 0 v GROUNDWATER NO ELEVATION GROUNDWATER PER GIS MAPS ENCOUNTERED t5ins•3113 TMo 5 ORIcial tnspoaian Form:Subsurface Sewage Disposal Systom-Pago 17 of 17 TOWN OF BA�R1;v STAB LE � LOCATION 14� �� V ' 1-S SEWAGE # QOO§'SS`�r Vla±AGE C e,/N I e rV I ASSESSOR'S MAP & LOT A/10 l f/ INSTALLER'S NAME&PHONE NO.��O�� SEPTIC TANK CAPACITY K—)- QOX LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER 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 a f \ t� � ' ,, .. QA�k � � � a � s� 3� y . � -� 3 41 s� C�Se,< - 4. i � k: No.r ti 3:5 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for Migogar *pgtem Com6truction Verinit Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel z(vi n I Installer's Name ddre s,and Tel.N . c a Designer's Name,Address and Tel.No. r+r� jp�� �Ok�3c�� 8��a g Go(4n ( Uu m pvj 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) , o SOX (t pA i 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 ugtil a Certifi- cate of Compliance has been issued—by this Board of Health. A �X ���� Signed � Date Application Approved by Date Application Disapproved for the following reasons Permit No._ 5 5s Date Issued - sA •�+ram..7 �j }/(�/'� Fee f yl THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ` Yes.. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS M iv ZIppYication for Mi0po0al &p$tem Conotruction Permit Application for a Permit to Construct( . )Repair( "Upge( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. p J 8 l ii J Owner's Name,Address and Tel.No.�( Assessor's Map/Parcel �n��u s Installer's Name�, ddres ,and Tel.NoSod -�f Designer's Name,Address and Tel.No. o� a , Gckor\ `JvM i1 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 t Nature of Repairs or Alterations(Answer when applicable) ,✓_ Sox (t pA t r � k s 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 un '1 a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by !' r Date Application Disapproved for the following reasons Permit No. �'l��i �� s Date Issued" ---------------------------- --------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS -Qox Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(6/) Upgraded( ) Abandoned( )by at 01U "5AMt.S OTS ?Ct- C wTrv,I( has been constructed in accordance with the provisions f Title 5 qad the for Disposal System Construction Permit No. Qm 5 34 dated 7 ./� �- Installer --S-. (� G• (",�)ihP US Designer The issuance of this permit sha 1 not be construed as a guarantee that the systeT fu lion as designed. Date 7� Inspector_ No. r7_0p � S _—Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 33fgpogal *potem .on!5truction Permit 1-3- BOX r`pA,*r Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at !�149 SA1nnm 3 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 m st be completed within three years of the d to of this pe 't. Date:_ (� �` Approvy t - lugCOMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION - Property Address: 126 James Otis Road Centerville. MA 02632 _Y ✓ , r Owner's Name: Mary&Robert Reardon C-D s� Owner's Address: u' Date of Inspection: July 22. 2005 Name of Inspector: (Please Print) James M. Ford Ln Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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 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 Needs urther Evaluation by the Local Approving Authority Fails Inspector's Signature: jffyV& Date: August 3. 2005 The system inspector shall sub i a copy of this ins ection report to the Approving Authority(Board of Health or DEP)within 30 days of complete g 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 ****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. .A' Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 126 James Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as 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(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 126 James Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 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 5.0 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 126 James Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/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_. ✓ 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 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 System: 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"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 126 James Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 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: Yes No ✓ _ 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(3)(b)]. 5 l� Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 126 James Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or,no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: . Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holdingtank resent es or no) P (Y 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: Pumped approximately 4 weeks ago-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 3125186-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 126James Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" 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: 1000 rzal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measurinv stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (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 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 126 James Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan) 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 broken down structurally. A new D-box was installed(Permit#2005-355). PUMP CHAMBER: None (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 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 126 James Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 a� 1.