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HomeMy WebLinkAbout0060 MADISON AVE - Health (2) + 60 Madison Ave. , Centerville 1� A= 247-098 _ No. 42101/3 ORA i8� ESSEETE 10% (0 0 0 0 0 I r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'Al, c°� •''a 60 Madison Ave. IZ5 , Property Address Sue Curran ` Owner Owner's Name 14) information is required for every Centerville MA 02632 4/20/2018 b page. City/Town State Zip Code Date of Inspection c' tF. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms Sl I ZC(l 3 on the computer, use only the tab 1. Inspector: key to move your cursor-do not' Paul Martin use the return Name of Inspector key. Cape Cod Septic Services reb Company Name 350 Main St Company Address rew W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/2/2018 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - --- 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is Centerville required for every MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank,and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and d the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a.public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts u- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •` 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on $10 CMR 15.203(for example:.110 gpd x#of bedrooms): 110x4= 440gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 6y0', 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2016=110gpd 2017=126gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments sy0,r 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes,.volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is Centerville MA 02632 4/20/2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1997 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 32" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): +10, Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): 22" 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: 2000Ga1 10-12" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 3-5" 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 2000Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers 14" below grade. Recommend service of tank. 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 Wins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts _ w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level.with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 6" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information isequired or every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-Maximizers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 4-Maximizer Chambers in a 11'x38'x2'Trench. Minimal effluent in chambers during inspection. No evident staining. No sign of overloading or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments vey't 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 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: +10' 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: Hand auger did not encounter water at 10'. Max bottom of leaching is 5'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Madison Ave. Property Address Sue Curran Owner Owner's Name information is required for every Centerville MA 02632 4/20/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION 60/44d/SON dVr SEWAGE#��,� VILLAGE ral/14.44AE ASSESSOR'S .MAP&LOT_Zyj,O INSTALLER'S NAME&PHONE NO. A & B CAN00 775-6264 SEPTIC TANK CAPACITY '20M GAI 71Iw4< tf l�x�M,zr+�.s WIV'370 �%Ix 2'' LEACHING FACILITY:(t pe) (size) NO.OF BBDROOMSPRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER J I M euh-rA O DATE PERMIT ISSUED: --7- 77 DATE COMPLIANCE ISSUED;_ 'S'- 7 VARIANCE GRANTED: Y No ✓ 3 .� �. OJ. O http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=24 098&seq=1 4/10/2018 � I h Town of Barnstah'--`^- '^`y' U.S.POSTAGE>>Pmvev BOWES `T yehyYi C. V:f +moo Public Heal .�i"v's ion / • �BMASSBLE.p` 200 M--'5? treet 0 lFO MnyA 0 -Ilya'nnis,MA 02601 ,. = ZIP 02601 ,. j 02 4w $ 006.730 0000336455 JUN, 08 2016. 7015 `1730 0001 4990 4889 1 - �Y li Susan F. Curran - 60 Madison Ave Centerville, 9;5`07 o R TtiR_N. 70 I AIMED -�ra A'A.G:to'i JI ES uY�9 43 yf d'II"9 G.fS N '1 Y 9 C 'f3.fP .