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HomeMy WebLinkAbout0011 KALMIA WAY - Health 11. ,almi a Way Centerville A= 188 — lib - 008 7 < I No._90L6 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ripfication for hiZg�raadAeW)jAbandon 6 tem Construction Perai Application for a Permit to Construct( ) Repair( ( ) ❑Complete Systements Owner's Name,Address,and Tel.No. Location Address or Lot No. // Am // Assessor'sMap/Parcel � AA1n4,,4 wf( Cew-tcJ✓-Iffe Installer's Name,Address,and Tel.No.b`l�,6w C> e/ Designer's Name,Address,and Tel.No. ,fire'i k dog ws , -4k 6 Y� ` Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(i" Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 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 Natu�of Repairs or Alterations Answer when applicable) ��Cr �e� <<,,,� /iZ2 G1 qty d S c// 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 Co�notto e system in operation until a Certificate of Compliance has been issued by this Board of Healt G i ed ca Date 0 �� Application Approved by B J Date Application Disapproved by Date for the following reasons Permit No.A '� Date Issued 10/No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLE, MASSACHUSETTS 1 21ppYication for bisipsa 6p� tem Construction Permit Application for a Permit to Construct( ) Repair( grade( ) Abandon( ) ❑Complete System (I—I Indiuu&al-Eom�nents Location Address or Lot No. // ku/� �"A--l/�4 y Owner's Name,Address,and Tel.No.7,3- �-G-r4 u n OOgAssessor's Map/Parcel / Ae4/.,,u,'q (,cJ/f Y nee yt,,/,li //e Installer's,Vame,Address,and Tel.No.D; -2., dN o scw-e/ Designer's Name,Address,and Tel.No. AacP 0(4 "— k Johµs 2(,e.+t, 5 r_ 02 66 k Type of Building: vd, Dwelling No.of Bedrooms YLot Size sq.ft. Garbage Grinder Other Type of Building / No.of Persons Showers( ) Cafeteria( ) v Other Fixtures Design Flow(min.required) 3?6 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title 1 Size of Septic Tank Type of S.A.S. 2 Ii000 p Description of Soil Nature of Repairs or Alterations(Answer when applicable) See'l Zee A N y w/ :7,-t$'7L4// f• Date last inspected: 'G—A 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 Cod not to place-the system in operation until a Certificate of Compliance has been issued by this Board of Healt . c i ed A A 171717 ° Date D �l Application Approved by (/ If ,B Y Date Application Disapproved by V Date for the following reasons Permit No. Date Issued v -- ------------------------ �_ THE COMMONWEALTH OF MASSACHUSETTS LL l BARNSTABLE,MASSACHUSETTS 6 n F Certificatcof Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) t a Abandoned b /,I at �/ °. ��, 1 (,u u.Y has been cons •cted'n acc.yd ce +• r with the provisions of Title 5 and the for Disposal System Construction Permit No ated Installer Designer #bedrooms Approved design flow gpd The issuance of his p it shall not be construed as a guarantee that the system wil I 'on on,, designJ Date ` Inspector /, o Q ---------------- Y----------------------------------------------------------------------------------- - --- No. // i Feed~ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction 3perm t Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at �c�/tkt -V t/I "le 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:Cons U o u b coxnpleted within three years of the date of this permit. ` Date Approved by �i �� � ��� r i Commonwealth of Massachusetts ��j -f�— 14 : .. Y Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name / information is required for every Centerville ✓ Ma 02632 3/6/16 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. _ Important:When A. General Information filling out forms / b on the computer, 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 r� Company Name 8 Johns path Company Address S Yarmouth Ma 02664 Cityrrown State Zip Code 508-364-9587 S103522 Telephone.Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/6/16 I snI pector'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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) i hnspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): l5ins•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 ^M 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown 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): Septic tank is leaking at center seem. System will pass after tank is sealed. ❑ 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 16.303(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 1 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 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown 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 Y 9 P 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 co of the analysis must 99 PY Y be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 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•3113 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 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 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 septicopened,tank manholes uncovered 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Citylrown State Zip Code Date of Inspection D. System Information Description: System contains a 1,500 Gallon septic tank as well as a distribution box and two 1,000 gallon leach pits. Pits were dry at time of inspection. System is functioning properly. Tank is in need of sealing. Number of current residents: 2 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 ears usage d 219 GPD 9 ( Y 9 (gp ))� Detail: 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 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown 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: None provided 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 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New leach pit was installed in 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 2 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 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 G M 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown 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.): Tees are in place and levels are normal. 