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit had Y ofliquid on the bottom. The scum line was at the same level. There did not appear to be any signs of allure. The bottom to grade was 9'. CESSPOOLS: None (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: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 126Jmnes Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 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. A Q. � k - Q a 3a so yJ. 3 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 126 James Otis Road Centerville, MA Owner: Mary&Robert Reardon Date of Inspection: July 22, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- 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 property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topo-araphic and water contours maps, the maps were showing approxitnately 25'+/-to-around water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied,relating to the system, the inspection and/or this report. 11 TOWN OF BAR.NSTABLE di ` - &0 7 LOCATION �01� -,AMCS CrUr �f'. SEWAGE # VILLAGE Ce^TtrvAU- ASSESSOR'S MAP & LOT L 2 `►b INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I 0 W LEACHING FACILITY: (type) PT (9 X`� (size) /DOD NO.OF BEDROOMS 3 BUILDER OR OWNER eAr on 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 leac_ 'ng facility _ Feet Via^ � . Ford Furnished by v JA 8 k a f 3a so rise', 3 3 Y/ s� y Sy yl IeTo......g6.. �-)i�e Fxs..... ............ THE COMMONWEALTH OF MASSACHUSETTS _ BOARD O F HEALTH ................0F........ 47..._............ ------------------------------------- Appliratiun for Uiupuual Works Tuni#rnrtiun Prrutit lii�ation ishereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal t S tem : .Q!ltvP. &m.nare tea. .... ........... ...................... 1 7. ---------•-----.................. Locatio Address Lot N ........... ....... --•. .... ..... . ....................... ................. . -- •••• ............ ................................ w Address Installer Address Type of Building Size Lot._.___4 _fr ..Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic AV Garbage Grinder ( /�O pa Other—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria a' Other fixtures ._�........................... W Design Flow........ ���.............gallons per person per day. Total daily flow.......... WSeptic Tank—Liquid capacit $".gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No ..------•--_-- Width sr•_.t-___-__-- Total Length.................... Total leaching area______-.------------sq. ft. Seepage Pit No...�................ Diameter........+(_....... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ F`jj Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_--___---_______--___.-. G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---•---•-----------------------•--•--._...------•-•----•-------•-•----••-•-•-•-••-•......------...•........................................................ ODescription of Soil.............................................................................................................................................................---------- W V .-------------------•-••-•-•---......•••--------•••--•-_........._._._.........................................-••-•••---•-•-•-••----•---•------._._.----••••-•----••._..._..__..._....---•-------------- W U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. -•-•-......---•-•--••--•--••••--•............................................................•--••---•-•-•-•....--•------•------•.....--•---•-••-•--••••---•...•-•--•---•..-------------•---............ Agreement: The undersigned agrees to install the aforedescribed Individual Se ge Disposal System in accordance with the provisions of iITL L 5 of the State Sanitary Code— The undersign further agrees not to place the sy em in operation pntil a Certificate of Compliance has been ' by the r health. li✓ ��-- �av�'C • G fined-- - •-- --------- ----------- �------� .............. Application Approved By....................... . ....... .....-- .... --....... D to Application Disapproved for the f ollo ' g reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo................................................... Issued-....................................................... Date i s' No.....----•------------; +Z Fu$......--...................... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH OF.....'...:j.. z s AvOration for Diovos ai Works Tomlrnrtton ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: , ..............`»__•-•---._....._..................._........................__...._...__.._._.._ ................................................_.._-_•__.._..-_-.._._.._...__...---........._..•. f Location-Address or Lot No. Owner Address M Installer Address Type of Building �••,,. Size Lot-----------------------------Sq. feet U DwellingNo. of Bedrooms........... .............................Expansion Attic ' r.: Other—T e of Building No. of ersons________________ r Garbage Grinder (- ) — aOther—Type g p ..... Showers ( ) — Cafeteria ( ) P4Other fixtures -------------------------------------------•---------..