-may 7 2 9 0,z 6 ra I L%41D a z I ° q 4 ■ Complete items 1,2,and 3. A. Signature ■ address on the reverse ❑Agent Print your name and X so that we can return the card to you. ❑Addressee Date of Delivery I B. Rece ived b Printed Name C. a ■ Attach this card to the back of the mailpiece, Y� ) ry a or on the front if space permits. i I — _ 1• Arti Susan F. Curran D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No 60 Madison Ave i Centerville, MA 02632 / { 3. Service Type ❑Priori Mail Ex ress@ ' II I'III'I I'II I'I I I I I I I�I ICI I II I II I I III'I III III ❑Adult Signature ❑Registered MaillTm ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted. 9590 9403 0521 5173 2826 92 ❑Certified Mail® Delivery ❑Certified Mail Restricted Delivery ❑Return Receipt for / ❑Collect on Delivery Merchandise 2. Article Number(Transfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationT � sured Mail ❑Signature Confirmation q{, 7 015 1?3 0 0001 4990 4 8 8 9 C�:; red Mail Restricted Delivery Restricted Delivery I i i `'�4 er$500) PS Form Jt5l 1,April 2015 PSN 7530-02-000-9053 Domestic Return Receipt Town of Barnstable Barn • Regulatory Services DepartmentMASS + 1 i 9� 16 " Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 SECOND NOTICE Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1730 0001 4990 4889 June 06, 2016 Susan F. Curran 60 Madison Ave Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 60 Madison Ave,Centerville, MA was last inspected on 2/26/2016, by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Need to replace broken Distribution-box • A new inlet tee for septic tank You are orderdd to repair/replace the septic system within one (1)year from the date you receive this notification. " Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH om s c ean, R.S.,�CO Agent of the Board of Health Q:\SEPTIC\Conditionally Passes Ltr\60 Madison Ave Cent Mar/2016 1 i iCo .. - a o OFFICIAL E. t' Certified Mail Fee H Extra Services&Fees(check box,add fee as appropriate) G "Nr ❑Return Receipt(hardcopy) $ � %P O ❑Return Receipt(electronic) $ C Postmark C3 []Certified Mail Restricted Delivery $ LA her&O 0 ❑Adult Signature Required $ ❑Adult Signature Restricted Delivery$ 0 Postage o01 1-911 Total Postage and Fees 7 J t g ^ $ Susan F. Curran 60 Madison Ave Centerville, MA 02632 Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mall label). for an electronic return receipt,see a retail ■A unique identifier f9r your mailpiece. `, associate for assistance.To receive a duplicate IN Electronic verification of delivery or attempted return receipt for no additional fee,present this; delivery. USPS®-postmarked Certified Mail receipt to the, i A record of delivery(including.the recipient's retail associate. C; signature)that is retained by the Postal Service- Restricted delivery service,which provides -r— for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent C? Important Reminders. Adult signature service,which requires the `a ■You may purchase Certified Mail service with signee to be at least 21 years of age(not '111 First-Class Mail®,First-Class Package Service®, available at retail). -r or Priority Mail®service. Adult signature restricted delivery service,which n Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified, ■Insurance coverage is notavallable for purchase by name,or to the addressee's authorized agent; with Certified Mail service.However,the purchase (not available at retail). �1 of Certified Mail service does not change the s To ensure that your Certified Mail receipt Is Insurance coverage automatically included with accepted as legal proof of mailing,it should bear a I certain Priority Mail items. USPS postmark.If you would like a postmark on r ■For an additional fee,and with a proper this Certified Mail receipt,please present your f endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for r— the following services: postmarking.ff you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion. of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply 7_1 You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.C3 electronic version.For a hardcopy return receipt, $ complete PS Form 3811,Domestic Return Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. I' Ps Form 3800,April 2016(Reverse)PSN 7530-02-000.9047 IKE Town of Barnstable Barnstable bwft Regulatory Services Department p SST"M � "16g. Public Health Division D m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 SECOND NOTICE Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 4889 June 06, 2016 Susan F. Curran 60 Madison Ave Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 60 Madison Ave,Centerville,MA was last inspected on 2/26/2016, by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Need to replace broken Distribution-box • A new inlet tee for septic tank You are orderdd to repair/replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH om s c ean, S., O Agent of the Board of Health • Q:\SEPTIC\Conditionally Passes Ltr\60 Madison Ave Cent Mar/2016 Postal CERTIFIED . . Domestic For delivery information,visit our website at www.usps.com". ru UME m r�- Certified Mail Fee ru $ j<../ ti��6 Extra Services&Fees(checkboX add,fee es appropdjte, Q J r� ❑Realm Receipt(hardcoPy) $ ' PQ`` C ❑Return Receipt(electronic) $ y" l Po�a* ❑certified Mail Restricted Delivery $ ,^ Her�g4j 0 ❑Adult Signature Required $ co) ❑Adult Signature