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HomeMy WebLinkAbout0204 JAMES OTIS ROAD - Health 204 James Otis Road, Centerville ,A t i UPC 12534 ' No.2_ 1�LQ�R Ate,,, MA#TIROS On a .y G No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplitation for Disposal 6pstrm Construction permit Application for a Permit to Construct( ) Repair([/jUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or�Lot ,No. ,20y Qvrtic6 J)ti 5 � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel - 170 .211 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �..A 3(o oc j LNc Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 'r C516(a' ii G No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) .3 gpd Design flow provided 3 q gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank C'M b}1 N Type of S.A.S. 10 C�+►m_6#i toi y S-fon,°e. Description of Soil Nature of Repya_irs or Alterations(Answer when applicable) ..1-nZjr.�j �� y c� rf c"c) 2 5W CAC ! A-16 OqUA Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. SianDate Application Approved by Date (a Application Disapproved by Date for the following reasons Permit No. O Date Issued s No. a Fee _ I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUB IC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS . Z[Oplication for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2061 30meb 0t1,) Owner's Name,Address,and Tel.No. Assessor's Map/Parce� 190 a 11 Installer's Name,Address,and Tel.No. Designer's Name!Address,and Tel.No. 9DS-14CQ-W S7y a61� dog, Type of Building: ' ,Dwelling No of Bedrooms \ Lot Size sq.ft. Garbage Grinder( ) Other Type•of Building F'S1(�AV�t G No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow(min.required) Ij('7 gpd Design flow provided 3 N c( gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank "16t,N!S Type of S.A.S. 2 500 4J) 0-10 (6,I)m ad V 5 iG,,J .. Description of Soil Mature of Repairs or Alterations(Answer when applicable) Tic (j �� �' r7 X ���[� 4 50D C.�Ct�) 0'16 y1UVk,�1r(S CAS 'C9�CmN C-)N �DI[Ant Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in,• accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of j r . Compliance has been issued by this Board of Health. • 1 S d Date � Ally Application Approved by Date to / ` Application Disapproved by U Date for the following reasons Permit No. 20 Date Issued - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( 1/ill,' Upgraded( ) Abandoned( )by :DA tow r- j NC • at 16 4 :1 CCL"—r+!$ has been constructed in accordance h with the provisions of Title 5 and the for Disposal System Construction Permit No. -2 t) dated Installer Designer jELW 41,501u #bedrooms �, " Approved design flow A? gpd The issuance of this pe it,hall not be construed as a guarantee that the system w• func n as das ise gn Date (� (, ' Inspector h� Fee THE No. © b { �� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -MispoSal OpBteupConstruction Permit. Permission is hereby granted to Construct( ,) _-••Repair,( ) _ I" "S . U/�rade - Abandon( ystemlocate M' p dat ) f/ K ) - and as described in the above Application for.Disposal System Construction Kermit. The applicant recognized his/her duty to comply with „Title5 and the following local provisions or,special conditions. Provided:Construction rpp t be completed within three years of the date of this permit. Date s►'1,.,�x� APProved by . , r� 3 i xa,`s� ... v.r .d+S:_^'NF.a 4-Yv.�,.a. bka......... r � ,.., r•.7x .atb .'M.+*AW':rF.k,x`r✓�i: -„ .. 1 Town of Barnstable �FTME l0 Regulatory Services Richard V. Scali, Interim Director + BA STABLE, y MASS'16.39. A Public Health Division �FDt"a't'' Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: /% Sewage Permit-4 d Assessor's Map\.Parcel 17 -;U Designer: �nc� i rleer,n� ln�ya l-1,tS n C , Installer: Address: IZ W, C�s�+ .e (� 1`�1 Address: ,( C�22GL/�, On ((;t �rT was issued a permit to install a (date) (installer) septic system at Z_Li a {-�S � C %j% based on a design drawn by K e r %, iM c-E-+-ce -?L (a dre7—ess') Evt�i(lei c "nCr Wr-rbu /4 C , dated (designer) t 1 certifythat the septic stem referenced above w c, p y as installed substantially accordm� to the design; which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system. referenced above was installed with major changes (i.e. Greater than 10' lateral. relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were.found satisfactory. I certify that the system referenced above was constructe nce with the terms of the RA approval letters (if applicable) z%OF �- PETER T � MENTEE N CrWli nsta let's Signature) NO.3gtoo ISTE (Designer's Signature) (Affix Designer tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISIOI\. THANK YOU. QAScptic\Designer Certification Fonn Rev 8-14-13.tioc Commonwealth of Massachusetts - : TIT 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M 204 James Otis rd Property Address € Justin Murphy f Owner Owner's Name information is - required for every _Centerville ✓_ _ _Ma_ -- 02632 4/14/17 page. City/Town State ,Zip Code Date of InspeZiflon i°w.'1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A General Information on the computer, 7 use only the tab 1. Inspector.- key to move your cursor-do not Michael DiBuono use the return --- — __..----- --... --- --- — - ----- ------------ key. Name of Inspector DiBuono Sewer and Drain rea Company Name 8 Johns path Company Address erum S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/16/17 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 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 James Otis rd Property Address ' Justin Murphy__ Owner Owner's Name information is required for every Centerville_ _ ' _ Ma _ 02632 4/14/17 page. Cityl.Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E /always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1,000 Gallon septic tank as well as a Distribution box and a 6x10 leach pit. Leach pit has very little liquid in it and is leaching well B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,-not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 James Otis rd Property Address --------- -- -------- Justin Murphy Owner Owner's Name ------ ------ ----- ---. information is required for every _Centerville _ Ma 02632 _ 4114117 page. CitylTown 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 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 - Commonwealth of Massachusetts w F Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 James Otis rd Property Address Justin Murphy Owner Owner's Name information is Centerville Ma 02632__ _ 4/14/17 ' _required for every --------. -------------------------------...------------- --- ------. _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ---- - -- 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet'of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of (Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �a 204 James Otis rd Property Address Owner Owner's Name information is Ma 02632 4/14/.17 required for every Centerville _ — _ _ __ — page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface'water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a7-one 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence :of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. ° Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ ..the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to'any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under-Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts This 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments IAI 9 204 James Otis rd Property Address Justin MuTh_yOwner _ -- Owner's Name information is Centerville Ma 02632 4/14/17 required for every _ 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 r available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? . ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information ----- ----- - - Residential Flow Conditions: Number of bedrooms (design): 3-- Number of bedrooms,(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: .1.10 gpd x#of bedrooms): 330 Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ,, Commonwealth of Massachusetts TRIe 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 James Otis rd Property Address ------------------- ----- Justin Murp>�_ Owner Owner's Name information is required for every Centerville Ma 02632 4/14/17 --------- ------ ------=-- ----- ----- - -- - ._ ------ --- ------ --- —.— page. City/Town State Zip Code Date of Inspection D. Systems Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system"inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ear 259 GPD s usage d 9 ( Y 9 (g ) Detail: w Sump pump? ❑ Yes ® No Last date of occupancy: date Commercial/Industrial Flow Conditions: Type of Establishment: --- - -- - -------- Design flow (based on 310 CMR 15.203): Gallons per per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): ------------- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? k _ _ El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: -=- — l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ".°°Y 204'James Otis rd --- - .._._.._.. .... --...._..----------- -- -------- -----—------ ------------------ --------- Property Address Justin Murphy Owner - --.--- - - - -------- --- Owner's Name information i e _Centerville Ma 02632 4/14/417 required for every — _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date — Other(describe below): _ General Information Pumping Records: Pumped in 2014 Source of information: Pump —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 Y maintenance contract(to be obtained from system owner) and a copy of latest inspection of the l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 James Otis rd Property Address Justin Murphy Owner —--------------- ------------ Owner's Name information is Centerville _ Ma 02632 _ _4/14/17 required for every _ __ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ----. — — Approximate age of all components, date installed (if known) and source of information: 1989 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer (locate on site plan): Depth below grade: 1.5 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.): System_is vented at the roof Septic Tank (locate on site plan): Depth below grade: 1feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 If tank is metal, list age: — years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ Nq'' Dimensions: Sludge depth: 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 _Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -- Y a 204 James Otis rd Property Address --- Justin Murphy -- Owner Owner's Name -------—---- ---- -- —---------——------- - -- -- information is required for every Centerville -__ _ _Ma 02632 4/14/17 p6ge. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle -24"------ --- --- " Scum thickness 3_ _ - _ Distance from top of scum to top of outlet tee or baffle 42" 4. Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick How were dimensions determined? Tape Measure Comments (or pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, 'liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: --- --- - --- --- -------- feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: -------- Scum thickness Distance from top of scum to top of outlet tee or baffle ------- Distance from bottom of scum to bottom of outlet tee or baffle --- ---------- Date of last pumping: ----- -------- - --- ------ Date 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Fr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 204 James Otis rd Property Address Justin Owner -------------------- Owner's Name information is Centerville Ma 02632 4/14/1.7 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structura,l integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: --- -- --------- ----- Capacity: gallons .