----•••••••-----------•-------•----•-----•-•••----•-----------•-_.....--•-•----.........•--•-- W Design Flow.......... .............................gallons per person per day. Total daily flow_.__......__._._.............._.._________.gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench f No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.__....r_--___-_-__ Depth below inlet.................... Total leaching area....._............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-----------.......... ... (sI Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---•-----------------------------------------------------•----------............•--••-••-•--•---•---......................................................... 0 Description of Soil.................................................................................................................. ----------------------............................. U •••••••-•-••-----•-•...-----•------•--•-••••-------•••••-•----••--••-••-•----------•-•--•------•-•--------•-----•••-------------•-•••-----------•-•-----•----•••--•--•-......---------•---•--••---••--- W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•----------------------------------•--- ---------------------•--------------........-----------•---.....--------------------•---------------•------------------------•----......-•--•-•......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation.until a Certificate of Compliance has been issued by the•board of health.- Signed.... �^ -- .............................................................. .'.. ... • ------- Application Approved By -...Y./_4:-- 1 -----__-__- -_ e .... Application Disapproved for the f ollo i g reasons-------------------------------------------------------------------------•-••---------..._.....------•--••----- ---•.................................•---••--•--...------------------------------------.......-------•------•---•-------------------------••---•-•--•----------••----•---------•---------------••.....-- Date PermitNo......................................................... Issued_.................-- ....-----••-•--•......• Dattee ---^-- .. .,...._-- .. THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH ............... ...............OF............ ..........................._... fizler#tfirate of TontpliFanrr THIS IS TO CERTKY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ..........t ,N..p� --------------------------------------------------------------------------------------------------------- Installer at. _ ` ..._.. 1N1��- �-- ----..... .-)........... f- V._7-jE.1W. _!-1)- ---------------------------- has been installed in accordance with the provisions of TITIF 5 of The State Sanitary Code as d scribed in the application for Disposal Works Construction Permit No....... dated-.-----� . ._� .. �1_________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANT E THAT THE SYSTEM WIL FUNCTION SATISFACTORY. s--�---' DATE........ - ------•---------------•----•---•--•----•- Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No... FEE..%-=: .......... Disposal lgorkn_T11nstr inn rantit Permission is hereby granted................ ....... '----------........................................................ to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systern at No. C. ,._� .......... -------------------- �o ------ •----• -44u�n £�. r `ree Street as shown on the application for Disposal Works Construction Permit Noe6_'_.)_!.6..._ Dated..... _1. _�•_�6______________ �. -Ile. �^ .`: '��9`..`'��_c.!.ar (�... ward o ea FORM 1255 A. M, SULKIN, INC., BOSTON (,o V S 1 NC-l_E FAM 1 l..li - 3 F3C0lZv o t`'� L oT �� .No GA�ZI3AG-E G�2�NDCl�-. i OAIL-Y Fl_Ovd 110 )k 3 330 G.P tb _ SE�';'1C TA►JIC. � 33o n iSo�o ' 4�S G.P• 1�• � 1z5.'t3 uSE 1000 GAL. TAK�VV p 1 I z9'r :DiSPoSAL PST �sE C�) t000 GAL.. . v; 62`,- . . 51 DGWAt L A 2EA s I S'o l - I TO s:,F 2 ,S" ,: . . 3 75' fr P. O. a p P. b N 3 1 To TA t- OEs'&Q = 4ZS' G. �. P. 0. `T TA L 1: A IC.. FLoW = 3 3 o 6-. P. p, P TioN 2ATS : 1"IM 2 MsN .ofL LESS I �1 rdq fS , 34 t I PETER %N;. �. u o. .. SULLIVAN No. 29133 R4CHARD �� Q Sy' 131.Z 3' -' A. 00 ?� �o BARTER b f S. cISTk� `y<4 No.24048 �Fss/p EtiG� � �� . . �.o r bo 6 TEST HOI-C ZSoS BAxTbz-f rU`t'� ?nG, _TcWAJ TA COL 1 i .2.7 �,�. r• • 4. • , soy c. oa loon ( s� oisr. /.vl/ /G,4L /A4 GAIN / 1 Box Is P,7.. Tsrni ' G,2.4tt .r w -4 /' 57,.9 c,E.eriF%�o PLor ,ot:aw .* . s7-o AJ E . .•b , � � .5_•Wit; �' Sv O� 2-6-g4 PRO Fl LE --------------- 1�0 SC-ALE �� /'=CENT/,c'Y Tf•'.4TTy�' Fou�u��9Ii�RJ.}SHDW.V . ..�.C��Vi� /���I�L'9W,�� .yE,�Eav c�i►rPLY.S W�TX/7i��'.SioE,cii�� ,B.QxT�,2 ENE' I've. //p.SET1�/�C� .e641J/,eEHI�iVTS'd� Th' .C�.EGisr�.ecD.tarvo.Stiey �S Tox.c!of Bf�2�U ST}�3L.L AV47 1.S me/ ,7- G S*7252Y/LGc �• ,tl,�.� - �Zw�'�$� T.f/lt,at„Q.v /s �YoT r3,4s�o a�v.4�v/ysrx- d�JE�YT.Sv,2�/EY.4�t/O T.S/E a�F,S•� // �n �cr a LOCATION l��E r SEWAGE PERMIT NO. J D -cam/ L VILLAGE V Mc I-D-G INSTALLER'S NAME&ADDRESS c a BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ga el( a# JIAS o 36 L 6 C A 10 iN STWA G E PERMIT HO. ."17 07 7:� VILLAC 'u ��- INST A LLFR'S Ps A M r, 8, ADDRESS el- a ull. O�Eg on 0 rim vt —_Zl iqA 5 DATE F PERMIT ISSUED �.��"� e_—__..o ._ _ BAT I C 0 M, PLIANCE I S S 1) 1 D i m a,. r •