Restricted Delivery$ o Postage ru $ rr-1 Total Postage and Fees 73 $ Susan F. Curran N 60 Madison Ave. Centerville, MA 02632 I Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique Ifierdifier for yoar mailpiece. �r , .for for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPSO-postmarked Certified Mail receipt to the ■A record of delivery(including the recipients retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specked by name,or to the addressee's authorized agent Important Reminders: Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority WHO service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified ■Insurance coverage is not available for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a' certain Priority Mail items. USPS postmark.If you would like a postmark on ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for the following services: postmarking.If you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barooded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return II Receipt attach PS Form 3811 to your mailpiece; IMPORTAIWP Save this receipt for your records. Ps Form 3800,April 2015(Reverse)PSN 7530-02-000.9047 CERTIFIE I MAIL .o r U.S.POSTAGE>>PITNEY BOWES oF,'; Town of Barnstable �w a © ' Public Health Division MRN BLE. 200 Main Street f ®� r ZIP 02601 $ 006.73 rEoxv.+°� Hyannis,MA 02601 02 41N {. 0000336455APR. 12, 2016 d � 1 7015 1520 000 2273 3241 r, �� » 'h roa Susan F. Curran / 60 Madison Ave CentervilkiL W 3RETURN TO SEND.ER . 'UNCLAIMED UNABLE TO FORWARD SC: 0.2601400200 *0322-12266-'33-37 jl :�..i,,...l.I.I.1..!l.31...I.I.II....I•' l'I'i`1'1°'Ellt"1!I' �_ �I It' COMPLETECOMPLETE • • DELIVERY ■ Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverse X ❑Agent I so that we can return the card to you. [I Addressee ■ Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery or on the front if space permits. 1. Article Addressed to:_ D. Is delivery address different from item 1? ❑Yes I (—.Susan F. Curran If YES,enter delivery address below: ❑No i 60 Madison Ave. I Centerville, MA 02632 _ I 3. Service Type ❑Priority Mail Express@ lI I IIIIII I'll III I i I I I II II Ilill I Il IIIlll I ll lli ❑Adult Signature ❑Registered Mail- 0 Adult Signature Restricted Delivery ❑Registered Mail Restricted ❑Certified Mail@ Delivery 9590 9403 0922 5223 6279 91 ❑Certified Mail Restricted Delivery ❑Return Receipt for 0 Collect on Delivery Merchandise ' 2. Article Number(Transfer from service label) ❑Collect on Delivery Restricted Delivery O Signature Confirmation"' O ❑Insured Mail Signature Confirmation ❑Insured Mail Restricted Delivery Restricted Delivery over$500) PS Form 3811,July 2015 PSN 7530-02-000-9' 7 015 1520 0001 2273 3 2 41 __�..: Town of Barnstable Barn Regulatory Services Department ANWEdUM 1 1 sAxivsrAsce, Puc Health 839� A bli Hlh Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0001 2273 326-�-- March 312016 Susan F. Curran 60 Madison Ave Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 60 Madison Ave,Centerville, MA was last inspected on 2/26/2016,by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Need to replace broken Distribution-box • A new inlet tee for septic tank You are orderdd to repair/replace the septic system within one (1)year from the date you . receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH . e — Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Conditionally Passes Ltr\60 Madison Ave Cent Mad2016 ; Town of Barnstable Barnstable 0 Regulatory Services Department Q �.y i639. � ' Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1520 0001 2273 324- March 312016 Susan F. Curran 60 Madison Ave Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 60 Madison Ave,Centerville,MA was last inspected on 2/26/2016,by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Need to replace broken Distribution-box • A new inlet tee for septic tank You are orderdd to repair/replace the septic system within one(1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH . Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Conditionally Passes Ltr\60 Madison Ave Cent Mar/2016 Town of Barnstable + iwxtvsrAeLF, q 8 Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6,-2007 Rev. 7/6/15 DEADLINES TO REPAIR-FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA. ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year.not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool • ONE (1)YEAR DEADLINE CRITERIA. ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or,cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) ❑.