— —'------------- .Design Flow: gallons per day ----- --- Alarm present: ❑ Yes ❑ No Alarm level: ------- -- Alarm in working.order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): _.:..- ------- ---- - - ----------------- - - ----------- ---- ---- --------- --------- *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments LIM, 204 James Otis r d I Property Address Justin Murphy _ Owner ------- ----- ------- , Owner's Name - —-- --- ---- ---.----- reoation is uired for every Centerville _ _ Ma _ 02632 4/14/17_requir _ _ page. City/Town 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 Level and at normal level 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.): Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* a 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: ------------- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 James Otis rd Property Address Justin Murphy Owner - ------------------- --- ---- --- ----. Owner's Name - - -- information is required-for every Centerville --- Ma__ 02632_ 4/14/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: -- ❑ leaching trenches number, length.- El 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 indications of failure 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 ------ ---- t Materials of construction --------------- -- Indication of groundwater inflow ❑ .Yes ❑ No 15ins•3113 - Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form — — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 204 James Oti_s_rd Property Address Justin Murphy - _k _ Wner Owner's Name information is required for every Centerville Ma 02632 4/14/1'7 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) --- — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: -- --------- ----- Dimensions - - ------._.. - --- -- Depth of solids --- -- -------------- -- ------------- -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I . Commonwealth of Massachusetts _ Title' 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 04 James Otis rd Property Address — Justin Murphy Owner — -- -- Owner's Name information is required for every Centerville _ Ma_ 02632 4/14/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) — -- — Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Forra:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts -- - _ Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i; 2N James Otis rd I r Property Address Justin-Murphy— OwnerOwner's-—. ._.. - ._ _..- - - - - - -. _ -- ----- - -- -- --- --- ------------Name information is C re airs Centerville d for every M _ _ __q ery a 02632 4/14%17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar El Shallow wells Estimated.depth to high ground water: 15+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate -- ------- -- ❑ 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: Local USGS maps =-------------- -------- - -------- ---------- -- ---- ...-----—...-- .:.- --------------------------------- -- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17 f assessing As-Built Cards Page 1 of 2 WN OF BARNSTABLE LOCATION467"fr -TAMGS O ( r S. SEWAGE -'70 3 i VILLAGE (flen/rPac v< ASSESSOR'S MAP Q LOT 0.INSTALLER'S'NAME& PHONE NO._,-/? 0(/x C5 SEPTIC TANK CAPACITY_/&U-0 !�O ;q LEACHING FACLLrrY:(tyFe) (GIze) $NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 41,4 t y/ I .DATE PERMIT ISSUED: i i DATE COI<1PLIANCE ISSUED: � VARIANCE GRANTED: Yes No e • r i http://wvvw.towiiofbarnstable.us/Assessiiig/HM(lisplay.asp?lnappar=l 70211&seq=l 4/12/2017 ? Commonwealth of Massachusetts a Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0�. 204 James Otis rd Property Address Justin Murphy Owner Owner's Name information is . required for every Centerville _ _ _ _Ma 02632 _ 4/14/17 page. City/Town State Zip Code Date of Inspection C. 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 } Cornmon earth of Massachusetts r — pectio a� Subsurface Sewage Disposal System Farm-Not for Voluntary.Assessments k1 204 James Otis Road _ _ ....... -- Property Address __... Frank Norton owner Owner's.Name inforrnation.is . required for every Centerville iliia 02632" 7/112013 —_ — City/Town - _... page.: _ State : :_ Zip Code Date of inspection,.:-' inspection resu Its:rndst be subrnitted on this foirtt�. inspection fora gray not,be':altered in any sy.Please see completeness obecklist at.tht end of the fora. Important:When A. General:Infor atio filling out forms on the computer, use only the tab 1 Inspector: :: _. "key to move,your cursor-do not Sean M Jones use the return _.. _ - Naine,of Inspector key. _ _gapewlde Enter rises p_W. r`t3 Company Name 153:Commercial St. . - Niashpee _ MaI. 42649 _ _. ..._... ....... _ . . Ciky/Town State Zip Code 508.477 8877 SI 4522 Telephone Number ---License,Nurnber —.. Ceffification I certify that I have personally:inspected the;;sewage disposal system at this adtlress and thattne iriformaton,reported tebw is true;accurate and complete as"of the#ime of the inspec#ion. The inspection was performedbased on my"tcaining and experience in the proper function and maintenance of on site sewage disposal systems. I ai>� a DEP apxroV dzystern.inspectorpursuanttp: eetion 1:5>340 of Titie,6.310 r FZ'1 Q00).The system: Q Passes` ❑ Conditi+anally Passes ❑ Falls ❑ Needs Further Evaluation bp.the Local Approving:Authority �aa Ins p ctors Signature 'Date -— — - Th "system'Inspector st'ajl submit a copy of this inspection report to the Approving Authority(Board of ealth ord.EP)within 3Q days of completing this inspection. If the system is a shared system or IL_ r g C� �� h a?desi n flow of 10,000 gpd or greater, the inspector and the system owner shall submit.,the rje wiry to the appropriate regional'office of the DEP. The original should be sent to the;system owner r, a opies.sent to the,buyer, if applicable, and the approving authc rlty. O — 4 ** *•This repgrt:only describes conditlons:at the time of inspection and carder the conditions of use at t at"time, 'ThisAnspectiolt does not address how the system will perform in the facture under the zar e.,pr different,cpnditions:of:use. 15ins 3f13 15,oftin coon Form Subsurface,Sewagp Dispns2[System^Paae,1 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 James Otis Road M Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 204 James Otis Rd Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a precast leach pit. