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HomeMy WebLinkAbout0009 JUSTICE DOUGLAS WAY - Health rJustice ©oe jglas Way enterville' . ,P A = 191 194- ' 44� No. i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zippfieatiou for Misposar *pstem Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.cl '4LrS,r(ce DOA14F,Co4S; LOM Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 191 ( d"Vi gJS� L e>4&j M� , .�fvice n4 s4�! f=u vt Nth Installer's Name,Address,and Tel.No. j A'% q-Z"Z -8&j,it Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) N 147 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)_(sue Le^&,__ f !s f�Wo&4_ " u .- P 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. Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ' —��r7 Date Issued - -- -----_- ---___-_--- - �1�v. --- — - - - - -- - No. Fee -7-57 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 's 01pplication for Misposal 6pstrut Construction 3permit Applicifion for a Permit to Construct Repair(� Upgrade Abandon El Complete,System Individual Components Location Address or Lot No.9.,'JUST(CFE 4W Owner's Name,Address,and Tel.No. I OS Opea*A;� 4-PA*� H*AA46�G�� Assessor's Map/Parcel JMV&JC Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Acxsstr G 0&* A&M e- J�!W WIA -Type of Building: Dwelling f No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( Cafeteria( Other Fixtures Design Flo*w(min.required) gpd Design flow provided .4 Aj L�_ gpd Plan ' Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) MWAe— 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 coinpliance.has been issued by this Board of Health. S, Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. r7 C 2 Date Issued -------------- --------------------------------- ------I------------------ --------- ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS,IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired Upgraded Abandoned( )by 6066AT 6 0QA_ do at !?' ,TQSTEM has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N_Qg_0 dated Installer R066K= G acia Designer #bedrooms- A Approved design flow gpd The issuance of this t shall not be construed as a guarantee that the system w Y ilfM_ 1atio designe Date 26 Inspector, kA ------------ NO. _,- 077 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit. Permission is hereby granted to Construct Repair Upgrade Abandon System located at 9 -!,T ci Sri ce -cjr-4AC W�Ca�M;W__\_/UZ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be lompletIl within three years of the date of this Coermit. Date Approvee�.X It 1 ti Town of Barnstable Barnstable Iu-amMicacihr , Inspectional Services , I I I I.F SARNSTXBLE, MAC Public Health Division Are° s 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9453 February 1, 2019 KENIRY, EDMOND P & TINA MARIE 9 JUSTICE DOUGLAS WAY CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 9 Justice Douglas Way, Centerville,MA was inspected on 01/03/2019 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Need to replace line from septic tank to leaching pit. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH cKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\9 Justice Douglas Way Centerville.doc R , Town of Barnstable • SARNSI'ABI.E, • ,, �, Regulatory Services Department -- - - ---- Public Health-Division - 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO(2) YEAR DEADLINE CRITERIA ❑ Single Cesspool 7*ny"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Jan, 30 '201,9 14:10 HP Fax page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form w� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /c p, 9 Justice Douglas Way Property Address rr Rushmore Mangement Owner Owner's Name t;a, information is Centerville required for every MA 02632 per, City/Tom 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. `\�ptatul i u rrrrp,,,,` Important:When . . �. filling out fwrns A. Inspector Informationon the s��---, use only tab JAMES y, y James D. Sears key to move your Name of Inspector — cursor-do not Capewide Enterprises =* ' use the return key. Company Name •,�,��T PE ��..��.G�`;. 153 Commercial Street '-%�,,, S INS `�����`� _I� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1-9-19 ctor's gnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t8insp.doc-rev.M612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pagel of 18 Jan 30 '20119 14:10 HP Fax page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Justice Douglas Way u� Property Address Rushmore Mangement Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Conn Pass-Line change. The system is a 1000 Gal Tank and pit 2) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined"(Y,N, ND)for the following statements. If"not determined," please explain, The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/2612018 We 5 Official Inspection Fan:Subsurface 5ewage Disposal System•Page 2 of 18 r Jan , 30 '201,9 14:11 HP Fax page 22 X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name information is required for every Centerville MA 02632 1.3-19 page. atyrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box, System will pass inspection if(with approval of Board of Health): ® broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Need to replace line tank to pit. ❑ The system required pumping more than 4 times a year due to broken or obstructed-pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: 15insp.doc-rev.V28/2018 Me 5 iJffidal Inspection Form:Subsurface Sewage(Disposal System-P89e 3 of f8 Jan, 30 '2019 14:11 HP Fax page 23 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments h v 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 per, City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other; 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc•rev.M612018 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 4 of 18 i Jan, 30 ''2019 14:11 HP Fax page 24 Commonwealth of Massachusefts Title 5 official Inspection Form k,Q�r'-'016 — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Justice Douglas Way Property Address Rushmore Man ement Owner Owner's Name Information is required forevery Centerville MA 02632 1-3-19 page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6"below invert or available volume is less than Y2 day flow P0/ ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15,303, therefore the system fails, The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section C.4. 