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §3 60-9.1) OTHER 8_rukev) 9-6( cincp Nud ,, /el • - Repair deadline: V U�r 6ASEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc h 0 /7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Madison Ave Property Address f�1 Susan Curran y Owner Owner's Name information is required for every Centerville J MA 02632 2-26-16 page. City/Town State Zip Code Date of Inspection y C71 Inspection results must be submitted on this form. Inspection forms may not be altered in any IND way. Please see completeness checklist at the end of the form. Important:When A. General Information �p�J filling the computer, `� / ��``��ZN OF o use only the tab 1. Inspector: key to move your cursor-do not �: JAMES use the return James D.Sears =�: Name of Inspector = A R0 key. Capewide Enterprises, LLC Company Name 153 Commercial Street Company Address B Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 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 2-26-16 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. • ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 , ti0 vs f - Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 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: Conn Pass-D Box- inlet Tee. The system is a 2000 Gal. Tank D Box and four chambers. B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Need to replace D Box. Need to install inlet tee. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR • 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: M **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters is 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 is less than 6" below invert or available volume is less than '/2day flow 4E, 61#1,ir- t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M a'' 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 • DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 2000 Gal. Tank D Box and four chambers. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2014-275,000GaI2015-44,000Ga1's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract • ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1997 Permit #97 -224 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 18" 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: 2000 Gal. Precast H-10 Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments °M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 18" below grade. No inlet tee. Out tee. No sign of leak age or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness • Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: • Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x`IT-28" below grade w/one line out. Box is broken - H-10 W/solid carry over. Need to replace box w/H-20. • Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: • t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is Centerville MA 02632 2-26-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: • ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is four maximizers w/4' stone 38'x11'x2'. Ck D Box and camera out to chambers. Wet bottom , clean wall's. No sign of over loading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer • Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: . Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): • t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i -� - 3 -3 t n 9-3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts r W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells MO Estimated depth t high ground water: 10, 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: A Hand Auger 10' no G.W.. Bottom of leaching at 5' below grade. Bottom of leaching at 5' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Y P Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Madison Ave Property Address Susan Curran Owner Owner's Name information is required for every Centerville MA 02632 2-26-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file • t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 6Fy W1, Department of Early Education and Care Mass. 2: Su ;�a EEC Home 0 Mass.Gov Home LiState Agencies MState Online Services Our Organization Contact EEG News&Updates W. EEC Board Meetings o If ou would like to receive email updates on EEC's progress, lease I Board Public Presentation Y p p g p EEC Board Members 03(07/06 complete the email form. Mission,Goals and Principles _ o. Newsletter 03/08/06 EEC Fact Sheet If you have a specific question,please send your email to the Workforce Development Plan EEC Staff Directory Commissioner's Office. • 01/04/06 Child Care Licensing . EEC IT Report 12/14/05 •Adoptions and Residential Carejf you need directions to EEC offices view EEC offices and locations • Early Educator Scholarship ,. �..�,� _.. ra ,,,,,, Child Care Financial Assistance Information and Questions& Family Support Programs Child Care Provider Answers a Grant Programs l Teacher Qualifications Curran,Susan F. 05 611 2� �-70 . PCG Executive Summary (CCR&R and CPC Study) bi PCG Full Report(CCR&R and - - - �— ------• --�- 60 Madison Avenue,Centerville,MA 02632 CPC Study) Key Resources ?