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0593 LUMBERT MILL ROAD - Health
593 Lumbert 14i.11 'load A = 146 - 031 Centerville i I IN y UPC 17534 No.2153COR IsASTINOS.YN i oF� Town of Barnstable o� -Regulatory Services HARNSPABM ; Thomas F.Geiler,Director MASS, �m Building Division QED MA'1 A Tom Perry,Building Commissioner 20 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: [_ JOB LOCATION: V ' ! +� 7E'r V number street �ry 'r village -a 2 7�-�'��� 7 "HOMEOWNER": �� �Tffamdo, lv?..l'u- O 16®.M 03 (�- % 7 pG 3ILI- qj�--- name �,,•..home phone# hone# CURRENT MAILING ADDRESS: �O.X �'Ia • 0/9.a/ ci Vtown state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,_that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned'$omeowner"assumes responsibility for compliance witli the State.Building Code and other applicable codes,bylaws,rules and regulations- The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will.comply with said procedures and req '' em� f , Signature of Homeowner 1 Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMIMON- The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming-the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt Doc: 1P062s159 04-26-2007 8:58 BARNSTABLE LAND COURT REGISTRY I DEED RESTRICTION WHEREAS, �C�7r '� of Ss�—,ama>73OY4 l a - D/` f MA G�'(address) is the owner of S_'73 oltLf�&At � � located ddress) at tt MA (hereinafter referred to as and being shown on a plan entitled "Subdivision of Land in cLlp e_ MA, Property of , et al, duly recorded in Barnstable County Registry of Deeds in Plan Book , Page ; . � plan 3r] 3d-�} 5 Z-C Or on Land Curt Sian Number � 0", L- 0. b/�,ej')U7�, Ctnc� SCt'9TT H ��WHEREAS, as the owner of said lot has (ownees name) 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 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compiance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring*that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record'with the Barnstable Cou-n_t-Y Realof Deeds by recording this document, YAZORU qua�} ':'• ;� -r 1 ::� . Se o-CT- 9 N NOW, THEREFORE, VwOs hereby place the I (owner's name) 0 . • ry following restriction on his above-referenced land in accordance with his o agreement with the Town of Barnstable Board of Health, which restriction shall o. . run with the land and be binding upon all successors in title: �= )?oad- may have constructed (address) - bedrooms. o up n the.lo a hou a contai s g n more than �(3) 'Di agrees hit i lJ-ll be permanent deed o (ownees name) S q(p CQI'l3 t l(P� V restriction affecting bi-15 located on J5 q3 u N644+A 1��R� c being shown on the plan recorded in Plan ook_ , Paged r � .• Or on Land.Court Plan. - 5 2-4- i For title of see the following deed: Book , Page; Or Land Court Certificate of Title Number Executed as a s+paled instrument day of 0- 406wer,'-q, signature wner's signature Owner's signature COMMONWEALTH OF MASSACHUSETTS ss , 20 0!1 Then pe pally appeared the above-named known to me to be the person who execute the foregoing instrument and acknowled d the same to be free act and deed, before me, Notary Public "q�WN 8j My commission expires: zj ,a o.� r� . asF�eM _ rV 'O . 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Property Information: forms on the computer,use 593 LUMBERT MILT_ROAD "7 only the tab key Property Address to move your EMILY NELSON 7 (� cursor-do not Owner's Name use the return key. 593 LUMBERT MILL ROAD �. Owner's Address CENTERVILLE MA 02632 Citylrown State Zip Code 6 Date Date of Inspection: sate � 2. Inspector. DAVID J. BURNIE — Name of Inspector DAVID J. BURNIE&SONS Company Name 307A COMMERCE PARK N. Company Address S. CHATHAM MA 02659 Citylrown State Zip Code 508-432-7420 Telephone Number B. Certification a"j (711 , I certify that 1 have personally inspected the sewage disposal system at this add and tt�the-' information reported below is true,accurate and complete as of the time of the i on.<The in9jection was performed based on my training and experience in the proper function and ntenanogy of orNite sewage disposal systems. I am a DEP approved system inspector pursuant IV,ectiortA5.34A,;Df Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fail '•-r ` ❑ Nee 'F h r a y,th pproving Authority Ins ors Signat 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. titles 2006_blank.doc.doc•0312006 Tdie 5 official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 s r Commonwealth of Massachusetts R Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cunt.) 593 Lumbert Mill rd Property Address Centerville MA 02632 City/Town State Zip Code Emily Nelson 9-25-06 Owner's Name Date of inspection Inspection Summary Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: system Is functioning properly and shows no sign of failure y 9P p Y g 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: BLANK T-5 USE SAVE AS ONLYM.