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 James Otis Road Property Address Frank Norton - Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is,within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part,C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth & Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 James Otis Road M Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2011= 143,000 total = 392 gpd 2012= 183,000 total = 501 gpd * includes irrigation system Sump pump? ❑ Yes ® No Last date of occupancy: vacantDate 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 204 James Otis Road M Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original system installed 8/24/1989 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons 6" Sludge depth: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. Cityrrown 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 3" Scum thickness 3 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? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is Centerville Ma 02632 7/1/2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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 was in good condition, no rot, water level was even with outlet invert. 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: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 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.): Leach pit had 1' of standing water with a stain line 1' higher. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 l Commonwealth of` assacsetts 4 m ...� _ _. Subsurface Sewage Disposal S.yttem Form -Not for'Voluntary Assessments' 204 James Otis Road �L f ..............................................._. ....... . _ ....... __ ..w ...... Property Address _ _____ _. Frank Norton; Owner Owner's Name information is Centerville Me 02632 70/2013 required for every _ _.-- — ___. —__ W - page:. CitinoWn State. Zip Gode' Date of.lnspectlon D.System I for ati (cunt.} Sketch Of Sewage Disposal System Prautde a view of the se age:tlisposa(system, incltaing ties to at least two permanent reference;landmarks or,b' hniarks.'Locate all.weils:within 1.W feet. Loeate where public water supply enters th6.building.Check,one of the boxes below:- ® hand-sketch in the area below ❑ drawing attached separately .. I 4 I:. ... 3 lj IY 4.1 fir. 121,, : 5 ; i {{pp [:6,f l ,m 15ins•'3i13. Tiite 5;Q ficial Inspect an Form 5ubsur ace Sewage;p sposal,Sysferl•Pag0,15 of 1T :: Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 204 James Otis Road Property Address Frank Norton Owner Owner's Name information is required for every Centerville Ma 02632 7/1/2013 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ` - YFA* DATE : PROPERTY ADDRESS : Carl'"Bbnson 204 'James Otis Road Centerville,Mass . 02632 , On the above date, I Inspected the s-eptic system at the -above addre86. This system conslsts of the following: 1 . 171000 gallon septic tank. 2 . 1 -Distribution box. 3 . 1 -1000 gallon precast leaching pit. Based on my Intkc,actlon, I certify the following conditions: 4 . This is a title , iv septic sd•ystem.' ( 78 Code ) 5 . The septic sy t ;.; is in proper working order at the present t:ilne. • SIGNATUR!' : i Name : J , P , Macomber Jr... Company:_J , P_ - Macoalber Son- 'Inc .. Addre8a :_g _66------�--- --- __Centervi1Le ,_Mass__02632 , Phone : 5 R � -5--.3.338_____-- - 1 THIS CERTIFICATION DOES NOT CONSTfTUTE A GUARANTY OR WARRANTY a �OSEPH P, MAC-OMBER & SON, INC. - TankrC�upoolrL�achfleldi . Pump+d L InsUllyd Town Sower Connections P.O. Box 66 ' Centerville, MA 02632.0066 775-3338 775-6a12 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I DEPARTMENT O T F ENVIRONMENTAL PROTECTION> ONE WINTER STREET. BOSTON, :'�tA 02108 617.29' S50 �1 12 u ILLlAN1 F N ELD Go cmor _*Pea el � ARGEO PALL CELLI'CCI 14& Lt Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE N F � PAT A CERTIFRCATION � ryo����.1,9`9� w Property Address: 204 James Otis Road Centervillitfress of Owner:` ' Date of Inspection: 11 /3/9 7 Mass , (If dif-ferent) �e 5 Name of Inspector: Joseph P_Maeomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & SON INC. Mailing Address: Rnx Fti CPntPrvi 11 e.,Mass n2632 Telephone Number: d08—H d 333A CERTIFICATION STATEMENT I cen,ly that I have personally inspeded the sewage disposal system at this address and that the informat.on reponee czlo_ i; U_e ac<_ and complete as of the time of inspection. The inspection was performed based on my training and experience in the prD;,er i';nc On a maintenance of on-site sewage disposal systems. The system: -/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails a /J 7 Inspector's Signature: Date: /)—/- The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing In, �nspect'on If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system ci ref sr•.a,. S_c the report to the appropriate regional office of the Depanment of Environmental Protection The original shoulc ce sen: :o :re s e^. o, and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as dei,ned :n 3'0 C,,- Any failure criteria not evaluated are indicated below. COMMENTS: e) SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass" section need to be replaced or repairer >— completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes. �o, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined-, exp:a:n -c The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cen: :a,e Compliance (attached) indicating that the tank was installed within rwenry (20) years prior to the date of t:-.e its,.r.Cior the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial in(ilitatton or ext;t failure is imminent. The system will pass inspection if the existing septic tank is replaced with a confo,rm.ng as approved by the Board of Health. rr.vi..d 04/19/971 Y.9. 