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HomeMy WebLinkAbout0489 MAIN STREET (CENT.) - Health (2) 489.Main Street (Cent.) Centerville P ````-- —� 208 085005 III__!___n J�,aECYC(paCo UPC 12543 No.5�R ogDOST CONS���a HASTINGS,MN Apr 13 2017 23:24 Jim The Inspector Man 5085349919 page 1 09s, Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessmentskvzv) ry i�•y d .m, 489 Main Street m Property Address Robert Diamond c1b Owner Owner's Name v information is t`' required for every Centerville V/ MA 02632 4-13-17 page. Chy/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information S/# Q ,%j111i111rljrj' filling out forms I as a/ on the computer, �.� t�..• Sq �,,� use only the lab 1. Inspector: � ��' •'cy key to move your JAMES = cursor•do not James D.Sears ' use the return key. Name of Inspector Capewide Enterprises %�• -�'�c- s6�•=� NTiTr t -z � Company Name NSp�'G��`���` _153 Commercial Street ``` Company Address Mashpee MA 02649 CitylTown State Zip Code 508477-8877 S1623 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 16.340 of Title 6(310 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-13-17 ;sWpeMwre'sgnature 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 DER 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. t51na.doc•rev.6116 Title S OMcid Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17 �v I/� Apr 13 2017 23:24 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is -Centerville MA 02632 4-13-17 required for every entery State Zip Code Date of Inspection page. City/Town 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: The system is a 1500 Gal, Tank D Box and two pits. Note: All units H-20. 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): t6ins.doc•rev.ell Title 5 official Inspection Form:subsurface Sewage Disposal System•Pow 2 of iT Apr 13 2017 23:24 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 4-13-17 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 ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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): I ❑ 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.doc•rev.U16 Title 5 Official Insoection form:Subsurface Sewage Disposal System Page 3 of 17 Apr 13 2017 23:24 Jim The Inspector Man 5085349919 page 4 i Commonwealth of Massachusetts ugTitle 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Main Street l — Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 4-13-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment; ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 411111111M is less than 6" below invert or available volume is less than 1/2 day flow P1 rs 15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewape Disposal System-Page 4 of 17 Apr 13 2017 23:24 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond owner Owner's Name information is required for every Centerville MA 02632 4-13-17 page. Citylrown State Zip Code Date of Inspection B. Certification (coot.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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. 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 5 of 17 Apr 13 2017 23:24 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required For every Centerville MA 02632 4-13-17 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 660 L ms.doc-ray.6116 Title 5 011icial Inspection Form:Subsurface Sewage Disposal System-Pap 6 of 17 Apr 13 2017 23:25 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name informalion is Centerville MA 02632 4-13-17 required for every State Zip Code Date of Inspection page. city/Town D. System Information Description: The system is a 1500 Gal, Tank D Box and two pits, 0 Number of current residents: 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 201"7,000Gals Water meter readings, if available(last 2 years usage(gpd)): 2016-103,000Gal's Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date Commercialiindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seaWpersonslsq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 WWI Inspection Forth:Subsutface Sewage Disposal System•Page 7 of 17 tSins.Coc rev.6116 Apr 13 2017 23:25 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is Centerville MA 02632 4-13-17 required for every State Zip Code Date of Inspection page Cityrrown D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: NA 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: 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) ❑ InnovativelAlternative 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 UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): mns.doc•tev.el16 Title 5 Official Irspedion Forth;subsuAaca Sewage Disposal System-Page 8 of 17 iL Apr 13 2017 23:26 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 4-13-17 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: 1995 Permit#95- 111 4-2017 New D Box. 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): 18" 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: 1500 Gal. Precast H-20 Sludge depth: 2" t5l is.doc•rev.W16 Title 5 official Inspection Form:Subsur`ace Sewage Disposal System•Page 9 of 17 I Apr 13 2017 23:26 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts RMOWN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is Cill MA 02632 4-13-17 required for every -Centerville Stale Zip Code Date of Inspection page. CityfTown D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle NA 1" Scum thickness Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Asbuilt-Tape How were dimensions determined? _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 at 18" below grade w/inlet cover steel at grade. Inlet tee,outlet tee. Outlet cover at 6" No sign of over loading or leakage Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date tSins.doc•rev.8116 Title 5 Official inspection Form:Subsudece Sewage Disposal System-Page 10 of 17 Apr 13 2017 23:26 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 4-13-17 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 t5lns.doc•rev.6116 Title 5 Offidal Inspection Form:Subsuft�$Sewage Disposal System-Page 11 of 17 Apr 13 2017 23:27 Jim The Inspector Man 5085349919 page 12 Commonwealth'of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 4-13-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 42" below grade wltwo lines out. Box is H-20. Box is New 4-2017 wlcover at 6". 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.dor•rev.6116 Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Apr 13 2017 23:27 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts v Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is Centerville MA 02632 4-13-17 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cost.) Type: 2 ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ inn ovative/altem ative 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 two H-20 pits. Both pits are dry. Pits are 5' below grade w/covers at 6". No sign in pits of over loading. No high stain line. 