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (font.) 593 Lumbert Mill rci Property Address Centerville MA 02632 Cityrrown State Zip Code Emily Nelson 9-25-06 Owner's Name Date of Inspection B) System Conditionally Passes(cunt.): ❑ 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 pipes)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 BLANK T-5 USE SAVE AS ONLY!!!.doc-0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- �-fb Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Fora B. Certification (cont.) 593 Lumbert Mill rd — Prope Address Centerville MA 02632 Cityrrown State Zip Code Emily Nelson 9-25-06 Owners Name Date of Inspection C) Further Evaluation is Required by the Board of Health(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, perforrned 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: BLANK T-5 USE SAVE AS ONLY!!Ldoc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Certification (cunt.) 593 Lumbert Mill rd Property Address Centerville _ MA _ 02632 edyfrown State ZipCode Emily Nelson 9-25-06 Owners Name Date of Inspection 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 Y 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. ❑ M 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 of 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. Yes No ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. BLANK T-5 USE SAVE AS ONLYM.doc•03P2006 Trite 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 �J Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cost.) 593 Lumbert Mill rd — —� — Property Address Centerville MA 02632 Cityrrown State Zip Code Emily Nelson 9-25-06 Owner's Name Date of Inspection 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 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 DeQartment. BLANK T-5 USE SAVE AS ONLYM.doc•0312006 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 6 of 16 ��L TOWN OF BARNSTABLE JaOCATION � `1 J I H . SEWAGE # i a�a VILLAGE M " ASS SSOR'S MAP & LOT lq46 ®,�i 1 INSTALLER'S NAME&PHONE NO. `�C . SEPTIC TANK CAPACITY I D b © �. 1� LEACHING FACII.II'Y: (type) ` I' ' Vv`S. (size) NO.OF BEDROOMS BUILDER OR OWNER aLA Q '0 moAs. 1� PERMITDATE: 0 -qI COMPLIANCE DATE: 1/,'0- Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 fPleac 'nLfacility) ,,L, Feet Furnished by t- r 5® ® 3a7 0 Commonwealth of Massachusetts Title 5 Official Inspection For m Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 593 Lumbert Milt rd Property Address Centerville MA 02632 Cityrrown State Zip Code Emily Nelson 9-25-06 Owner's Name Date of Inspection Check if the following have been done. You must indicate ayes"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 �/6 this inspection? // Were as built plans of the system obtained and examined?(If they were not x/ a available note as N/A) �L ® ❑ 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,211buding 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)] BLANK T-5 USE SAVE AS ONLYM.doc•0312006 True 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 593 Lumbert Mill rd — property Address Centerville MA 02632 Cityrrown State Zip Code Emily Nelson 9-25-06 Owner's Name Date of Inspection Residential Flow Conditions. Number of bedrooms(design): 3 [dumber of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): unknown 2 Number of current residents: 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)): 04=165gpd g 05=143 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currently occupied Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.€f., 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): BLANK T-5 USE SAVE AS ONLY!!!.doc•0312008 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cunt.) 593 Lumbert Mill rd Property Address Centerville MA 02632 Cityfrown State Zip Code Emily Nelson 9-25-06 Owner's Name Date of Inspection General Information Pumping Records: Barnstable Board of Health Source of information: Was system pumped as part of the inspection? ❑ Yes N 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/Altemative technology.Attach a copy of the current operation and maintenance contract Ito be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 1995 +per info on file at BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No BLANK T-5 USE SAVE AS ONLYIII.doc•03I2M Tine 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System information (cunt.) 593 Lumbert Mill rd —— Property Addrew Centerville MA 02632 Citylrown State Zip Code Emily Nelson 3-25-06 Owner's Name Date of Inspection Building Sewer(locate on site plan): 2111 Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: town water feet Comments(on condition of joints, venting, evidence of leakage, etc.): viewed pipe with sewer camera and pipe is oK Septic Tank(locate on site plan): 15" 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 ❑ Yes ❑ No certificate) Dimensions: 1000 gat Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? S � Ifi BLANK T-5 USE SAVE AS ONLYI!!.doc•0312006 Vile 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cunt.) 593 Lumbert Mill rd Property Address Centerville MA 02632 _ cityrrown State Zip Code Emily Nelson 9-25-06 Owner's Name Date of Inspection 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 at a normal level �— Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass Cl 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 El metal 0 fiberglass ❑ polyethylene ❑other(explain): BLANK T-5 USE SAVE AS ONLYM.doc•0312006 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts MARMON Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cunt.) 593 Lumbert Mill rd Property Address Centerville _MA — 02632 Cityrrown State Zip Code Emily Nelson 9-25-06 Owners Name Date of Inspection Tight or Holding Tank(cent) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes El 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 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.): box is in good condition and the cover is 22"deep Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No BLANK T-5 USE SAVE AS ONLY!!!.doc•03f2006 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System �� Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form D. System Information (cont.) 593 Lumbert Mill rd _ — Property Address Centerville MA 02632 citylrown State Zip code Emily Nelson 925-06 Owner's Name gate of Inspection 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: me Type: ® leaching pits number_ ❑ leaching chambers number: leaching galleries number: 'I-infultrator ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: Li 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 leaching components were found dry and in good condition BLANK T-5 USE SAVE AS ONLYM.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System V-4 Paget 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 593 Lumbert Mill rd Properly Address Centerville MA 02632 CityrTown State Zip Code Emily Nelson 9-25-06 Owner's Name Date of Inspection 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.): BLANK T-5 USE SAVE AS ONLYM.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 ...... ..... . Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 593 Lumbert Mill rd — rroo rty Address Centerville MA _ 02632 City/Town State Zip Code Emily Nelson 9-25-06 Owner's Name Date of Inspection 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. F C2 f A(7 I A k= o� E 3 a F 3? - c s " :D 3 0 E3 � . .37 ' G =alv ' BLANK T-5 USE SAVE AS ONLYM.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M D. System Information (cunt.) 593 Lumbert Mill rd Property Address Centerville MA 02632 Cityrrown State Zip Code Emily Nelson 9-25-06 Owner's Name Date of Inspection Site Exam: Slope /U6,12 e Surface water /\/o/7C Check cellar ye; - Dry Shallow wells IVO Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: See attached installers statement and permit also certificate of compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: SDW-253 Zone C water level 46.9 1.5x12=18"ADJ You must describe how you established the high ground water elevation: From documents on file at the BOH they show ground water to be 14'+from bottom of the infultrators. Total distance from grade to where ground water is known not to be is 18'.The total distance from grade to bottonm of leach pit is 10'(that is the lowest leaching component). You add the 4'seperation plus the adjustment of 18"and the total is 15'6".You are separated from ground water by 2.6'+ also see attached paperwork. title5_2006 blank.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- „ s Page 16 of 16 t 11A 1 No., "� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z(Ppfication for Moozat Opgtem Congtruttion permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. w j&i,,S Designer's ame.Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( ) Other. Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil C�l I II-A Nature of Repairs or Alterations(Answer when app'cab ) s t t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by this Board of Health. Signed Date !0 " ?d `4S" Application Approved by 17 Application Disapproved for the following reasons Permit No. Date Issued 149"' CYW_&_ THE COMMO'�EAL'�� EALTH OF MASSACHUSETTS P BLIC D1 ISION - BARNSTA E, MASSAChT. ETTS Y c . Coniiante THIS IS TO CERPW,t}aatth site eag4isposal System installed(V000')or repairiMeplace' )on 4 by .