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Home My WebLink About0350 MAIN STREET (CENT.) - Health (2) 3 50 MAIN STREET Centerville A = 208 - 044 - 002 /// S M E A D KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED INITIATIVE CONTENT 10, Cartified Fiber Sourcing POST-CONSUMER www.3fiprogram.org SF{ Im MADE IN USA GET ORGAANUED AT SMEAMOM No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4phration for Disposal *pBtpm ConstCuttlon Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. ISO n st v Owner's Name,Address,and Tel.No. Assessor's Map/Parcel aoc f�yy as a-C�,n ie�t' 'Ile 6W-"CCLA-r r- /7Mc ri-e6jr jDr,.,_ Installer's Name,Address,and Tel.No. 50 i& j1(; Designer's Name,Address,and Tel.No. Qvr c,koi+; CoV��Yll�=�1�C9ll� nC �/S'JVLQttl��ft� iZr� Ai 1) box Onl Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re jred) Ff— gpd Design flow provided gpd Plan Date U Number of sheets Revision Date Title Size of Septic TV1 Type of S.A.S. Description of Soil ! 1 Nature of Repairs or Alterations(Answer when applicable) 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 oIthe Environmenta C6d d not to place the system in operation until a Certificate of Compliance has been issued by this Board Health. Signed Date Application Approved by _ Date J Application Disapproved by Date for the following reasons Permit No. 0 Date Issued No. 2- / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for Misposal 6pstem ConstrUCtion permit Application for a Permit to Construct( ) RepairsO Upgrade( ) Abandon( ) [:]Complete System c❑Individual Components Location Address or Lot No.350 Jl-o.( St• Owner's Name,Address,and Tel.No.4,/,2-4/5'- f79 i�IC Iawct. L-1J—r" /7 A404 la.;r Pv,u� Assessor's Map/Parcel2C�/G`/'//av"�._eev)kr t! tl0041i 104 0.11760 Installer's Name,Address,and Tel.No.5v Designer's Name,Address,and Tel.No. ��vr4 olcsi f Civlyk,wcl40"tTrc �1a�atxr� <Llr.tts, a zr�otJ$ AJ JiA Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures /,. A ; A Design Flow(min.required) gpd Design flow provided gpd Plan Date ` ia Number of sheets Revision Date Title Size of Septic/Tank ( p Type of S.A.S. Description of Soil pl o � IVY^je /�,�a� t (c t t i�r� , .1,)ny t rl Nature of Repairs or Alterations(Answer when applicable) 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•-C'od�a?hd not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Signed ...- � {� a W-- Date Application Approved by ��'��,Ca:`}CK, ��- Date JC 'h ' J Application Disapproved by Date for the following reasons ' Permit No. C� �"v ` ' 6 2 Date Issued --------.---------------------- - - =- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance T S IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Pi') Upgraded( ) Abandoned( )by/ r to lottz. �. ��-)S� L)-! 41,r 1 -Znc ' 7 at�� (�1 l n� 5 f• - �1N ht k7.�: has been constructed in accordance ;Z.j with the provisions of Title 5 and the for Disposal System Construction Permit No.'s/u''�yr,�1��0� dated Installer) {>r#c� ( C0Y)c /tXf/�i),,�-,�' Designer �11//�} i�.✓ )e_C x Onk.r �Y #bedrooms A �� Approved design flow gpd The issuance((of this permit shall not be construed as a guarantee that the system will function as designed. Date L F, Inspector /V V J -----------r-----------------l!----------------------------------------------------------------------------------=------------------------ No. Fee J THE COMMONWEALTH-OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS �Dispbsat 6pstem Construction Permit Permission is hereby granted to Construct(/ ) Reper(� Upgrade( ) Abandon( ) System located at-35U /y /sy �T. t e-VI kruf O e and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit.,,---' f l Date �n" ;V Approved by .✓'l 4 �• w �� Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;.. 350 Main Street Property Address Whitworth Owner information is Owners Name required for every Centerville MA 02632 1/17/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C:2 0 ` --- G- A C-- E ---•. �r SC-pn��cM,�C Ev i �LkLf� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sevrage Disposal System•Page 16 of 18 - Town of Barnstable Inspectional Services anatv�ragLe, r "`" s6;q. Public Health Division �0 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4988 1449 February 27, 2020 WHITWORTH, E LEO JR TR 29 TIFFANY DRIVE RANDOLPH, MA 02368 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 350 Main Street, Centerville was inspected on 01/17/2020 by Frank Nunes III, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The pump need to be replaced. The H-10 distribution box is in the driveway. See attached policy on H-10 components discovered beneath driveways. You are ordered to replace the distribution box within sixty (60) days 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., Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\350 Main Street Centerville.doc 9 , ISM o* Town of Barnstable Barn MAS&` Board of Health """"°`caC"" 200 Main Street,Hyannis MA 02601 11111.1 2007 Office: 508-862-4644 FAX: 508-790-6304 October 9,2012 Revised November 20,2013 Public and Environmental Health Program Policies,Procedures, and Guidelines H-10 Components Discovered Beneath Parking Areas and Driveways During Septic.System. Inspections Conducted Under 310 CMR 15.301,State Environmental Code,Title 5 No.2012-005 When a DEP certified inspector discovers an H-10 septic system component located beneath a parking area or driveway during a septic system inspection, conducted under 310 CMR 15.301 State Environmental Code Title 5,the system shall be deemed as a"conditional pass." The system owner will then be ordered,by the Board of Health,to correct this problem within two (2) years and will be provided several options to rectify the issue, including by: a.) replacing the septic system component with a new component relocated into another area of land which is not beneath any parking area or driveway, and properly abandoning the discovered H-10 component; or by b.) replacing the septic system component with an H-20 component beneath the parking