1 of 10 DEP on the Wono Woe WeD. hnp rrwww magnet state ma vvoeo Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propeny Address: 204 James Otis Road Centerville,Mass . owner: Carl Benson 031e of Inspection: 1 1 /3/97 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is Oue to Oro,e" Or OC-s:'_�c'_' pipes) or due to a broken. senled or uneven distribution box. The system will pass inspect,on it (w,m a�•�c.a Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced j The system required pumping more than (our times a year due to broken or obstrucied pipe(s) T n e syste^ ass insoecl,on if (with approval of the Board of Healthy broken pipets) are replaced obstrucsion is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ,616— Conditions exist which require funher evaluation by the Board of Health in order to determine if the system ,s laJ,ns :0 public health, safety and the environment 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONI�'C IN A WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank and soil absorption system (SAS) and the SAS :s within 100 feel to a s.nacc a.„ _o tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a pubic water s a. tee: The system has a septic tank and soil absorption system and the SAS is within 50 feet of a pf-a.e -2:er s-Do . Ak> The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 tee, -:),e private water supply well, unless a well water analysis for coliform bacteria and volatile organic cornpo_ncs �c—a,es the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate mtroge" less than 5 ppm. Method used to determine distance {�'� (approximation not valid) l) OTHER of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR o PART A CERTIFICATION (continued) Property Addres9: 204 James Otis Road Centerville,Mass . Owner. Carl Benson Date of inspection:1 1 /3/97 D) SYSTEM FAILS: You must indicate e,. er "Yes or "No' as to each of the following A),j i have determined that the system violates one or more of the following failure criteria as dei,nec 310 for this determination Is Identified below. The Board of Health should be contacted to determine wnat w,lt ;,z the failure Yes No Backup of sewage Into faCilrry or system component due to an overloaded or clogged SAS or cessaoo' Discharge or ponding of effluent to the surface of the ground or surface waters due to an o:eioaeec or c og3E­: _ cesspool. Stalk liquid level in the distribution box above outlet Invert due to an overloaded or cicggec SAS c, c=ss_c 0," �7 L,Qu,d depth n Goa Is less than 6" below invert or available volume is less than !.'? c3'. JD Requ,red pumping more than 4 times in the last year NOT due to clogged or obstrucieo Number of times pumped i Any ponlon of the Soil Absorption System, cesspool or privy is below the high groundwater eleva:1 Any ponion of a cesspool or privy Is within 100 feet of a surface water supply or tribular. :o a s na,c -3:e, s_ Any portion of a cesspool or privy is within a Zone I of a public well Any pon,on 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 pr .a:e -a:er s c: -r acceptable water quality analysts. If the well has been analyzed to be acceptable, anacn coo,, of .-ell a-.a ., > col,lorm bacteria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen E) LARGE SYSTEM FAILS: You must Indicate ether 'Yes" or "No" as to each of the following: The following criteria apply to large systems In addition to the criteria above .06 The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system s 3 s.zn public health and safety and the environment because one or more of the following conditions exist Yes NO the system Is within 400 feet of a surface drinking water supply the system Is ,,thin 200 feet of a tributary to a surface drinking water supply QL1� the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a rrt;,:cC _„ public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the ground. a.er treaiTe- ,- requirements of 3 1 a CmR 5.00 and 6.00. Please consult the local regional office of the Department for further in;ot,m.at. tr.vs..e 04/2$/971 ➢.9. 3 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 204 James Otis Road Centerville Mass . Owner: Carl Benson Date of Inspection: 1 1 /3/97 Check if the following have been done: You must Indicate either "Yes" or "No" as to each of the following Ye Np Pumping Information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been rece, ,ng no,, ,! now rates during that period. Large volumes of water have not been introduced into the system rece-,!, as pan of this inspeoion. As built plans have been obtained and examined. Note if they are not available with N/A _ The faciliry or dwelling was inspected for signs of sewage back-up. The system does not receive non sanitary or industrial waste flow. _ The site was inspected for //signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for cond,i,on baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum The size and location of the Soil Absorption System on the site has been determined based on - . The facility owner (and occupants, if djfferent from owner) were provided with information on the groper ma,n;er;nce Sub-Surface Disposal System _ Existing Information Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance > unacceptable) II5.302(3)fb)) Ir•v1••d 01/75/97) D.g. 