-��..� lls,.—�►...gctci� for fit . ,� ' 1 i JOG_ coati cf � accordancei(tt the provisions of ltle i the'or E sal ystem ons ctionPenmit No. 9t� Ldsb of this system is conditioned on compliance with the provisions set forth below: F 9 - No. 5�5 - Fee 3�' la THE COMMONWEALTH OF MASSACHUSETTS 00 P PUBLIC HEALTH DIVISION - BAR_ N9TABLE, MASSACHUSETTS arce i p 1 f _ es migvogal *'Votem Congtruction permit Permission is hereby granted to 4!fa- to construct( )repair( &4an On-site Sewage System located at _T r�z , i -- •,�. and as described in the above Applicahon for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5-and the following local provisions or special conditions. All construction must be completed within two years of the date below.j Date: PP Y �A� _ ," Approved b ' CERTIFICATION OP SKET WUNKS CONSTRU APPLICATION FOR A DISPOSAL ' CTION PERMIT ITgOUT DESIGNED PLANS - i hereby certi#y that the application for disposal works construction permit signed by me dated f p — — 3 concerning the property located at 3'�3 � + � - following criteria; meets all of the • There are no wetlands within 300 feet of the Proposed septic system • There are no private wells within ISO fe et of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no in g crease in flow and/or change in use proposed • There'are no variances requested or needed SIGNED LICENSED SEPTIC SYSTEM INSTALLER DATE; _I D ALLER IN THE TOWN t?F.BARNST,4ELE AMBER [Attach a sketch plan of the proposed system.A this plan should be submitted]. so if the licensed in staller posesseS a certified plot plan, ...... _ b .. .. LA. V 1 No. ^ Fee 3 D THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppYtcation for M,44pozax *pgtetn Construction Vermtt Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. PA Installer's Name,Address,and Tel.No. s— YYjCk�, $' Designer's ame,Address and Tel.No. w. - �—Cirl � w cl•��LS . Lfl) ' 345 A, Type of Building: Dwelling No.of Bedrooms J Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when app 'cab e) s' s k Date last inspected: d T C 7 ( y � Agreement: rpm+I•� The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health.o Signed G Date f ® — 3 a '-4S Application Approved by - Application Disapproved for the following reasons Permit No. / / tv_� Date Issued /46 sx THE COMMONWEALTH OF MASSACHUSETTS PUBLIC BLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS -- 1. /6(ertiridate of �tCom Yf ante �` " y►, 1 THIS IS TO CERT that the,0P-`site Sewage Disposal System installed*10 or repaired/replaced( )on Lfe ivA Y i b r� Y-��.,� 1k.....�Ci.,,.�,c..lc,s for I1..k 4 0 �e�s o w yt i A fa � «�tias been;rconstructedfiii accordance with the provisions of Title 5 4d the`for Disposal SystemVons&ction Permit No. !2 - P1 Q :;) dated UsI of this#system is conditioned on compliance with the provisions set forth below: No. �f Fee. wPl5a� THE COMMONWEALTH OF MASSACHUSETTS � 03 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Pa��_ Is mfg ogar * stem Construction Permit Permission is hereby granted toc� to construct( )repair( y4an On-site Sewage System located at j? and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: //A �S� Approved by PA No. Fee _ ' r THE COMMONWEALTH OF MA3S,SAC SETTS R41C H L-TH DIVISION TOWN O�FRNSTABL' - MASSAC.HUSETTS s � iration r- �Con � o I pgtem Con�tru tion Permit Applica,ion is hereby ma a ford a Pe t to etruct( )o Repair( )an On-site Selge Disposal System at: Location Address or Lot t ' ! �` Owner's Name,Address and Tel.No. Vtt�'��'1`t�. Installer's Name,Address,and Te Lt"'� . J- t YVlti �� S `• Designer's Name,Address and Tel.No. `-t77 Type of Building: 100, Dwelling No.of Bedrooms J Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Ct Other Fixtures "S, Designk ow.. ,+ce ��. r%. . • •gallons per day. Calculated daily flow r1.7 gallons. Plan Date 'Number of sheets Revision Date Title ` lJoescription of Soil i Nature of Repairs or Alterations(Answer when app icab e) � "$!' r-"'"'l1` �'�••• Date last inspected: Agreement: fe undersigned a .ree�too ensure the construction and maintenance of the afore described on-site sewage disposal system . i�aecordan.ee� thxthe� oviSions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Comyliance has been iss of this Board of Health. t�gned �;... ��ti► /� Date A'` 1ica n Approv by ApplicationrD�*sapgroved f r-the�follo wing reasons Pert I`Y , APB!? Date Issued __....____. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 10 — 3© 9� , concerning the property located at 693 L,`,r,�_+ m�its Roo — c@l ; (c meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED :CGA� c -/�� DATE: l D —3'b "?s— LICENSED SEPTIC SYSTEM INSTALLER.IN THE TOWN OF EARNSTABLE NL?MER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. l 40 `._�______��----r � _�t��,��i-p-�l�-��_._.f�__.j l�� _._.; 779 15��-_ �"�ll�"V/./VY'�, " t ' � { � j t I l � E E �-___. l I i � �. � I � � 'f`. 