area or driveway, and properly abandoning the discovered H-10 component, (or in the case of leaching pit,replacing the top of the leaching pit with an H-20 slab top); or by c.) relocating the parking area or driveway in such a way that no vehicle will have access or the ability to drive over the existing H-10 septic system component. If it is unknown whether or not a particular system component which is located beneath a parking area or driveway, is H-10 or H-20(for example: a leaching pit is located beneath a paved driveway without an accessible steel cover to grade and there are no records on file indicating whether the system component is H-10 or H-20),the system shall also be deemed as a "conditional pass". In this case,the seller must make the potential buyer(s)aware of the "conditional pass" status,the unknown construction of the septic system component(s), and it's safety concerns. Wayne Miller,M.D. Paul Canniff,D.M.D. Junichi Sawayanagi Q:\POLICIES\H l OComponentsBeneathDriveways&PaikingAreasRevised2013.doc BAR�SfABLE, Town of Barnstable i + A b 9 11 Inspectional Services Department rf0 MA'S Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 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 ❑ Structurally unsound septic tank or SAS 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 VAny "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER PUMP f e IM C(O, - U 0 - box 1'. drive ,vc, Repair deadline: d G Q:ISEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc a08-oyzf-oo L Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; 350 Main Street Property Address Whitworth ' Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information (`, Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Ilay 1/17/20 Inspect Signature "bwp Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7//26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 L l 5 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments n 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. City(rown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: **Pump chamber pump to be replaced **D-box to be replaced. H-10 D-box is in the driveway and it is not designed for vehicle loading 2) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20'years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): Z Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): **Pump chamber was backed up at the time of inspection. Found pump panel in silence mode. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ,�-p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •t,, 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cQ Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •� 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form 110 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom design plan on file at BOH Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: 607,000 gallons used in 2018, 463,000 gallons used in 2019. Numbers are high due to a pool and irrigation system Sump pump? ❑ Yes ® No Last date of occupancy: Seasonal Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1990 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 12" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts lP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle >12' Scum thickness trace >211 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Cityrrown State Zip Code! Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons t Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' •u 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 D-box is in the driveway, it is not designed for vehicle loading, it is 10" below grade, no adverse conditions observed t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form j~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ® No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Chamber is flooded at this time, alarm at the panel was found in the silence mode * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ► Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers were video inspected, no indication of past hydraulic failure, top of chamber is approximately 2'6' below grade 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 L_ i Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I •a Ar E s�-UL A-ftrv-K 6U- zc t44(40 e ' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts ,n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 7.6'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: GW adj. at 7.6 on 1990 plan Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: 1990 test hole GW at 10.5 ft ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 26'msl and nearby surface water at 16'msl You must describe how you established the high ground water elevation: Per the info in the file the SAS is not within groundwater however there may not be a 4'seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 18 l5insp.doc-rev.7/26/2018 P 9 P Y 9 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 350 Main Street Property Address Whitworth Owner Owner's Name information is required for every Centerville MA 02632 1/17/20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 f Fimic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Dwpasa1 orkii Toro rur#ion ramit Application is hereby made for a Permit to Construct V_�or Repair ( ) an Individual Sewage Disposal System at: �:ns ......� .. ... - .......... --=. -------- ........... .......................... Location-Address Lot No. .--... .!.. -------------------•---------- -A21... .`i� .�:xT�FA�4S.�_..�V Owner Address `f=__.... 1 ►�..Jb -`'�--- `�--------}........ ........•---. V F....... Installer Address Type of Building Size Lot----------------------•--_--Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures -----------•--•-•-•---•---•--•-- . W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--.----------_ Depth_............. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------------_-_---- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.----..---------.