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 doc•rev.6116 Title 5 Officlel Inspection Form:Subsurface Sewage Disposal System-page 13 of 17 Apr 13 2017 23:27 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts fleaRRIM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 4-13-17 page. CitylTown 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.): t5lns.doc-rev.6116 Title 5 Official irapection Forth:Subsurface Sewage Disposal System-Page 14 of 17 Apr 13 2017 23:27 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information Is Centerville MA 02632 4-13-17 required for every page. Cityffown 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 t5lns.coc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Apr 13 2017 23:27 Jim The Inspector Man 5085349919 page 16 � 98 N 5r r�aNr 0 P,r o s" 3 P1►a /3 3-3 /.4 i4 , N� 0 /3 -3 : 33-'-17 Sr �3)_ACK ton 43 y = 3 Apr 13 2017 23:28 Jim The Inspector Man 5085349919 page 17 <f,_\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner owner's Name information is required for every Centerville MA 02632 4-13-17 page. CityfTown 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: 30'+ teat 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: Lot High. Rear lot drop's off 30'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.dac•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r- Apr 13 2017 23:28 Jim The Inspector Man 5085349919 page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 4-13-17 page. Cityfrown 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Selvage Disposal System-Pape 17 df 17 Mar 01 2017 21:48 Jim The Inspector Man 5085349919' + page 20 • a0�-��S=ems Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is ~; required.for every Centerville MA 02632 2-15-17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: nWhen is filling out forms A. General Information /a/s--� `wtttumuiu4�i� on the computer, ``��� `ZH OF iygsS use only the tab 1. Inspector: key to move your ate: cursor-do not JAMES m use the return James D.Sears =�: :-,_ key. Name of Inspector Ca ewide Enterprises . �'•o o:'�; ay Company Name 07(e'••.. 153 Commercial Street '`I;NStp,t\\��0 Company Address � 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 CHAR 16.000).The system ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 'tom 2-28-17 js0pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. t5ine.doc•rev.5116 Title 5 Offltlal Inspection Form:Subsurface Sewage Oisposal System.Page 1 of 17 Mar 01 2017 21:49 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 2-15-17 page. City7own 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. The system is a 1500 Gal. Tank D Box and two pits. Note: Tank and pits are H-20. 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. i 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): t5ina.doe•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 r Mar 01 2017 21:49 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 'r 489 Main Street Property Address Robert Diamond Owner Owner's Name Information is Centerville required for every MA 02632 2-15-17 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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): Need to replace D Box,P Need to install outlet 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 ❑ NO (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.doc•rev.6116 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 3 o1 17 Mar 01 2017 21:50 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 2-15-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health (and Public Water Supplier, If any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: `• This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 1111W is less than 6" below invert or available volume is less than 1/day flow P ir.F 15ms.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 4 0117 Mar 0� 2017 21:50 Jim The Inspector Man 508534991.9 page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y( 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required rorevery Centerville MA 02632 2-15-17 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.doc•rev.6l7 6 _ Tltle 5 Official hspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Mar 01 2017 21:51 Jim The Inspector Man 5085349919' page 25 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner 6w ners Name information is required for every Centerville MA 02632 2-15-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 6 Number of bedrooms (actual). 6 DESIGN flow based on 310 CMR 16.203(for example: 110 gpd x#of bedrooms): 660 I t5ins.doc•rev.6/16 Tide 5 Official Inspaction Form:Subsurface Sewage Disposal System•Page 6 of 17 Mar 01 2017 21:51 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owners Name information is required for every Centerville MA 02632 2-15-17 page. Cityrrown State zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and two pits. Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection information in this report,) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2015-67,000Gais Detail: 2016-103,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercialflndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15,203): Gallons per day(gpd) Basis of design flow(seatslpersonslsq.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.00c-rev.6/16 Tllie 5 official Inspection Form:Subsurface Sewage Disposal System-Pape 7 of 17 i I - Mar 01 2017 21:52 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 2-15-17 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) ❑ InnovativelAlternative 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.doc-rev.6116 Tillie 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 17 Mar 01 2017 21:52 Jim The Inspector Man 5085349919 page 28 C Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owners Name information is required for every Centerville MA 02632 2-15-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known) and source of information: 1995 Permit#95- 111 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: 1500 Gal. Precast H-20 Sludge depth: 2'r I5ins.doc•rev.6118 Title 5 Offidel Inspection Form!Subsurface sewage Disposal Syste n•P39e 9 of 17 Mar 01 2017 21:52 Jim The Inspector Man 508534991 Y page 29 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 2-15-17 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness ill Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA 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.): Ta nk at working level. Tank and outlet cover at 1 B below grade wlinlet cover steel at grade, Inlet tee,outlet baffle. Note: outlet baffle is broken. Need to install outlet tee. No sign of over loading or leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t$ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 10 of 17 Mar 01 2017 21:53 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 2-15-17 page. CityrTown 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 Bolding 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.doc•rev.6116 Title 5 OfFlcial Inspection Form:Subsurfaoa Sewage Disposal System•Page 11 of 17 Mar 01 2017 21:53 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owners Name information is required for every Centerville MA 02632 2-15-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (Cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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"x16"42" below grade w/two lines out. Box is H-10-wall's are gone. Need to replace D Box. 