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 G M 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): No signs of push back or carry over 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): System is vented through the roof 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•3/13 Title 5 Official Inspection Forth: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 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 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.): No ponding no break out 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 Commonwealth of Massachusetts Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityfrown 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 © C C. 30 13-G /7 6 r tD W � D .rr3-9 /?�`/ � t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown 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: 10+ ft 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: 3/15/94 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: Test hole data on plans shows NGE at 10+ft 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 Ix W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Kalmia Way Property Address Tom DeGraan Owner Owner's Name information is required for every Centerville Ma 02632 3/6/16 page. Cityrrown 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addr4abnd that We C> information reported below is true, accurate and complete as of the time of the inspe>tion. Th nspQon was performed based on my training and experience in the proper function and riair enance ofaon 9P sewage disposal systems. I am a DEP approved system inspector pursuant to."S ction V5.340 q, Title 5 (310 CMR 15.000).The system: `� ® Passes ❑ Conditionally Passes ❑ Fail ❑ Needs Further Evaluati by the Local Approving Authority 00 10-10-13 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. d gal Z15 t5ins•3113 Title 5 Official Insp o Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 r 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 7M 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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. r' 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 F1 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 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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 . 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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- 1 0,000g pd. ❑ ® 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I , Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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: Sump pump? ❑ Yes ® No Last date of occupancy: 8-2013 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 'r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A 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 °M 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 30"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: 1500 gal Sludge depth: 12" t5ins•3/13 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 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 page. 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 20" Scum thickness 1" 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 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. 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 Llt5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts y Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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.): Good condition with water.at working level and no sign of back-up from pits. 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.): i * 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 Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-1000 gal ❑ 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.): Both leach pits were in good condition and empty at inspection with pit"F" having no visible usage stain lines. Pit"G" had visible stain lines at 36" below inlet invert. 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.3/13 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 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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.): I ' 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 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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 9 1 J 1 1 ! �/ I u 41NN/1f Y y �- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 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: 20 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: USGS and town maps show groundwater at greater than 20'. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Kalmia Way Property Address Helen Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-10-13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 � LS JH p-E.- 39oeck , F ao ,6„ TOWS I OF BARNSTABLE ml, wr" y SEWAGE # - -- - - LOCATION �� g . VILLAGE Leo �er U r Gl_e ASSESSOR'S MAP&LOT JNSTALLEWS NAME&PHONE NO. SEPTIC TANK-CAPACITY LEACHING-FACRXrY: (type) " I�— (size) 4 1606 (1 NO.OFBEDROOMS - BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE; Separation Distance Between the: Maximum Adjuster!GroundwaterTable to the Bottom of Leaching Facility - ---- Feet Private dater Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any w lands exist within 300 feet leaching facility ���� ` - - Feet_ Furnished by -- ,�✓I � �s —low'/,f 0 C o o � _ O A TOV+IN 0 BkRNs ABLR a0 h fe%.� `lTei — �. s>rssOi �s ! A.L0 4pIIZ'S NA11 B 1410i tE N0. •----�---�--- �-�-- C r . 0 -DR06ms . w Dolia aR OVIMR IAration Distmom ocftwoomi the. ,... Fki tcltttutli l�cijustcil Cbpuia�iw�tfec'1'�ble td tlbc.l3tttlnm a!)E.ruGhcrt�k1acilit+� ..--.�..; �.,..-�-�-- -�- �a8�; 1ntc t up ply,Well Dotd fGca4hatA�Pap q ,cny 54 scot. li cdand mid1L,eacCti�t�l acx3lsy'.