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HomeMy WebLinkAbout0042 LIMERICK COURT - Health 42 Limerick Court Centerville / A 169 083 r TOWN OF BARNSTABLE LOCATION Q SlMeeA C0u,7--CCj1- SEWAGE # �069 " VIL,-AGE ��!/ re ��� ASSESSOR'S MAP & LOT —Ce'3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 11000661 gxw i G LEACHING FACILITY: (type) (size) 1d SQ0' P/cry 0,-t-0� NO.OF BEDROOMS Q BUILDER OR 7T PERMITDATE: 3 COMPLIANCE DATE: 13®3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 9A a I Commonwealth of Massachusetts �93 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 limerick Ct ` '1v'i f P1 Property Address -� Mike Delbuono CIO Owner Owner's Name QJ information is required for every Centerville Ma 02635 11/12/18y page. City/Town State Zip Code Date of Inspection r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane Company Address Cotuit Ma 02635 City/Town State Zip Code 508-364-9587 SI 13522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11/12/18 4'15spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v � 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. CityrTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1000 Gallon septic tank as well as a concrete distribution box and a field of pipe in stone 12'X 30'with a 5' over dig 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1' �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is C required for every enterville Ma 02635 11/12/18 page. City/Town State Zip Code Date of Inspection i C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �x hs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 C Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 limerick Ct `V Property Address Mike Delbuono Owner Owner's Name information is Centerville Ma 02635 11/12/18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recent) art of ® Y Y or as p 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)] t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is Centerville Ma 02635 11/12/18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 218 GPD 9 ( Y 9 (gP ))� Detail Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2015 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form 1a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 limerick Ct `J Property Address Mike Delbuono Owner Owner's Name information is Centerville Ma 02635 11/12/18 required for every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the 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: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5 Depth below feet grade:g Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: p pp y feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts �x Title 5 Official Inspection Form _ la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z� 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 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: 3 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 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" 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.): Pumping is reccomended t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form �Io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is Centerville Ma 02635 11/12/18 required for every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form w; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 u 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is Centerville Ma 02635 11/12/18 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 12'x30' ❑ overflow cesspool number:p ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding no break out system is functioning as designed 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form , a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 11/17/2018 Assessing As-Built Cards J TOWN OF BARNSTABLE L40CATION ///a U�Mee�c� �Oci�T-C�/. SEWAGEN ' bd�� VILLAGE l eil lerw./�c ASSESSOR'S MAP&LOT -083 INSTALLER'S NAME&PHONE N0. J•I�,C�-/�s?c r Yak=ssa9 SEPTIC TANK CAPACITY 110006e1'tkC) kc LEACHING PACII.iTY:(type) lewc y fe6 (size)Ja se 0, PA. NO.OF BEDROOMS. BUILDER OR OVER tvsreo eA(,iTT PERMITDATE: 8-/a-03 COMPUMCE DATE: cf Separation Distance Between the: l Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge.of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 93 ' tf 01 r $A4k a 3 http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=169083&seq=1 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 limerick Ct `r Property Address Mike Delbuono