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 204 James Otis Road Centerville,Mass . Owner: Carl Benson Date of Inspection: 1 1 /3/9 7 FLOW CONDITIONS RESIDENTIAL: Design flow. '��Q 9-p-d./bedroom for S.A.S. Number of bedrooms: J Number of current residents:1 Garbage gander (yes or no):411,1 Laundry connected to system (yes or no): Seasonal use (yes or no).ND Water meter readings, if available (last two (2) year usage (gpd): gird, y7. (�n�'(•� Sump Pump (yes or no): /l d fC/��" O 7%���� v '�7 0-ilQ Last date of occupancy COMMFRCIAUINDUSTRIAL:;,d T ype of establishment. ,/J/T Des,gn 11ow: AAallons/day Grease trap present. (yes or no),d& Industrial Waste Holding Tank present: (yes or no)A)p Non-sanitary waste discharged to the Title S system: (yes or no)&4' water meter readings. if available. ZIA 424 Last date of occupancy. OTHER: (Describe) Last date of occupancy GENERAL INFORMATION PUMPING RECORDS apd sour of infor a(, n: System pumped as pan of inspection: (yes or no),0 If yes, volume pumped: 1 gallons Reason for pumping T-YPE Of Septic tank/distribution box/soil absorption system V,0_ Single cesspool .L)D Overflow cesspool Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) I/A Technology etc. Copy of up to dale contract Ocher APPROXIMATE AGE ofjjI compon ts, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) Aele lr.vi.•d 04/25/97) ➢•q• 5 of 10 SUBSURFACE SE�VACE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 204 James Otis Road Centerville,Mass . O-ner: Carl Benson Date of Inspection: 11 /3/97 BUIIDINC SEWER: .locale on site plan) l� Depin oelo- grade 1' Mdlerial of consttuciion / cast iron Z40PVC _ other (explain) D,stance from lJpr�va(e water supply well or suction line 4114 D iameter Comments tcond-t,on of joints, venting, evidence of leakage, etc.) SEPTIC TANK locate on site plan: t Depth below grade watenal of construction. concrete _metal _Fiberglass _Polyethylene _other(explain) c tank is metal. list age 1�1114 Is age confirmed by Certificate of Compliance&d(Yes/No) D,mens,ons PP'l6wV si'cge oeptn t J^l�{ Distance from top of sludge to bonom of outlet tee or baffle Scvm th,ckness /7 D,stance from top of scum to top of outlet tee or baffle YiQI�/ D,stance from oonom of scum to bonom of outlet tee or baffle ^how c,.mens,ons were determined Comments ,recommendation for pumping, Condit n of inlet and outlet tees or baffles. depth of liquid level in relation to oullet n:en. s:r c_:.; ^tegr n, evidence of leakage, etc.) .Q T v S N / CREASE TRAP:,e2,j/rVe ,iocate on site plan) Depth below grade -4& M.a:et'al of con slrucl'orbit,&_concrete4,�4metal/aFiberglass4APolyethylene,Lgother(explain) _AJ/fl D'mens,ons: Scum thickness A141 Distance from top of scum to top of outlet tee or baHle:a/, Distance from bonom of scum to bonom of outlet tee or baffle: V14 Da:e of last pumping to Comments uecommendation for Pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet even. s:r,,.-._•a niegnry, evidence of leakage, etc 1 r ir.vi..0 0�/7s/9)1 ➢.g. 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 James Otis Road Centerville,Mass . owner: Carl Benson Date of Inspection:) 1 /J/97 TICHT OR HOLDING TANK:4�2&&(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade .(lh material of construaion4.�Lconcrete,�lmetal;l�F berglassN�Polyethylene.lJ/Jother(explain) Dimensions 'VA Capaciry: 1,14 gallons Design flow V,�¢ gallons/day Alarm level* 4/4 Alarm in working ordeAl 4 Yes:A/,4 No Dale of prev,ous pumping W'1A Comments (condition of inlet tee, condition of alarm and float switches, etc 1 DISTRIBUTION BOX: (locate on site plan) Depth o: I,cu,d level above outlet nven Comments (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc ) 'Q-A;4 A cam Z-a,�� , A14 - .,/1 a al e 'eC a2&2 C.�S e-v a �WA, �A 19ae4it:- 4G� Av'W1 O"'7 4-1 PUMP CHAMBER:1 (locate on site plan) Pumps r. „orking order: (Yes or No)� Alarms n working order (Yes or No)—&,61 Comments (note condition of pump chamber, condition of pumps and appunenances, etc.) (r•v:.•G Os/15/97) P.g• 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 204 James Otis Road Centerville,Mass . Owner: Carl Benson Date of Inspection: 11 /3/97 SOIL ABSORPTION SYSTEM (SAS):Z,04b�4&V &45'4 A>' locate on site plan, if possible, excavation not required. but may be approximated by non intrusive methods) If not determined to be present, explain: Tye j leaching pits, number. leaching chambers, number_ leaching galleries, number: leaching .trenches, number,length: leaching fields, number, dimensions: (% overflow cesspool, number: ti Alternative system: Name of Technology: Comments (note condition of soil, signs of hydraulic failure, livel of pond in con ition of vegetation, etc.) ApAMU 5 r CESSPOOLS: 4 (locate on site plan) Number and Configuration: D Depth-top of liquid to inlet inverl Depth of solids layer. Depth of scum layer: Dimensions of cesspool. Materials of construction: 0 Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) A /%t e Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) �L Materials of construct n: /J//T Dimensions Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) /S Ir.vi..d 01/7s/97) P.g. 8 of 10 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 204 James Otis Road Centerville,Mass . Date`' Carl Benson Dille 01 inspif lion: 11 /3/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: ^Uvde ties to at least two permanent references landmarks or benchmarks lccate all wells within 100 (Locate where public water supply comes into house) rOC r Coll/L �D w r4e 00i, lr.�s..e f /J9/971 P.q. 9 of 10 SUBSURFACE SEsvACE DISP, : SYSTEM INSPECTION FORM C SYSTEM INFOI iON (continued) Properly Address: 204 James Otis Road Centerville,Mass . °miner Carl Benson Date of Inspection: 1 1 /3/9 7 Depth to Croundwaterc Feet Please incicate all the methods used to determine High CroundwatCr EIL'.auon: Ob:a,ned from Des,gn Plans on record Observat,on of Site (Abusing property, obserYation hole, basemarsF s,mp etc.l ,//Determine it from local conditions ZChec%. with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers use 'uSCS Data Desc,oe , your own words how you established the High Crounctwxcf'I le�al,on (Must be completed) Used Cape Cod Commission Map September 1995 Water Table Contours And Public Water Supply Wellhead Protection Areas lr•v1•.c 04/79/97) P•c. of to r -.•+ nrrr•rr..+'.-nr.rmra-++�+ar:+.rr-r.:•.�•.�o.r:+r.•-++�++ r-�-as*.v�rrw.r+z+ rrns.s.-.r.r�-,s n.-.---r-�-.�- _. ._ 1 T r 'I.OWN OF WARD OF HEALTH � SUIISURFACF 9EHAOF DISPOSAL ,SYSTFM IN311FCTION FORM - PART U - CERTIFICAT10" {I �, �...._._.r.....,-_era---n.r.nn•n:mr.rr.ra-vr�-eta-.r--•.'