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 supplywell t5insp,doc-rev.7/26I2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Jan , 30 '201-9 14:11 HP Fax page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �v 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304,The system owner should contact the appropriate regional office of the Department. 6, You must indicate"yes" or"no" for each of the following for all Inspections: Yes No ❑ ® 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 NIA) ® ❑ 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 Y sewage disposal systems? P The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.712 612 0 1 6 Tige 5 OiGclal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Jan 30 5. 201-9 14:11 HP Fax page 26 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: 1000 Gal.Tank and pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2017-0 Gales 2018-0 Gal s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NADate t5insp.doc rev.7126,12018 Tide 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 7 of 18 r Jan. 30 '2019 14:12 HP Fax page 27 c Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Justice Douglas Wa i2v g Y Property Address Rushmore Mangement Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditlons: 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/201 B Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 16 Jan ,30 `2019 14:12 HP Fax page 28 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name information Is required for every Centerville MA 02632 1-3-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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 IIA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32 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.): Pipeing is 4" PVC SCH -40. l5insp,doc-rev.712612018 Title 5 Official Inspacdon Form:Subsurface Sewage Disposal System•Page 9 of 18 Jan, 30 �2019 14:12 HP Fax page 29 Commonwealth of Massachusetts IV Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 9 Justice Douglas Way Properly Address Rushmore Mangement Owner Owner's Name Information is required for every Centerville MA 02632 1-3-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): " Depth below grade: 21 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 Gal. Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 0 il Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank and covers at 21" below grade. Inlet old type wall baffle, outlet baffle. No sign of leakage or overloading. 15insp•doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 Of 18 r Jan, 30 `2019 14:12 HP Fax page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name requir reqtlonuired Is Centerville MA 02632 1-3-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5lnsp.doc•rev.7/7IEW4 Title 5 oftldel Inspection form:Subsurface Sewage Disposal System•Page 11 of 18 Jan, 30 '2019 14:13 HP Fax page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form Uipvt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name Information is required for every Centerville MA 02632 1-3-19 p"e. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No Box 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.): t5insp.doc•rev.7126/2018 Title 5 O(fidei Inspection fom:Subsurface Sewage Disposal System•Page 12 of 18 'Jan, 30 2019 14:13 HP Fax page 32 Commonwealth of Massachusetts . Title 5 Official Inspection Form + Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name Information is required for every Centerville MA 02632 1-3-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.): " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: Type: ® 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: t5insp.doc-rev.7/261201B Title 5 Official Inspection Formi Subsurface Sewage Disposal System-Page 13 of f88 Jan. 30 '2019 14:13 HP Fax page 33 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Justice Douglas Way Property Addraw Rushmore Mangement Owner Owner's Name Information i9 required for every Centerville MA 02632 1-3-19 page. City/Town state Zip Cade Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.); Leaching is a 1000 Gal. precast pit w/1'stone. Pit and cover at 32" below grade. Pit is dry w/stain line around 18"off bottom. 12. 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 Indicadon of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): tsinsp.doc•rev.7/28/M18 Title 5 Offidal Inspection Fam:Subsurface Sewage Dlsposal system•Page 14 of 18 `Jan. 30``2019 14:13 HP Fax page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y7 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.&,c•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Tart, 30 '2019 14:13 HP Fax page 35 Commonwealth of Massachusetts Title 5 Official Inspection Form `i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name Informrequired �s Centerville MA 02632 1-3-19 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below; ® hand-sketch in the area below ❑ drawing attached separately i2 t ra R 0 0 0 f3 -I A'ja % 10-10 /3 -z A-3 = .3-5 - C -3 • 3 t5insp.doc•rev.7/20/2016 Title 5 Official Inspection Form:Stbsurface sewage Disposal system-Page 16 of 16 i Jar, 30 '2019 14:13 HP Fax page 36 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Justice Douglas Way v Property Address Rushmore Mangement Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells O Estimated depth t 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 propertylobservation 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: 12' No G.W.. G.W.off const.permit, Bottom of pit at 9' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Nnsp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i� "Jan, 30"2019 14:13 HP Fax page 37 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Justice Douglas Way Property Address Rushmore Mangement Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B.Certification: Signed & Dated and 1, 2,3, or 4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included o I 15insp.doc•rev.717612018 Mile 5 Official Inspection Farts:Subsurface Sewage Disposal System•Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS (f 7( EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z d DEPARTMENT OF ENVIRONMENTAL PROTECTION W � d t RECEIVED 6�0 J U N 0 4 2003 TITLE 5 TOWN OF BARNSTABLE OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSM EALTH DEPT. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,MA MAP19 ILOT ,(q$2632 Owner's Name: ALICE BICKFORD Owner's Address: SAME Date of Inspection: 5/6/03 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 pet formed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditional P es _ Needs Furt er aluation by the Local Approving Authority Fails Inspector's Signature: Date: 5/6/03 The system inspector shall submi copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe ion. If the system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner s all 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 THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS FOR MAINTENANCE AND RAISING COVER TO LEACH PIT. ****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. Title 5 lncnPrtinn Fnrm 6/15P)OnO 1 IPage2 bf 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,MA MAP[0j j LOT 49`02632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS FOR MAINTENANCE AND RAISING COVER TO LEACH PIT. 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. n/a 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: n/a n/a 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: n/a n/a 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: n/a .Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE, NIAPtCj'LOT jqj 02632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a.surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "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: n/a iPagetHof 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,MA MAPIC-11 LOT q+2632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN THE LAST YEAR. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory;for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. d I i Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,MA MAP 19t.LOT jq+2632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 Check if the following have been.done. You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X _ Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection'? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ 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 X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] S Page 6.of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,02632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: n/a Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [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)): ��� Sump pump(yes or no): NO Last date of occupancy: 1/1/990 oo COMMERCIALANDUSTRIAL w Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YEAR Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1976 INFO FROM AGENT Were sewage odors detected when arriving at the site(yes or no): NO i Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,MA MAP 19t LOT tgAO2632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron =40 PVC other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" , Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 101"t Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 2" 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:t, 06 How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTU2ALLY SOUND. RECOMMEND PUMPING EVERY TWO YEARS FOR MAINTENANCE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 iPage8'0f 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contim::d) Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,MA MAP IS' LOT `qA02632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)floca.�on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explaii:j: n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of so As carryover,any evidence of leakage into or out of box,etc.): NO-BOX AS PER ASBUILT PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a L R iPage9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,MA MAP 191 LOT J(jA02632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not:equired) If SAS not located explain why: n/a Type LEACH PIT 6'X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT HAS NOT HAD MORE THAN V IN IT. BOTTOM IS AT 9' RECOMMEND RAISING COVER. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a i 4 Page 1 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,MA MAP 191 LOT tj4jj02632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 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. vjzal-ki a �9 AA 5� C � `1° in Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 JUSTICE DOUGLAS RD CENTERVILLE,MA MAP 191 LOT IC�02632 Owner: ALICE BICKFORD Date of Inspection: 5/6/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from syste►p design plans on record-If checked,date of desig.:plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY HAND AUGER- 12-NO WATER ENCOUNTERED 11 N fst'� Fmic.. ................ THE COMMONWEALTH WE.A. .L..T.H. :OFE rs �O� O� H lay ALTH ----.....------------0F....... V' Appliration -far ]iiipagat Works Towitrurtinn Vanift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys 5 _,G ...P606.L& ��� ---4 2 Location•Add �,s �- or Lot No. Owner . Ad � dre s a ----------- - •-------•-- z 1. /.................................. Installer Address Type of Buildi Size Lot../- .�'z'Sq. feet U Dwelling No. of Bedrooms...._. .....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures •-----•--------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow-----------------------------------.