�Yt arty wetlattci5 east k e tys9.laicb:l4f?fc:ca �(lC�ttil �' e y � �• - 7.y• ,00g �� � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information �� (n 1. Inspector. Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Eva ation by the Local Approving Authority 7-10-09 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. —7l t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR.15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document•OW08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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. t5insp official document-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than d 00 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/ day flow ❑ ® 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. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 CM 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. ❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area'-IWPA) or a mapped Zone 11 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 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 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 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 CM 15.302(5)] t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 7-9-09 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding-tank present? ❑ Yes ❑ No Non-sanitary,waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. CitytTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner not pumped 3yrs 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): Approximate age of all components, date installed (if known) and source of information: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M0 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 36" 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 30" 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: 1500ga1 Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20' Scum thickness 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 14" How were dimensions determined? Tape t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 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.): Tank is in good condition with baffles installed and no sign of leakage. 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.): 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): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 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.): ` Good condition. Pump Chamber,(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-1000gal ❑ 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"F"was empty at inspection with no visible stain lines. Leach pit"G"was at 36" below inlet invert. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 L A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): it .. t5insp official document-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Kalmia Way 'M Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. b4 JH 35J E- 3V ' tb' Dec t=- yL1•6 t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 16 40� ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM ' 11 Kalmia Way Property Address Joseph Donohue Owner Owner's Name information is required for Centerville MA 02632 7-10-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' 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: USGS maps show groundwater at 20'. I t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 15 No.. .d...... Fps ..1 ... /1..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apli iratilatt for Uhi-Vi1iitt1 Wurkr, Cnowitrurttnn Prruttt Application is hereby made for a P rmit to C struct ( ) or Repair ( an Individual Sewage Disposal System at: j ® Location-Address or Lot No. .. - A!0 re 34A....d:5........................................................................... Owner Address Installer Address d Type of Building /, �g ""'� Size Lot��©�!_r�_y.._..Sq. feet aDwelling— No. of Bedrooms__.`1...\:!_; _____________________Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width-----.-_.__---.- Diameter................ Depth---------------- x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No...................... Diameter-----.----.---.----. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------_------- ............................................ Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit-----.-_-_--_--__- Depth to ground water........................ fr Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •--•-•-••-•--••...........................................••---•-••--........_...--•---------....---........................................................... 0 Description of Soil---0-. Z•--�V��-- •---•---•--•-_`-.--_'........ O S�. .."r�"`$`J..-•--.. 1N��x ....................................... U ---•-•-••••-•---•---•--•...•------••--•---•--•••-•--•--•-•-----•-------•-------------•-••-•••••-----------------•--••-•......-••--••---- W U N ure of Rejairs or Alterations—Answer when applicable....�4%.-.----- � --- . .....CAUr��._._ t wl, �`� ` •.........a:......._5 ...._._-•-•-•e.....---........ n w G.-------• �-s V"'Z=/ ....................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ..... . ........ ........................- .............. - . ......ZZ .�..� Date �/ Application Approved B '..:.....:..:........._.... - / Date Application Disapproved for the following reasons- --------------------------------------------- . . ..... . ........................................................ .................... -- .-- .............................................. . ......... . ................ Permit No. .---- � f`.. _.... Issued - ;C.°'. .1........ Date BARNSTABLE LOCATION L-jr SEWAGE # `'VILLAGE C etJ214y'le ASSESSOR'S MAP & LOT j%-j0?ji-0og INSTALLER'S NAME & PHONE NO. ��Q't-cvk7 SEPTIC TANK CAPACITY 1 1 d OCR LEACHING FACILITY:(type) (size)_j. Z NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER ! :)_ BUILDER OR CqNR DATE PERMIT ISSUED: 'I DATE COMPLIANCE ISSUED: 3I 1 'I VARIANCE GRANTED: Yes No l_ s - n� Lea � i V M:� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ger#tfirate of Cnompltttnce THIS IS TO CERTIFY, That t e"IndividuaI'S wage Disposal System constructed ( ) or Repaired ( ) by �- ..... .. ......... ----------- Insral Ier at .