Owner Owner's Name information is Centerville Ma 02635 11/12/18 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 95"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: 8/12/03 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 plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 limerick Ct Property Address Mike Delbuono Owner Owner's Name information is required for every Centerville Ma 02635 11/12/18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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 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 Evaluation by the Local Approving Authority 5-19-09 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. 4. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Dis osaUm•Pa e 1 of 15 P 9 P9 `r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is wired for required Centerville MA 02632 5-19-09 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-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 3 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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 mannerwhich 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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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`fifes"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 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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 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)] t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 220 Number of current residents: 0 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: 5-09 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 42 Limerick Ct M Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 1/A system by system operator under contract Tight tank.Attach a co of the DEP approval. ❑ 9 PY PP ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 Title 5 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 ,M 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is Centerville MA 02632 5-19-09 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 12"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): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 0 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 16' 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 Se wage Disposal System Form Not for Voluntary Assessments M 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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): i 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 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 I' 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.): 9 A Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-30'x 12' ❑ 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 field in good condition with no sign of back-up into d-box or surrounding stone.. t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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.): t5insp official document•03/08 Title 5 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 M 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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. e ac a0 23 r q5, F � _ `qq , t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Limerick Ct Property Address Brian Loughlin Owner Owner's Name information is required for Centerville MA 02632 5-19-09 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: 95 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: Original design plans show groundwater at 95". Bottom of field at 30". t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Fee ZW 3 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,MASSACHUSETTS - Yccat t+cou for �io ossal *POtem� couotructionjoermit � or Repair(iel an On-site Sewage Disposal System at: Application is hereby made for a Permit to Construct( ) P _ Owner's Name,Address n Tel. $•�• Location or Lot / /Q ,�'aw�l2� /(F �/� %meek t m��� pesigner's Name,Address and Tel.No. installer's Name Address,and Tel.No. �� Do7(C �-SSO C. ���� k�tc.P-c-lG:5?cr 1 sda.-563'-1•991f Type of Building: Garbage Grinder("I Dwelling No.of Bedrooms Showers( . ) Cafeteria( ) Other Type of Building No.of Persons Other Fixtures y Saa o G�� gallons. Design Flow gallons per day. Calculated tail flow o Number of sheets / Revision Date Plan Date ---- Title Description of Soil S �� `$6' A ) il�irrri Nature of Repairs.or Alterations(Answer when applicable Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance and not o place the systemsin operatioite sewagen until alCertifi in accordance with the provisions of Title 5 of the Environmental � Cate of Compliance has been iss by this.'i�rsLo IIealtl t Date 1 Signed. Application Approved by • Application Disapproved for the following reasons 3 � Hate Issued Permit No. 2W�- g _ . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS (Certificate of (compliance IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(j%jon. THISb let- for FO y has been constructed in accordance C Win. etc3 dateA .JY�cA� ok� Permitction with the provisions of Title ction 5 and the for DiSposCeS isthe p ovt sions set forth below: Use of this system is conditioned on comp Fee No. 2,0o 3�353 y • THE COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: COnotrticti0n ermit. permission is hereby granted to 4- to construct( )repair(man On-site Sewage System located at above Application for Disposal,System Construction Permit.The applicant recognizes his/her duty to and as described in theP comply With Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. S -(2_63 Approved by Date: r TOWN OF BARNSTABLE i / ^ LOCATION -1102 Gi!)le��e lOcir�—Ceti/. SEWAGE # C?/G3 -.3a' VILLAGE ��/en:���c ASSESSOR'S MAP& LOT IV 'Q3 INSTALLER'S NAME&PHONE NO. 0-So1 Q SEPTIC TANK CAPACITY 11D60.6,31 £�c 6 1,=,g i IeWco! X� la�S( v, es�c-c� LEACHING FACII.TTY: (type) `� ( �size) 3o' a/ NO.OF BEDROOMS o BUILDER OR OWNER MyIZZ PERMITDATE. -03 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on,site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 93 It, A3 ya ,q&fg - �y, es do _ Lek a 08-11-20 3 DEED.RESTRICTION WHEREAS, Edward P. Leavitt, of 42 Limerick Court, Centerville, MA 02632 is the property owner at : 42 Limerick Court, Centerville, Massachusetts, hereinafter referred to as the "lot" or "property" and being shown as Lot 66 on a plan entitled " Centerville Crossing for Copley Turnpike Trust, Thomas E. Kelley, Surveyor" duly recorded in the Barnstable County Registry of Deeds in Plan Book 223 Page 139. WHEREAS, Edward P. Leavitt as the owner of said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.00 State Environmental Code, Title V, Minimum Requirements for Subsurface Disposal of.Sanitary Sewage. WflERE AS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.00, State Environmental Code; Title V, Minimum Requirements. for Subsurface :Disposal of Sanitary Sewage, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on this lot be put on record with the Barnstable County Registry of Deeds by recording this document, NOW, THEREFORE, Edward P. Leavitt does hereby place the following restriction on his above-referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. 42 Limerick Court Centerville Massachusetts may have constructed upon the lot a house containingno more than two o (2) bedrooms. Edward P. Leavitt agrees that this shall be. a permanent deed restriction affecting 42 Limerick Court, Centerville, Massachusetts, being shown as Lot 66 on a plan entitled " Centerville Crossing for Copley Turnpike Trust Thomas E. Kelley, Surveyor" duly recorded in the Barnstable County Registry of Deeds in Plan Book 223 Page 139. For title see deed recorded in Book 3821 Page86. Executed as a sealed instrument this day of August; 2003. Edward P. Leavitt Jr Commonwealth of Massachusetts Barnstable, ss August 2003 Then personally appeared the above named Edward P. Leavitt known to me to be the person who executed the foregoing instrument and acknowledged the same to., ' free act and deed, before me, WED RESTRICTION � 'a Z. 0 Jasleen Dewan, Notary Public My commission expires: Commonwealth of Massachusetts My Commission Expires 7/14/2006 BARNSTABLE COUNTY REGISTRY OF DEEDS ATRRUUE COPY,ATTEST F.WADE,REGISTER BARNSTABLL REGIb IRY uF DEEDS /j / TOWN OF BARNSTABLE I OCA I'[ON 7 L/ i',M eri G kC:� SEWAGE # r j VILLAGE /V`U rS �`5 �� �S ASSESSOR'S MAP& LOT___ __ .�. INSTAL. ER'S NAN E&PHONE NO. j SEMIC.TANK CAPACITY 4' / � LEACH NG PAdLITTY': (type) (size) NO,OF'BEDROONdS 42 j BUILDER OR OWNER, PERMITDATE:,._,,._,,,r. C(31V,( UANC,E 1DATE:,,.._,.__.�,_ .� Separation OisWce Between the:. Maximum Adjuster!Groundwater Table to the Bottom of Leaching Pacility Private Water Supply Well and Leaching facility (1f any wells exist on site or within 200 feet of leaching facility) . Feet Edge 0 Wetland and leaching Facility(if any wetlands exist within 300 fret leaebing facility) Il ec c Fur«i�hud by_,.....,�. enck L t Q 0 C- I 0 60 r �►'C6 Swer Permit No. Name Location Installer's'Name and Address 1 i Builder';Name and Address '�J ��``'�' Date Permit Issued: Date Compliance Issued: �� L� r. 8 Cl IX 4 r , h 9� 9 No. 2-. 