00 It -4-4-4 m9p C- �-- _ � - ( -�` � -fit�.. � iT-V- ryl- i c:J do r LL I A N ..... FEic ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1/7 ..........0 F........... . . . . .. ....... .... ............................ Appliration -for 43ispasal Workii Tonstriartion Vanift Application is h r by ?rm de a it to Construct (Vil"Or Repair an Individual Sewage Disposal S,stem at: 7�rla) - A................. .......... .......... %A ,.,............a ..................................................................... cation,Address L►ot No- A_ .................. L Owner Address ,Wj .AIL ------- ... ...ZqL. -4 ..4..Aj..S.. ...........H .......................... ..... ........... -------------------------------------- Installer Address U (a$_f------Sq. feet 1� Type of Building Size Lot-./.-).r Dwelling—No. of Bedrooms__-_ .............................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons..__-____--_______-_-_---_ Showers Cafeteria aOtIl er fixtures ------------------------------------------ .................................................................. ...................................... j -son 7r day. Total Design Flow...... .0...............................gallons per person yij� flow______._..?.-. ..0......................gallons. 04 Septic Tank—Liquid capacity(M---gallons Length----k.-_4--- WidJl..... ... Diameter................ Depth---------------- Disposal Trench—No_ -------------------- Width--- ----- Total Length......_._.......__._ Total leaching area---`-------------sq. f t. Seepage Pit No........I........... Diameter.c.x--- Depth)bel;)nlet Total leachingarea. 47-!;-----sq. f t. Other Distribution box Dosing tank AV-1, -77 v Percolation Test Results Performed by.......................................................................... Date.....___._._.__._........__.._.......... Test Pit No. I................minutes per inch Depth of Test Pit......._.____....... Depth to -round water------------------------ w Test Pit No. 2----------------minutes per inch Depth of Test Pit_....___._.......... De h,;to grpuno water ------------------ ............................................................................................. ------------------_ 0 Description of Soi ....CL Lkt4.. kkv.tt,.. ---------6........................................I----------------------- X � X I -------------------------------------------------------------------------------- ----------------------------- ____........ U ------------------------------------- ---------------------------------------------------------- ;---------------------------------------------- ----------------11----------------------11------- u Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ .................. ------------------ - --------------------------------------------------------------------------------------------------------------I------------------ ........................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issue b the boaq o�health. Signed t I.... �.......... ...... ...... Da e Application. Approved By---------- .. . ....... .. ..... A3-77----- ,Compliance a en S hh ig ned .. . . . ...... . Date Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- ............................................................................................................�--------------------------------------------------------------------------------------------- Date PermitNo................................I......................... Issued....... . ......................................... Date --—------------------------ -- -- L'O-,,CAT,ION � ' SEWAGE PERMIT NO. �v tiy 7 3 �o VrLLAGE _ O-e-n INSTALLER'S NAME & ADDRESS 6UILDEt� OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED =" +7; s n � D ��� ye LrIE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH Appliration -for Bhipoiittl Works Towitrurtiou Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal �. ..,,__..._ System at: w Location•&&4ess or Lot ; L.. - d /� .... a ss rr� ...... •----- Owner /� Address W] Installer•-••r-••-••........................•... ......•.-{ Address e � k4 _ d U Type of Building Size Lot_ 7.:.6/-Y/__Sq. feet Dwelling—No. of Bedrooms..._..__... - ...................Expansion Attic ( Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) - Cafeteria ( ) dOther fixtures ------------------•-----------------------------------------------------'-----------------------------------------•-•----. -------------------------- g 7(0....................... allons er erson er a Total da•1 flow-__--___--__ Desi n Flow.............. _ W Septic Tank Liquid capacipod'/__gallons P Length person __- Wid�li.