+^'i.mr-�nrnivr'�-�*sv� r� mnn•rmrn-r-.rv-rm.r+.••—.-r.- .-._. ._. A -TYPO OR PRINT CIXARLY- PROPERTY INSPECTED STREET ADDRESS 204 James Otis RnAH rent-Arvllle,-Magg ASSESSORS MAP , BLOCK ANO PARCEL 0 OWNER' S NAME Carl Benson PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & 'tcn , Inc . COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066 5tr99t Town or City 5t t 11P COMPANY TELCPIIONE (508 775 -3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and v complete as of the time of :inspection , The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one ; ZSystem: PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any fail(ire criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have cond acted has found that the system fails to Protect the public health and the environment in accordance with Title .5 , 3l0 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . '< Inspector Signature A Date %�" � Z" -07 One copy of this certification must be provided to the OWNER , the BUYER ( where appl icable ) and the 130ARD OF 11EALI'1l . * IC the inspection FAILED , the owner or"'operator shall upgrade the eyate,•n � it.hin one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 16 . 305 , partd . doc Ln yJ� � SS byy -3/71�� THE C OMMONWEi A LTI-I OF M A.SSACHUSETTS DEPARTMENT OF ENVI[ ZONMENTAL PROTECTION BE IT INN O WN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERT i i D TITLE S SYSTEM INSPECTOR as provided in 310 CMR 1 S _340 and Section 13 of Chapter 21 A of the General Laws " Issued by The Department of Environmental Protection. 1unc 8. 1"S -- r -- —---------------&1 !tnf ControlAcnnK [)tr--ctor of (hc l No._.1.1.�:.. Fn$......7i..``-. ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH GAGoo✓. .........OF...../5 -� 44F....................................... Appliration for Uhipaii al Works Tnnitrnrtiun rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _._ /'. . .--•--�r�5.............................. - Location-Address or Lot No. > .................................... 1wner Address •-•--•- f6... ..................ate--------------------------- Installer Address d Type of Building Size Lot_.------_----------------_Sq. feet Dwelling—No. of Bedrooms......._..............................Expansion Attic Garbage Grinder (/-a) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... . . Design Flow................ _��......_._.._.._...gallons per person per day. Total daily flow-_-__-...._ _3.__._..._..............gallons. d WSeptic Tank—Liquid'capacity.(B:e'ngallons Length._..___.._._ Width.._CL �0."Diameter---------------- Depth................ x Disposal Trench—No..................... Width.....$.............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------- __ Diameter--_.1.Z.------. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date--------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--.__-_______-_____-.-. f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 .............................................. ............................................................................................................. 0 Description of Soil....................................................................................................................................................................... W U W x ---•-------------------------------------•--••••---••-•--•---••-•-••-----------------••-•--•-••-••-----•--•-••-•-------•-------•---•--•---•-•-------••-•••--••-•••-•-••-••••......---•-•-•--•-•---••--- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------------------------------------------------------•--------------------------------•-----•-••----------------------------------------- •-----------------------........................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with � P'i x;'. the provisions of T .E ;of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of C �eb has be 'ssued by the b rd of health. �^/ . ! 14/ to 'y �5?'`�_ Date Application Approved BY �F .E�t....... . e/" �1' V Date Application Disapproved for the following reasons:----•-------•----•--------------•--•--------------------------•--•--------------•------.._....-•••••--•---..._.. ....................................................................................................................................................................................................... Date Permit No.........S .?zc---C/�- 5.................. Issued_....................................................... Date Fx$....�:.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -Ca�ft'..............OF.OF..,, M> Appliratiun for Disposal Workii Tomitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: a. ~ Location-Address or Lot No. _ Owner _ Address Installer Address Type of Building Size Lot............... �_......Sq. feet Dwelling—No. of Bedrooms..........................................Expansion Attic ((V)> Garbage Grinder (/,%e)' a`4 Other—T e of Building •-------------- No. of persons............................ Showers YP g -----------••----•--------•-•--•----•------P ( ) — Cafeteria ( ) Otherfixtures ...............••- ......-•-•••••---•••••--------•••--------....._......••------•-•----•---•---•-------------------•-- Desi n Flow------------- -":: - ? W g ....................gallons per person per day. Total daily flow............. ._ gallons. WSeptic Tank—Liquid*capacity'A 3.gallons LengthE-__G°_ _._ Width.- `1P" Diameter________________ Depth................ .._.. Wi„th._�................ Total Length .•.....• a_....... Total leaching area....................s x Disposal Trench—'.`?o. _____•_..._._. -' g q, ft. Seepage Pit No------J--- Diameter-_- ...:'_.___. Depth below inlet.................... Total leaching area...._.............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_----______-______,_-. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M ................................. ----•-...........