`.s�.._..��----------c?D,Lv�,--E.------..w..^-`z-------------C-L-w�--rz--,���...----------------------------------------- ------------_------------------------. has been installed in accordance with the provisions of TITLP of The Sta nvironmental Code as described the application for Disposal Works Construction Permit No. '" ....._/ _.. dated..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UEA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... ..",'.... ,..... .. `.... ... Inspector,.' ..1"---------- "-s � � c�:!. -------------------------:`''--------------------- ---- —————— r---------- THE COMMONWEALTH OF MASSACHUSETTS / 88 --/ tQ -008 BOARD OF HEALTH f�� CJ TOWN OF BARNSTABLE Uispnoa1 Permission is hereby granted..- \fietc" ......... _ __ to Construct ( ) or Repair (Jk:'Z) an Individual Sewage Disposal System at No ...�.� A`w-��, ' ``:........................................R ,1-1----------------------�(,a-� -----�------------------................ ....... . --- Street as shown on the application for Disposal Works Construction Permit jI'o�-- --c—Z---- Dated--- // -------------- ...................f..`.......... — - --- DATE------. / 'Board of Health �f FORM 36508 HOBBS B WARREN.INC..PUBLISHERS No..`.. Fxs :. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I TOWN OF BARNSTABLE Appliration for Biopo3al Workii Tonotrur#ion rrrmit Application is hereby made for a Permit to C-ristruct ( ) or Repair ( an Individual Sewage Disposal .System at: / CL Aj 5Lsav,\tom---••••............. ---.........--•----•---•------•---•--•-....---- ...�_ Location-Address or Lot No. -•-••-a..........................f)MA N U- - ----•------•-- - ---------•--....--•-••-••-------•---------------•-••-•••-••--•--•---•••...... Owner Address w � k cOV-S` ca �"`� ,-� 3 2Z?Sh 24 l:\tC h+J - . - =C' Installer / nn Address PQ d Type of Building (( �.) � ClCFM.h Size Lot-_�'�_----©1-_�3. Ll.....Sq. feet U Dwelling—No. of Bedrooms... .?. �....:........---.-_._-Expansion Attic ( ) Garbage Grinder ( ) a ---- Other—Type of Building ------------- ---`.---4--- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------------------------------------------------•----------------.........---.......---------•-----------------------.........••••-- w Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacitv............gallons Length................ Width---------------- Diameter.-.-..-------_- Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area----- ..............sq. ft. Seepage Pit No...................... Diameter...........--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aTest Pit No. PercolationN I suits , Performed nutes per nch Depth of Test Pit_------------------ Depth to ground water.................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.-.--..._._---._-•-. Depth to ground water........................ 1:4 .................... ...................................... ODescription of Soil.... ...... v -•-------------..................................................................1 - ` !" U -•••••••-------------------•••---------•-•-••-•-•---------•-......•---•----....--•--•. .....------•••--••----••-•------•••--••••............---••-•....-----••••••••-••-•-•-•---•--•---••-•-----••..... W x ••-•••------------------_-----------------••-••---•---•------------------------...-•--------•-•-•------------••-----•------•---••••---•------------•••••••••---------------•-••......--•-.............. U Nature of Repairs or Alterations—Answer when applicable-----Y! %--------- a S..........�,rdQ ..... .................................� t1t�4 ..................................••••••------.......-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ...... �N-. ----.. ..� !y�. ...:...... � Dace Application Approved B :......... -Yv -_ 4.�• - =....e r� Dace Application Disapproved for the following reasons: ...... . ................... ....... . . . .............. .. ......................................... ---------------------------------------------------- ----------------------- --------------------------------...-............---------------------------. ........................................ �•a---• CDat Permit No. .............1 ---------------------- Issued -------------- Dare J I TOWN OF BA,RNSTABLE UtCA.TION ,L(�-� f�AI ff,i fA (,,,jA(4 SEWAGE # ASSESSOR'S MAP & LOTyV?LsAGE 0 6� .STALLER'S NAME & PHONE NO.Q - y )1--Ve(-A � I l�Lfe) I")SEPTIC TANK CAPACITY 1600 G-f-)l 00.1 LEACHING FACILITY:(type)Pfccn- 1 (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER +I�BUIi.DER OR OWI+TER {H , R c �� ) Id, t1 c tj 12 DATE PERMIT ISSUED: DATE COZit LIANCc ISSUED: VARIANCE GRANTED: Yes No �� A !�''" j w�� �� `� �� ��. � 1� •1. Y 1 k'q���a �;�� ' .. ,q �✓ " Fps No21..._..----- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .Gl71J-...... .....OF..--.... Ptf2!14e7.r�lz......................................... Appliration for 1 upati al Works Tonstrnrtinn tirrmit Application is hereby made for a Permit to Construct ( '' or Repair ( ) an Individual Sewage Disposal System at: � ........w. r . ... .............. 4Ltion-A r ess Q----•- =-•-•-•--•------------•-------------- --•--• • .....Q5-•--- ............... ................ Owner Address a -•.l... •--- ---- .--••-••--••------------------------------------------•--• --•--- -• ................_......... ................------ Installer Address d Type of Building Size Lot..._20,1514L...Sq. feet U Dwelling—No. of Bedrooms...............2-------------------------Expansion Attic ( ) Garbage Grinder ( ) pa,, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures-.............................................................. W Design Flow........................*:A.5�............gallons per person per day. Total daily flow____-___-___--.