-_.�.y..-._ Diameter-----_-__-___ Depth-_ gallons. x Disposal Trench—No..................... Width------- ______..... Total Length_____-_-_-_____--- Total leaching area-------------------- . ft. 3 Seepage Pit No-----------`....... Diameter..I�__-V. ______ Depth below i let"t.................. Total leaching area... _sq. ft. Z Other Distribution box ( ) F ' ` Dosing tank ( ) � e,/A /-/-e,- 4; a Percolation Test Results Performed by--- :------•--------------- --------•- ............................. Date-_-.--•--•--------------•---•-------.... Test Pit No. 1________________minutes per inch Deptd%, of Test Pit-------------------- Depth to ground water.._._...__.__._-.-_.._. 44 Test Pit No. 2____•-_____-....minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------_-_ W -•-•- ---- ------•------ ------•--••-------•- . ---•-•----------•----•••--••--•------------------- ---- - - O Description of Soil.__ _ ._ r� = -- ---- ------------------------------------•----------• ----•------------------ W V Nature of Repairs or Alterations—Answer when applicable._.---------------------------------------'_---_..._._-_-----------.----------..____.------------ --------------------------------------------......................------------------------------------- •-------------•-•-•----•---•-----------`-----.----.-------------------•----------------------- Agreeriient: a: The undersigned agrees to install the.. aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by t e board of health. / 1A Signed _ ---- -- - (� f •, � ate Application Approved BY---••---- •-!*e to,.._... •! = ------------•----- .'. +- -!7 Application Disapproved or the,following Date A PP PP f f ing reasons:----•-----------------------=--•----•-•----••--•-•-•--••----------------.........-•---------•--•----...--------- --- ----------------------------------------------------•----------- Date PermitNo. ..................•--------_. Issued........................................................ Date t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ..........OF..... " ' ........................... Q-Prtif iratr of f"ompliatta THIS IS TO ERTIF , That t Individu Sewage Disposal System constructed ( ) or Repaired ( ) by ------------ ---- nG J / aiin taller at ...............•--�-----------------•----.....cam-��---- --- _ e �: 'f"'- - n tie application for Disposal Works Construction Permit N __ _______ ___................ dated._�rx._"" _aS`__ _,✓�_................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. yDATE--•--•---•-----------------I..................................--............... Inspector.--A-----IL9.. �_..... f ------------------------- THE COMMONWEALTH OF MASSACHUSETTS Y BOARD OF HEALTH . ' 7 ......... . `�.............O F:_z,,.�..�,.,.:..%:. . '.�.. ......... No..-• -� G FEE-----f "' . . �i����ttl ork.� (nool�trtt ti1�8t rrmit Permission is hereby gripted---------- .r C ---•--•--._�_l_--- ',.!-:n-----=---------------------•------...--------------...---•-- ...... to at Nonstriict_( ) or Repair ( ) an Individual Sewage Disposal System /r' 47 . ------ ------------ ------a---------- ---•------- Street as shown on the application for Disposal Works Construction Perm' ~ ._.�._._ D lt _. '-•_L,�- ' ! -... .....„ tLol-,/-.4 �� ------------------------------- DATE----- - ".2...7................................................ Board of Hea FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS igg», 'At No .Pl'jjj➢�r{j'�1Y�4'J"" t e.,r It .i. k I ' 44 wo 44) G p Nti te1 }� R 0111 Y t ti'+•r BARNISTABLE COUNTY HEALTH DEPARTMENT BARNSTABLE, MASS. 02030 7accrwowu 362-2511 Ext. 331 Date: June 23, 1977 To: Tally Ho Farms, Inc, Lumbert Mill Road Barnstable, MA 02630 On the basis of a sanitary survey and a laboratory examination on the sample well of water taken from a . . . . ... . . . .. ... . .. . ... .. .. . ... . . . . . ... . . . . . . .. . . . .. . .. . . located on the premises of Tally. Ho . Inc- . .. . . . . . . . , . . ... . . . arms . .. .. . . . . .. . .. . . . . . . . . . . . . . located at Aqt, .1%5 Lujnbert Mill Road, Barnstable . , . . . . .. .. >. . . . . . . . . . . . . . . . . . . .. . . . . . . . . • • . . . . . . . . . on. . . . ..lune. As.A9.7.7 . . . . . . . . . . . . . . . .this supply is approved for domestic purposes at the time the examination was made. If you wish further information regarding this supply, please contact us at the County Court House, Barnstable, Massachusetts (Tel: 362-2511 Ext. 331) and we will be glad to assist you in any way possible. Signed.. . . . . . . . . . . .. . . . . . . . . . . . . . .. . . Public Health Sanitarian cc: Jim Hayes Barnstable Board of Health 3/3/77 500