� More news&updates New EEC Provider Rates Provider Type: $ Technical Assistance Papers Family Care Find Child Care i Licensing Forms Child Care Financial Assistance Citv/Town, Policies&Forms CGRR Name: Child Care Network Regulations&Policies 7ipcode � Grant Forms • Reports and Research CCRR Phone: Resource and Referral 508-778-9470 Type:, { Agencies + All Child Care Provider Regional Lists i Capacity: i Infant: r Toddler: Pre-School: 0 2005 Conxnonwealth of Massachusetts Privacy Policy Contact Us s No. p Fee S V C THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS 01ppYication for Die;poar *pgtem Construction Permit Application for a Permit to Construct( )Repair(XUpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Ax /.5 d 7'1 Owner's Name,Address and Tel.No. e�feruFI( - J IA& Cu air WA) Assessor's Map/Parcel �L/) O p d Installer's Name,Addres 'Ig.UNCO Designer's Name,Address and Tel.No. 350 Main Street Al/j W. Yarmouth MA 02673 Type of Building: Dwelling No.of Bedrooms �_ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow yyo gallons. Plan Date Number of sheets Revision Date Title Z4i;- J 1,1k .. Size of Septic Tank /o00y �e.r:r,<�., Type of S.A.S.�n ��ftR7fsrf 3��C ��X o? ` Description of Soil Nature of Repairs or Alterations(Answer when a plicable) ��nS)�A�� 4/ ` !1 F=t 1 feA r 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 issued by this Board o j4Aa Signed Date Application Approved by Date • � Application Disapproved for the following reasons ——Permit No. — — Date Issued j� ` — TOWN OF BARNSTABLE LOCATION l O�fhd/S0/� �Vr SEWAGE # VILLAGE & ASSESSOR'S MAP & LOT 2 7- Q?k -INSTALLER'S NAME PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY E t dTl6 Gx►� 71�4NK L'BACHING FACILITY:(type (size) NO. OF BEDROOMS - PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER A� DATE PERMIT ISSUED: DATE' COMPLIANCE ISSUED: A �S 7 VARIANCE GRANTED: Yes. No � Y j ,61 J ?COW No. •r ' Fee S U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes `PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS G I ZIpplitation for Migpogar bpgtem Construction Permit E � Application for a Permit to Construct( )Repair(/)Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. t S d LAk Owner's Name,Address and Tel.No. Assessor's Map/Parcel ( � `f I V i m Cul a✓2 11 AJ , �)q)to S-A(A�k, Installer's Name,AddW&aeTtAN`►O ` Designer's Name,Address and Tel.No. 350 Main Street All if W. Yarmouth MA 02673 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ���� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title &-piz. _�T i�rre, d ck tiz � Size of Septic Tank laoa v j!s;rl;., 1 Type of S.A.S. 2,,)Rht v 4 t-5- -1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) .1 a S 14 �� �� 1 A Pi /'A l d 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 issued by this Board o .Heap . Signed C Date Application Approved by - Date Application Disapproved for the following reasons Permit No.T��2` /l Date Issued ------ ----�--------------- -- ---- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( ---j�Upgraded( ) Abandoned( )by rU C at ; dAl A P has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ^ ! dated Installer Designer ` - The issuance of this permit shall not be construed as,a guarantee that the system will function as designed. Date Inspector 1 - No.—�2--���� -------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS i5o!5aY ,*pgtem Co ngtruction Permit Permission is hereby granted to Construct( )Repair( w<Upgrade( )Abandon ) System located atl� �i s a x� i'9(/� G112 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. Provided: Construction must be completed within three years of the date;o;f�th;is! 2ejmit. Date: Approved b - TOWN OF BARNSTABLE LQCATION lD0,NII 15ow ,4 yr SEWAGE # VILLAGE nmlo Mlle ASSESSOR'S MAP St LOT INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY E ! I f-114moPizers wy 7aN 9 LEACHING FACILITY:(t pe (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER C_ua -r A O -DATE.PERMIT ISSUED: DATE' COMPLIANCE ISSUED: VARIANCE GRANTED: Yes-, No ✓/� r ��e r 19 CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, �� Gc ucr.,•_ , hereby certify that the application for disposal works construction permit signed by me dated_�- J S > , concerning the property located at 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: DATE: —S LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. �ti � L 0 11 � SEPTIC- -SYSTEM DESIGN DAD. s AT G AL/DAYlBEDROOM _ GAL/DAY TANK: ® GAL/DAY x 2 DAYS = GAL USE /000 GALLON SEPTIC TANK �jeCisl�s� NG A:�A: I�ACNI , USE I NI PI LT RAT ORS .i[AX I MI ZER CNAMR�RS �I•L �/ITH � OF STONE AMUND (37.3 x if a Z DEEP) srDS AREA: 111z z = 191 Sp (.74) _ GAL/DAY �G AR�CA: x � qlo, S�'_ (74) = j.GALI DAY C.PACJ*Ty /DAY