---.---__.�3.0.....gallons. WSeptic Tank—Liquid capacity.].f,00.gallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—. o. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No______ ___________ Diameter............9-_-_- Depth below inlet...._..�P_....... Total leaching area....... ft. Z Other Distribution box ( +I' Dosing tank ( ) �_Z� � W Percolation Test Results Performed by._...._ P T —...t ._-.j QK.................... Date_....._.__.________._._.....__......_-. ,.a Test Pit No. I.......-L-.minutes per inch Depth of Test Pit......... �__-- Depth to ground water_- ............. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•-••---•---------------------•-•------•---••-•-•...•--•---•------••-----•--•-•-••--•-•-•-•--_•-----......................................................... 0 Description of Soil................. cx-> ---•------------------------------------------- L� f s��--------Atl,Ems?--------------�:A.14. -------------------------------•------------•--•----------------•-•------------ 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has, been issued by the board of health. Signed / ( Tf ce ApplicationApproved By --... .. ............... ...... ........... .. . .. - ---------------- ------------ Dace Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------------- IssuedPermit . - �-------------------------------------*------ --------------------------- -----------------------. �reQp- e � q Z�0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tip............3.." ... !:.................OF........I '.f'>.eF. t3:i. 'a. >........................................... Alip iratiun for Biupuuttl Works Toustrur#inn Prrutit Application is hereby made for a Permit to Construct ( '�or Repair ( ) an Individual j System at: A ation-Address or Lot No. ' Owner Address W Installer Address Q Type of Building Size Lot.. ...Sq. feet U Dwelling—No. of Bedrooms...............—s.........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures . Q ---- ---------.-.------•------------••-----------------------•----•----------------------••--•••---•----_----- W Destgn Flow........................ S .................... per person per day. Total daily flow..........................a3.0.....gallons. WSeptic Tank—Liquid capacity-)001-0.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------I........... Diameter............ .... De th below inlet........ Total leaching area.....�".sq. ft. Z Other Distribution box ( Dosing tank ) _ `-' Percolation Test Results Performed b .alp ..`.YL_... ............... Date........................................ Test Pit No. I......_.�r 'minutes per inch Depth of Test Pit.......... Depth to ground water ............... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ...............................................,•--.................------------T•-----•-----................................------••------------•---....-•-- 0 Description of Soil........................................................................................................................................................................ ...........................•--------....._....._......._......-•---.....----= -----.......... '------.._...,.---------•-----...-------•------•-------------------..._......-••---•-_.. W UNature 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 TITLE 5 of the State Enviro 01tald �g ersigned further agrees ngIA/*lej system in operation until a Certificate of Com�1' hd has been issued by the board of health. Signed --------------- --- �• Date Application Approved By -- �� -... /�' Date Application Disapproved for the following reasons- --------------------------------------------------------.............................................................................. ------------------- -- - ----------------------- .�. �•"'"n r� Dare Permit No. -------- ,50----_-------_------ Issued ...�� - )� 0..- ...................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �'`-'U;)t.�... OF ........... _ _N N°I p:Ftk f��_k�-.............................. Cie of C�ultyliattre TI�-1S IS 0 VE, � That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ---- pC ----------------- --- --------- ------------------------------- --. ..-- . . -- .................... . -- .............. at . �!\t1. �: ------f t'f. �,/�'�11 /� �1� �c�yr - -- ------..------- ------------------------..-- --------...-- has been installed in accordance with the provisions of TITLE 5 -f he tare Environmental Code as cribed in the application for Disposal Works Construction Permit No. ..... ....... THE ISSUANCE p F THIS CERTIFICATE SHALL NOT BE ON TRU D AS A GU RA TE HAT THE O S , SYSTEM WILL FUNCTION SATISFACTORY. DATE............., ...^ .. ........................................... Inspector ----------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD,,,OF HEALTH f /� 4....°(...�.... O F.........:::......................................................................... No.l,_�..,....... _e.. FEE./ .......... I iuu�u,�' �rku utt/rj�#i�un rrutit Permission is hereby granted......J_.0 _._ 1, ._:1/....................................... to Constr ct or Repair ( r an Indivi ual Sewage �ispos yst ,// at No.----- ... !y_.lr ._.. .�Y "��...le-.. .(�.....----- Street as shown on the application for Disposal Works Construction Per • No.[1__�_._�� ated.. ��A .............. .......... . --•---- •.----•.......... .......................... .......... DATE........----------�--------�-----�----------------------•--•------ Board of Health FORM 1255 HOBBS 4 WARREN, INC., PUBLISHERS 0 �1i.IGC.� �L�MIt✓`-( - 3 $1=D1ZfJONC +� -- ,� 33o, (mac % * 4-95 6.Po. / • U Ste- l 000 u,h,L. �- '- ' �lSPoS,Dt_ PtT USE - • -- l O oo GAL. ,r � � 1,W A .- AeEA = (5o 3775 G.P.D. tj TU7r+O.K aoeA= '6T=. (V f TOTAL' - >ESl6kj = 425 G.Pr_>. CP<T✓2oGT�A LLQ T�1o,dU► _�Q( 3W 6.PD. Smiw* 02 Lz!A. 4 Tl 1 e Of ,fin' r' ��.� d- N o RICN.4npl _.TERA. 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