-•••--------.....------........••----.._........---••....-•--•-----......-•-•............................ 0 Description of Soil..........--------------------------•---------........-•--.........---------...------------------•-•-------------••-------------------------••-•-••--••--------....._.. U --•--•----•••--•----•-•-------••-----------•-•-•-•--••-•-•-----••--•-••-•-----•---••••......•-•--.....-•--•----------•----••------•---•••-------•---•---••-•--•-••-•--•-•--••-•---••-•-----•-........._ -----------------------------------------------------------'----------------------------------------------------------------------------------------------------------•----------------------------•-•- 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 i I T t..E 14 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of C.Qwpii e has beennissued by the board of health. --••- - Date•-----.---- Application Approved By---•-•....�.e � .t.� ^-� ,, ..... --------�- -� ��^ Date Application Disapproved for the following reasons:.................................................................................................... ... --......--•-------------------------•---......_....•-•••-----......••-••--•-••---•-......._..----......-------•-•-•-•-•--••-•••-••-•----••--•-----•-•--•••-•---•--•----•-•-............................ Date PermitNo........� z................... IssuedL------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ' ............�. ,.........OF......... .. .................................... Trrfifiratr of Toutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed) or Repaired ( } r—r----;Installer at-•••-•--••�-f: 14...--•--•----- ----•--�- -r--5•-----....-•------------------••---•----------------------------•------------------------------------- has been installed in accordan with the provisions of TiTIE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.........�' .1-...V e...� .... dated...............____________-___-.•----______--. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT 7HE SYSTEM WILL FUNCTION SATISF��rACTORY. DATE.......................157..- ...... -.7..---•-••-•---•....... Inspector.............. 2)................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... ? . .. OF. ,:a:x. . t;/f _..0........................ FEE.._... �iu�rou�1 �ru �unu�rttr#iun rruti� Permission is hereby granted.............V :_,.....2 ...... to Construct ( ) or Repair an Individual Sewage Disposal System Street qq as shown on the application for isposal Works Construction P it Io..Fl--.L��'a1 ate .. ..................................... �/ ---•---•-----•--•-----•---........ Board of Health DATE........ _... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS } y _!j 1- ,� I •-t- I d r, I , _I_ �78, , :�. *.• ,� � 41 r (la OF t�l f''�IzvP I ZMI N. OZz , �y PETER o —SULLIVAN> R4CHARD t No.Z733 " A.. BARTER ¢ ' 3alZ Na 24048it T ? . ONAi }- - I I F•�a r a I , �', .. , ,o W—V la LA LL. I LC� b (cam Iry r�A -: r�aTld ]�KV'1LLI= - �I; 1,LDM�-4� 1�UITP "T1Ir �R-IS��$AG14 .a�t?,l .M�.tsT's bF-1'�•-kE" "�::-�h� I��� : - h����--; I f`x.., T 1T _ I PLQ. I , ��� � . t � _� -I ,__, , ; � , , f � , 1NS�l1M�T Su�?�L•.Y�tJa TEE: ,u��- m a - { ,�; ( , , .; � ��-f � � � � .� _�T S, 51--1v'W N ����o�►�l: S H�;Ut_D I.sct- I -�^� :L L/. j r F LA-5H i• 4( �L7 A _� ,_, .� -.-1 _G h ( r WN OF BARNSTABLE LOCATION Y! M.s d�rl S SEWAGE # O 3 VILLAGE CE!erf vt //e� ASSESSOR'S MAP & LOT ,,. INSTALLER'S NAME & PHONE NO. % 00C Co SEPTIC TANK CAPACITY l OV-0 �7p LEACHING FACILITY:(type) (size) S,NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER o BUILDER OR OWNER / 4/0 /J DATE PERMIT ISSUED: �' I DATE . COMPLIANCE ISSUED: °1 - VARIANCE GRANTED: Yes No �- 0 AsBuilt Page 1 of 1 CS 45� WN OF BARNSTABLE LOCATION Z1idMc.S OV S . SEWAGE #9,1�' 70 3 VILLAGE 1, e!� y<Ile ASSESSOR'S MAP& LOT INSTALLER'S NAME & PHONE NO, 0(11C 4J,�Q SEPTIC TANK CAPACITY /&trt) qLEACHING FACILITY:(type) G ICE (size) '�NO.OF BEDROOMS .3 /PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER S•/I A DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I A c� ao a� i i i i htti):Hissgl2/intranet/propdata/prebuilt.aspx?mappar=l 70211&seq=1 4/12/2017 instaoilti-ov,sfi7ar J ',3tf-' Environn-runtal Town or of Healm, q.(.gk; 19 %r4—ol septic sy,;te-n, shi� n linot be ins'a�;­i 6i.: ised town i, Six 47 87� 1.�W::�1'i't,l,�'f�'�� plri i{ j"sJ`�.. G+ � � rit,"0 installatioa.iiT..: the st-wer !I eXiSTing septic corto.-I in �` fi - �/ / � '� � i _:,s _- - r4 4 i ti;-; H C fir t 2 f t ;.I� of graviit�,,sewer p'jp!t:tg hedule 40 PVC at A:il" :;�!7 ee (list ribuTio 11 box 5:)'Ai b--� i'veL ping connections O;J•n- )_Cv9WAY 6Nq pro Jesign ula!t i, fof perty 1,;n.:- r fo! any othr.. iostallation. -kino shall be iYohit,-i t-_4 Mp I _ _j*t._1 ornponents unle.-1:, t H2O E J Al 6 it ex:stigcgr i- wd and0e it; ­ THe7 h c rum — - i C -sndurmen' Drocedv, i--in-v-..-.-.d cessp(-.oi(s1 and C (f.-1. i• :1 Wi hi t n ihp ;;r"Posed SAS sh.z!: be -'.::%fared with r:eap. sa!iJ'service line. ,A/;tte( Fne �i- -3ieevL-z1 vvim ar, f to'!We 40 P'V'( witi- i.; -i: TIF /()p7 ;;-eve be�sgj I o I oc) Pit, 5C.C., Vie !ine. gavlaage Srinder It is to bee remov,..� !-;,i, stf.-rij jN llet DL �igned to e r. r is re�,( arnur,.A' al. .,��perz y a.i,.-j t-J _,on the struclu:.., =rcrtjct.irt!s auring ti 1 i­hesppl;, y 044t -,-an be mp Vdt�0 ly repress' :vrerrients property Owner -�Jeria. to approve i.:%,tn *,, of bedrooms an(: vnt for the de,,igi` \ -' ,n flow. lnstallafic,- be dr.erned appr-,. bv the pro-p-q r t of. va . '. i Iiijily of this pl-l;!.- le-:� %the expiration of V­ Lu-wl, perrni pla n or the validii,: -!.i. 0_41 v. T �)T)Me(,%Xpif-; -s, itcate.. of Cumv! nc Xv -vwl Xok .114 '1 0: jed fur V,.c tvisti,11c, sy.sry fir, t�-o .1-his p! N OF Iv.4 DAVID ;rJ X.14, ES 'A-Z), 7 B. ✓ MASON No. 11 66 I ! ?Aq �j 1L q 6�y 14 E. 5= zINI 4,0d Z, 114, tt�0 , [_.�f 9" /��7rVA Cr . 3 Tj:: A IN 0 "V VI/ ILI (2 77 / 10 ASO,15 AftV /ZW