517 j+ Fimic 0 „ ............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........TOWN ...................OF...........BARNSTABLE--........................................... Appliratilan for Dhipus al Works Ton .rnr#iun rrmft Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at Lot # 66 Limerick Court, Centerville, MA ................_................................................................................ ---•-----------------.................-----...------------........................................ Edward Levitation-Address or Lot No. ......................_.......................................................................... ---.....••--•---------.....----•---••--------.......---------...--•-•---•---------•--•----•------- w .......... boa--qQ� ..Lv� dEkv..�--•-•-20-:.. (Kcs M4 --------------- -- ---- --- Installer Address 16,166 Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bed rooms............................................Expansion Attic ( ) Garbage Grinder (no) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ................................. W Design Flow........... 3EXX......110_....gallons pe4OXQ �1ay. Total daily flow..................330.................gallons. G4 Septic Tank—Liquid capacity1000.gallons Length___ . b't. WidthA '.1.0.!!. Diameter................ Depth. ii Disposal Trench—No. 1................. Width..�............... Total Length..28._.......... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area AQ49Pdsq. ft. Z Other Distribution box (yea Dosing tank ( ) aPercolation Test Results Performed by._.Sae.tsanAia.1 --1 ----J-,-Ellis..... Date..7/6// _�.....-2-125/83 Test Pit No. 1....�._2...minutes per inch Depth of Test Pit____7............. Depth to ground water------7_____.__.-_-_--. Test Pit No. 2....... ?_._minutes per inch Depth of Test Pit.!.2-............ Depth to ground water------9...u a •-------------------------------------------------------------------------------------------------•-........................................................ * Description of Soil...T.H.... .--__#1 0--2_'__ Y�XAK�.j,5���3E UARM_.loam__&___topSo- .al l.__2!_-j_':__med. x com acted, sand. T.H. #2 0 2' lo_am__ & tops_oil_s___.2' _.9_'___.med__cose._.. .and_,____- w 9-'•-1'6V----rine compacted sand; i0*i--f2' med. fine sand. x --------------------------------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLEI 5 of the State Sanitary Code— The undersigned further agrees not to place the s stem in� operation until a Certificate of Compliance has been issu d by the board of health. / agne . --------- .c. ..... ---- 3O_- � ApplicationApproved By.... --------------------------------------------------------------------- ....... .... ... .. ...... Date Application Disapprove or t following reasons:.............................................--------•---------------------------------....---•---------------- ---------------------------•---•----•------------------------•--------------------...........----------------------------------- -------------•--------------------•----------------------------•------- Date PermitNo......................................................... Issued....................................................... Date z� ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN...................OF.........-.B.ARNSTABIE u A;fp iration for lliopnoal Vorhg Tomitrnrtion Prrmit Application is hereby made for a Permit to Construct ( R) or Repair ( ) an Individual Sewage Disposal System at: Lot # 66 Limerick Courts Centerville, MA, ................................................ •-- ----............................... ...••••-••••--•----••............••••--•-••-••----••-••--••-••--••...-•--•---.....-•-......_-•••-- 'tom Edward 7 e�,;L91dtion-Address or Lot No. F.i...._......— ...u........3..�.i.. -_--- ----•--••....................:. W Owner Address a .••••-i•••-••-•--•--•••......_.................................••-•------._.---......_....---•--.. --.. ...................................................__._..................0•.........-...... Installer Address 1L 166 d Type of Building Size Lot-__-:__.47!_---------------Sq. feet V DwellingNo. of Bedrooms...........................:..:. ...._Ex Expansion Attic— -----.