--- Depth to ground water...-.-------_----.---. •---------------------------------------•-•--................--•----------------•---•............•••......................................................... ODescription of Soil........................................................................................................................................................................ x U -•-•-••-••--•-•••••-•--••-•-••-------•-•--•••-••--••••-•----•••-----------------•-•-.........-•-••-•••----------•-----•----......---•-----•--......•.................................................. ----•--------------------------......----------•-------------------------•-•-- - Nature of Repairs or Alterations—Answer when applicable. ?T L�-....Na-_j...... ...15.,1 .�.'!r.... -•-.- U P PP -�••--' ---... Px a................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned furt r agrees not to place the system in operation until a Certificate of Compli s issued by the board oTl l 1. Signed ------- --- --- -- - Lj___-Q..-- ------------- ---------------------.. t Application Approved B - +� cy PP PP Y '?m Application Disapproved for the following reasons- ------------------------------------- -----..................----------------------------------------------- ........... ------------------------------------------------------------------ ------ -----'--- --------------------------------------- -----------------------..... -- ---- ------. ----------- -- 9 Dae - ------------------- Permit No- -------------7C2--"- Issued ------------------------------------------------------------....... Dare 7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE I Appl#ati it fur-Ohipusal Works Tonstrur#tun rrrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ` ..... O MAl�v � " �', �.r ....it& . ...................�. ......- .............................................................. Location-Address 4 Lot No. ----------------------------- ...\2\.. 1...M:. . Owner ^, Address 14 Installer Address Typ�of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____----------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) QI Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY........................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_____________-_•-..----- 4.1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ C4 ........................--...........................-...................................................................................................... 0 Description of Soil---------------------------------------------------------------------'-.........----------------•-------------------------------------------------.......--•---•-•.----- x U ---•--------------------------------------------•------•------------ --------------------------------------- --------- ------------------------------------------------------------------------- ----------- W .... U Nature of Repairs or Alterations—Answer when applicable ....N ..... `..A aecr........Y�d --------•--•---' � - ----zfx*m ...... .....ni.%.Al........••••••••-----------•-----•---•---•-----•---•--•-•------------•-----•--••......•.........--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the - ,I system in operation until a Certificate of Com lia WE e n iss ed b"the board of he 1 .. Y P P Y Signed .....-- i 1 �a Application`Approved By ... ....... J J �---`--)• -_--��' Date - Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------------- - ------- --------------------------------------------- -------- -------------------------------------------------------- ---- .....................................................---------- ........................................ . Permit No- -------------- �-- - � Issued ----_--_------.. ...............................'----...................... te...... Date f U THE COMMONWEALTH OF MASSACHUSETTS BOARD OF (HEALTH TOWN OF BARNSTABLE Certifira e of C outplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Y -�yy •— �^ Installer at --_---------3._,ri^.---.I► .�....... ..T.........C.A.k__ ( -----------------------------------------------------------------------------------_----------_---------------"--_---- has been installed in accordance with the provisions of TITLE 5 ptThe State Environmental Code as described in the application for Disposal Works Construction Permit No. ........ -1 ...... /........... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.> - DATE-- - . ''. ✓ / --------------------------------------- Inspecto - ... %` /' �.... a...... ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 e� TOWN OF BARNSTABLE Disposal Varks � . - unstru rttutt "rrutft Permission is hereby granted...........1 .............5�. ..........- -----•---•••-•.....................................:.............••............-- to Construct ( ) or Repair (S,,) an Individual `Sewage Disposal System atNo...--•---..... •----- ------•-----. ....5f,.........-.... ...... ...........................................•-----....... PP P Street Q� ) p/ �� Z as shown on the application for Disposal Works Construction Permit No./.._.:._..j..�ed......�.y��V��Z)............... Board o Health �` DATE---=C �s -------------------------------•----...........---- FORM 36508 HOBBS Q WARREN,INC..PUBLISHERS AsBuilt Page 1 of 2 �O/J2 a cyi TOWN OF BARNSTABLE LOCATION c e,,M �tt'W !+/t SEWAGE # '.3q VILLAGE � � `am ASS SOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ///(/4'0_./ 4 SEPTIC TANK CAPACITY C LEACHING FACILITY:(type) T s,rce9 _(sue) NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDEReBUILDER R OWNER ISO p DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED: VARIANCE GRANTED: Yes No Mew �,�c jc/U � 4C ^ i l L � � r http://issgl2/intranet/propdata/prebuilt.aspx?mappar=208044002&seq=1 8/29/2017 TOWN OF BARNSTABLE LOCATION 0 Ad(� SEWAGE # 90�39� VILLAGE r✓�l�Q ASSESSOR'S MAP G LOT tog yy Z INSTALLER'S NAME Fa PHONE NO. 4c-6m SEPTIC TANK CAPACITY fC70(� LEACHING FACILITY:(type) OW PiR:05dfsize) NO. 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