--------gallons. 9 Septic Tank—Liquid capacity *I*.'O---gallons Length---------------- Width------.......... Diameter---------.------ Depth_...___-__---- xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching a ea--- .s . ft. .Seepage Pit No.__ i _ __.. Diameter.................... Depth below inlet.................... Total leachin _....--.---_--_ 1 Z Other Distribution box ( ) Dosing tankJ— aPercolation Test Results Performed by--------------------------------------------------------------------------- Date---••----------------------------- a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.--._-._:--_.-_.----_ LT, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water----.-.--__-.----__----. ------------------------ ------------------ -- -:G! `� x Description of Soil-------------jo _-.6------- ---_ �-..." -..,�y . -r--•-----• - 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 Article XI of the State Sanitary Code— The undersigned further agrees not to a the system in operation until a Certificate of Compliance has been issued by the board of alth. /� Sign d - -- ----- ---------- --- ---- ------ A lication Approved B y ?: °o- G _..4� ..-._•• Date PP PP Y------ ;�'-�- _ Application Disapproved for the following reasons:............................ . . •..................••------........................------Date ...---------- ............................... •------• -----------------------•----------------•-----•-•------------•--•--------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued.'.................................................... Date No. Fs$.... v.. +. THE COMMONWEALTH OF MASSACHUSETTS Z-O . OARD OF HEALTH ...............'.. ._ _................OF........!....1. '��''t ^-....It7�/ - .......... Appliratiutt -fur Di,ipuiitt1 Workii Tonfitrurtiutt Vrruiit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: *4 .... .2X.................................................... ........... � e jLocation-Address or Lot No. .� _ ✓ Owner ---••-......-•-•••......-- ............... --•------------------- Installer Address _ UType of Building Size Lot f-` -.�__.>-_ __Sq. feet Dwelling !—No. of Bedrooms--------`�_________________________-_:-Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building __.......................... No. of persons_______._.--..__--_._.___- Showers ( ) — Cafeteria ( ) QOther fixtures ----- ---------------------------------=-----•--------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitv__�_tx°•gallons Length---------------- Width......-.-..__.. Diameter................ Depth................ x Disposal Trench—No_____________________ Width... a1________._ Total Length-------------------- Total leaching area......__.____.-----sq. ft. Seepage Pit No.... �)!.`"l�_.. Diameter--------------7.... Depth below inlet.................... Total leaching area..._-.___-_._____sq. ft. z Other Distribution box ( ) Dosing tank ( ) U� /0 G/yam 3- / y' /S" aPercolation Test Results Performed by---- _________________________________________________.................... Date--------------------------.------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water___.___-._--_--__-_--... fzq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.__._--__-__-__-_.-._. G ............... �� Y �/ r Description of Soil Urr G �- 2 V �. 'd%?�1 �_..ee c_-z..... ------------------------•-- 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 Article XI 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 h,aaflth. y�y Sign �"<%_... -------- Date Application Approved Bjj:._ . Date ------------- Application Disapproved for the following reasons_-------------____________ .....................................--------------------- ------------------------•-------------------------------------------------------------•---•-----------------. --------------.--------- ---- Date PermitNo......................................---•--•-••--------• Issued..-................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1. ..........................................OF........................................................... w.wrtifirate of 0,uutphatur THI f iS T ,14ERTIF,\Y, That the Individual Sewage Disposal System constructed ( �or Repaired ( ) nst I . er has been installed in accordance vhth the provisions of Artie 'I of he State SaniYcfry Colle as described in the application for Disposal Works Construction Permit No. -- ----- 1_.....------ dated..f Jx(�-D-.---=?-..`I_..7�.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................... ............................ Inspector------------------,---------- ....................... ---------------•••---•--••-- THE COMMONWEALTH OF MASSACHUSETTS — BOARD O HE JF L " '! v..(............OF.......... ... ... ... hG��/".��/.... No. .=•............. FEE-- Ni-ti.u.tt1 ar4azTn trttrtiutt rrutit Permission}�'s ereby granted--------- ..... ------•--------------------------------------- ..•---•- •. to Construe or R .pair ( an Indi,Aoual Se a.e Dispo.h System',)X ------J� ?-- — r V Street / as shown on the application for Disposal Works Construction r It No.... ..:... ........ lted___CP..-__'�_`/'_7 :....... Board ofe.� _ h �/j DATE--- ----- -----�......------------------...--------------------------------- L FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS II (� TOWN OF BARN�S/JTAABLE LOCATION 11��� Qll/1( .' SEWAGE # VII:LAGE � Yet' V� I L X� ASSESSOR'S MAP & LOT —� '7n INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 UL SU off 5��1 W I U : pe LEACHING FACILITY ) U01 el1�iV)It (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) i Feet Furnished by -e fir J^ Paw i N i I d 39 2 ir2, `7 S t� -ZI A ra r Ft � Cfc-JT[.2✓t l.-t.-l+ 4� 30 �DarE �,/15/7c_ �trAiJ �L�E=Er7C�C� 71-/A r ,r&VUZ)A r10A.; kfMi940,U N6'e6-01J ce"'414-ee")IS' )D rye Pl-AU Foy ALA►J C WAu_ IWC L,/J ,/- 4,Us Dr ;,ram' TG«.v of �A r� MAI-c\-1 ZG Cct � 'G Fri tJ I t_LC A -SC. 0®&IZ1-7 o �e Al q 1 6 1 plow L-V7 77 { i i 3 t i 66 - a EX°s n6 - .;U5T 1 cF. 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