- p ( ) .Garbage. Grinder n( g i aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures . ---------...-------•----..... W ----------- Design Flow...........33EXX ._ gallons er g P t f1Wy. Total djiI, qow........................ ............ Ions. 1:4 Septic Tank—Liquid Li uid c acit lOflQ I W p q �p y __..gallons � Length................. Wid ` Diameter................ Depth..._._.__._.._-- x Disposal Trench—No._................... Width.................... Total Length............_....... Total leaching area.._L--- __...sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet................_... Total leaching area........._���q, ft. Z Other Distribution box (YfC S Dosing tank ( ) aPercolation Test Results Performed by._.:S.t�t.QQ�_. ia. � .�. x.... Date...T,.6f$3.._...2/2- �.13 Test Pit No. 1_.'..�.__,,..minutes per inch Depth of Test Pit_ of __�.i.____..._ Depth to ground water.......7._.._ 4z TestiPit No. 2........(.... minutes per inch Depth of Test Pit___.................. Depth to ground water....... . ....____. D Description of Soil.....T.H.--- # C • _ XT0 loam &....to Aso 11� ��'«�.'�'i---iii6d • Y ,�,x compacted sand. T.1-1. # 6-2' loam & �©�s0�.l.I --2�" ...................................................med ri�y w 9"..IV,...-I'ifff... npaetea- 5AM'i I10'" .2f--•med" Tine sand. x •-•-•-•---•----------------•----•--------•--------------•------•-•••-----------•-----•••••------•-----•------....------------...-•------•-•-----•-••-••--•••••......•----•-•--••----•••-••---••_... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -•---------.-----............................................................................................................................----------------•--•-•-------•-------------------------....-----•----------------------=-----------------------........_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I IT!L- 5 of the State Sanitary Code—The undersigned further agrees not to:place the system in. operation until a Certificate of Compliance has been issued by the board of health. lgrie ................•...--•- A Application Approved lOrth1following /'��/ PP PP :` P f � Date Application Disapprove reasons:............................................................................................- a.t.e.............. ...........................-............................................................................................................................................................................. Date PermitNo......................................................... Issued-----------........................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF Trrtifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sew. Dii os I System constructed ( ) or Repaired ( ) by-------------------- '---- - . Install at.. = /$---------- ---------•---------------------------•-------------------------••- . .......------------------------ has been installed in accordance with the provisions of TITLE5 of e State Sanitarys gibed in the application for Disposal Works Construction Permit No...e��. ............ dated.------__....................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI FA TORY. DATE............................................... . i_ Pa ............ Inspector-__'----- ------------•--------- ................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.................._.........................---...................................... " No._.�. .ftz FEE...( ........... �io�la��l oro �onotrnrtuan rrntit Permission is reby granted.........ff.n.1(fw1* -------•••••---• .......... ••.... •. ----•--•-- . •-••---• ............................................... to Construct ( o e ai ( ) a r3ual rage ys em 6.-••.--•-• ... ....... at No. •-••.----•---- ----........... Street as shown on the application for Disposal Works Construction Permit No.ep3_ ' __ ........... ............................ ................................................ ...................................................._ DATE................................................................................ B d of ealth FORM 1255 HOBBS & WARREN, INC., PUBLISHERS Completed by HIGH GROUND-WATER LEVEL COMPUTATION • Site Location: Z�M / /! C;� �— f Lot No._66 Owner: Address: Contractor: Address: Notes: !i STEP 1 Measure depth to water table to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. { date STEP 2 Using Water-Level Range Zone and Index Well Map locate ' site and determine: A) Appropriate index well . . . . . o97.�o B) Water-level range zone . . . . . . . . . . . . STEP 3 Using monthly report"Current + Water Resources Conditions" determine current depth to water 1-eve] for index well . . . . . mo yr STEP 4 Using Table of Water-level Adjustments for index well STEP 2A , current depth to water level for index well (STEP 3) , and water-level zone (STEP 2B) determine water-level adjustment . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STEP 5 Estinate depth to .high water by subtracting the water- ; level adjustment (STEP 4) from measured depth to water level at site (STEP 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I i or Ssls�-7%6 217,9 LI MEPICK COUR T id-L. /S./' �6L,/4,75 �EL•/¢,Z$ �EL /$,67' EL /fJ 02' G07r '�65 \ a �, I�F '30' LOT-=�`b.7._ i 1. : �.- L7WZ'4 lN¢ TEST .Yr},✓ EC 9.SO' � OD b J. r /000 6AL O $ x 28' LEAc14 1 �i,rrl3F�o,,./ o/Ffwso�g- 1-70 /o [�T 11166 EL�20.O I CERTIFIED PLOT PLAN /VO7c - WATg-R LOCATION C£NTe'Rd/L LF MA -4 7-Ao5 %.✓ 7-es-r h`OLe z - 7/6I,93 = SCALE L= 20' DATE _ :?Z C0 $-3 E[EV, 0. pa' PLAN REFERENCE _c��� ZO#16_�..__ O� C'y L'�3 !-s. 1�� GA/.P•CRn/ 1ST!�s� w -I CERTIFY 'THAT THE SHOWN ON THIS PLAN IS LOCATED ON THE GP,OUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF -- WHEN CONSTRUCTED PETI TIONER : ED WAPD L EVI T T DATE EL TOPOF FOUNDATION CONCRETE COVERS ; 4' CAST IRON �_ '-r-Ti,-TTTT,/ a: 12 MAX. , PIPE (oR d' SOH, 40 P.V,C, (oR Eauw,) ECiUIY) - MIN, PIPE MIN, 2"4.4YER . �✓gsNEo P I TIC H PER .3/B" RC-46T,0A/E PITCH %4^ PER FI ( 6740,1E INV E � ' EL OAT VINVERT INVERT a " - SEPTIC TANK DIST, o INVERT EL >��_.. BOX EL-?,A' 28 ELF. _ - - l�Q4:_ . GAL INVERT EL 7..37.1 iv�.E/ 7D2' Off �3- y <9/ F40W /O I /3 Di F 1 Soa s Lin/ED i,/i rN h 2 OF ►✓A,S ro S 7'101VE. PROFILE OF ( � , I SEWAGE DISPOSAL SYSTEM ' NO�� - �,/A-C.� f£✓EL /ID�'(�STME�I� _/ y' NO SCALE �� f i 44sm/G /.voEX Wei L A s,/230. - 201V6- ®, 9 SOIL L 0 G WITNESSED BY D A T E _ Z/25/83 _ TI ME _ 71-610 I TEST HOLE I TEST HOLE 2 i ELEV._8-_6$� _ ELEv, _Q.•�0� _ 1rLL/S?�-5fd-?_ _Q,/�RLL .7/AWENGINEER I / Lfr,,;,, OAM+i TO .50,j 6.65 2 / LOAM T4�SOi� { ��. ' 7.so SIGN,DE DATA 12 f ' NUMBER OF BEDROOMS._ - MEDIUM GARBAGE DISPOSAL UNIT- - - C'Onll? \SAAID - 7' TCTAL EST, FLOW f G'g0WV0P/47,-R 1 i A K ( //Q__GAL�BR�/DAY x13 BR.)- - - - - - 3V0 041-1DA t Gxawn A, k --�i.Qoo' REQ. SEPTIC TANK CAP (x150%)._`.. _495GA1/O�r_ I F'iidE COM? - � i /O' SAnip ACTUAL SIZE OF SEPTIC TANK __/000- 6R4 i2 LEACHING AREA REQUIREMENTS i SIDE WALL AREA eff. GAL/S.F, Pr-Rc �.�j7f C2Mad� I -- — — BOTTOM AREA _/_ GAL/S,F. pE�?C Rqr£ <2.v),i✓/j,✓, GROUAID\,✓47ER LEACHING CAP (BOTTOM SIDE WALL) 4'r //.q" El, APPROVED_ _._ _ _ _ _ _ _._ __ .. BOARD OF HEALTH RESERVE LEACHING CAP. • NUMBrR th7 LE'AlAIiNG TR£it1CNES / h/ITAI Tti/RFE { DATE- - - - - - - - - - - - - - -- - - - - - - - . . : .. _ , ' AGENT OR INSPECTOR 'L0K1- o1.rr&SQf?S 'J'/0 —_ OF ly S LOT 66 1_1-7,rPIC4 COURT r Crn/�'�f?ViL,CE,�YIA l��O I � /� [ 1 / SIN1111M�1► i PETITIONER FD WARD L C V I 1T /T s G/M/5H Fl- �L_ 3S. iC2 SO/L.S TEs'T �'C-s UL TS S�WA�E sYs`r'EM PRo�ILF _ p EL, 30• o A SANDY 7 S Y2 s/2 DE M//V, S<OPE of 2 7D 7, LOAM /3ASEMENT (,"MAX, g'' MIN- ---------- -- - SZAs ,D/sT,BOY w/,"soMP Ir-- 3(" MAX, 9"�M/n1- SANS o - /2"A41, /• //l/A/EIP ItJv. 28.6o 36" MAX 2" COVER of %¢"- �Z 570/\/457 --- 5CP• hb PVC a� IN 4 50 ¢a PvLc-vcz- 2 ls N V. sNc N. 4o P � "MIV. — .3a2 v 2$9 s 28.53 .<.t. y _ r - rfa MSEA ND 2f3.13 3 , �P LE „S�p GF' EL 27. 25 _h- l /2 TWICE h/ASHE� STONE � EPTH 6PFf CRUSHED .579 A _ STONE ' 3 I DY/Z USE' EX/5T/l/G i�000 GAL. 5 PTIC `TANK 5: 17' -O/L5 AFssO/'PT/O/V sys_T'EM C2 14�/1VE — „ G/2o un/.D WATER 2 2, o S I USE 4„o Sc H.40 P&RFOR47-E o / 'OTC CO/`/7-9ACTOR 5H.q LL 2C/4OVE ALL /MPE,eV/DUS' NJATE,e/AL htpE pcR 310 cM/Z 15.ZS .1c8) WITH/nJ THE S.A. 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D �� � �" < �0 ATE'P sFRy E 2 '`9�,PM. �8- : - A SO R pT/ON i41 PI�OV/SIOI� = v `� I <</"va 3g N P% E4. 3,9. G �E 30, G '32 \ ,J P� p _ s" �, L CUS cS MAPCALE . /, 3000 � q � N ,,, ,• � � s, � ,,�����3 of n�'��•��� SO •' �N F . O JO , AN.D 5�k/A G E PL AN ,� PRE P.�RClj FO.E' No.335$9 % 30• cy/wC oao,) !y�fCISTEP��o� E.6 Wi R.D L�,4 V/ 7"7- SUR��y 34- s" �o '3s"r l - IOROI'0.5'C-0 6W;V 9GC -s'YST�Al l �� 3 y or +r�s //P6R.�4DE WILLIAM sG 31' UEBERY �2 L/ME.C'!G K CO U/ZT ; AR 3sr 3� as 73971 �3�9�Z/V571ABLE NIA. 3 8 f �o N - 9 P t• ' `' - U Y /G ZO 3 /VOTE E Sys-rem NOT DE5/6^1Eb O YC-,41C01-,q/Z LOAD/N6, %/. DoYLE AasOGlA?E3' TELEPffo/J�: ,508 -SG3 - /994