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.doc-rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Mar 01 2017 21:53 Jim The Inspector Man 5085349915 page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 2-15-17 page. City7own State Zip Code Date of Inspection D. System Information (cost.) Type: ® leaching pits number: 2 ❑ leaching chambers number_ ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two H-20 pits. Both pits are dry. Pits are 5' below grade w/covers at 1'. Note: Covers should be raised. No sign in pits of over loading. No high stain line 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 15ins.doo•rev.6/16 Title 5 Official Inspeaion Form:Subsurface Sewage Disposal System•Page 13 of 17 Mar Q1 2017 21:53 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 2-15-17 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.doc-rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal syslem-Page 14 of 17 i Mar Q1 2017 21:54 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 2-15-17 page. CityfTown 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 l5ins.doc•rev,6116 Tille 5 Official Inspection Form:Subsurface Sewage Dlsposai Sysiem•Page 15 0117 ' i Mar Q1 2017 21:54 Jim The Inspector Man 5085349919 page 35 I)JA IN 51- 0 G � 0 0 s" 0VSX 43 OCK 1oP Mar Q1 2017 21:54 Jim The Inspector Man 5085349919 page 36 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner Owner's Name information is required for every Centerville MA 02632 2-15-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth t high ground water: 30+ 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 propertylobservation 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: Lot High. Rear lot drop's off 30'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev,W6 Ttle 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Mar Q1 2017 21:54 Jim The Inspector Man 5085349919 page 37 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 489 Main Street Property Address Robert Diamond Owner owner's Name information is required for every Centerville MA 02632 2-15-17 page, cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.dor-rev.6/16 Title 6 Official InspecWn Form:SubsLeace Sewage Disposal System-Page 17 of 17 e') No. Fee +� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliCatlon for ]Disposal 6pstem Const urtton permit Application for a Permit to Construct( ) Repair(W Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. !/LCow :s--, C—Oar Owner's Name,Address,and Tel.No. Assessor's Map/Parcel P®F3 &8 5 ®0 (p Cc -r An R VC a ji Svgj?- U K Installer's Name,Address,and Tel.No. Sc>S-4h —:8S 7-1 Designer's Name,Address,and Tel.No. CAo&_,_)taZ-: LL< N' " _ 00 - 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(min.required) Al I— gpd Design flow provided IT gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable O v t!-,VK ce t°rt6 iU SOX 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 Certificate of Compliance has been issued by this Board of Healt (� S' vC2 Date 3' Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 1 Date Issued r No. tt ; Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes �ppliLation for MispoBal *pstem Construction Permit Application for a Permit to Construct( ) Repair(,k� Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. WoffJ ST CVJt; Owner's Name,Address,and Tel.No. Assessor's Map/Parcel P0$ Og s 0'a• 4 . Ep M4 C!{ iiT AD Rk-4masa SckZlZt V K Installer's Name,Address,and Tel.No. Sp$-41177—$$-7'7 Designer's Name,Address,and Tel.No. CAPEW,of 6;).J1-e0 (563 Lcc ✓ Nl� Type of Building: "I Dwelling No.of Bedrooms /V/7Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria(' ) Other Fixtures Design Flow(min.required) gpd Design flow provided Ir gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicabl �V 57*C.L t/stj1 TW-e,t_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of J Compliance has been issued by this Board of Health f 7i Sig13 Date 3 Application Approved by Date r' Application Disapproved by Date for the following reasons Permit No. Date Issued --- -------' ---------------------------- --------------------------------------------------------------------------------------------- �� tJ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance F / THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by <2Ap �(be t--A t&<ES at <% ll lLC C has been constructed in ordance with the provisions of Title 5 and the for Disposal System Construction Permit No�go I�—8 dated r J Installer O-APEt x D Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector 1�G ------------- ------,x(--------�----�------------------------- -------------------------------------------------- No. / �� Fee---�-�------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS - . .—0.„ Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with k Title 5 and the following local provisions or special conditions. c Y �S Provided:Constru2ction�must be completed within three years of the date of this permit! r ?,� 6 Date J f !� Approved by ` i i t T�, Town of Barnstable Barnstable NE Regulatory Services Department 'caCf, s ♦ I I ' � BARN5CABLE, MASS.: *0� 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 CERTIFIE D MAIL#7- 0'''�-'z010 0000 2847 8 20 Son+ VI�t 6wne-r emai March 6, 2017 DIAMOND, ROBERT M & CAROLINE L 16 MARCHMONT ROAD RICHMOND SURREY TW10 6HQ UNITED KINGDOM ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 489 Main Street, Centerville, MA was inspected on 02/15/2017 by James D. Sears, 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: • Replace rotted distribution box and install outlet tee on septic tank. You are ordered to repair or 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\Letters Septic Inspection Failures or Future Evl\489 Main Street Centerville.doc Sousa, Vanessa From: Robert Diamond <robert@fernbrookpartners.com> Sent: Tuesday, March 07, 2017 12:32 PM To: Sousa, Vanessa Cc: Flynn;Judith Subject: Re: Septic Inspection Letter Received - many thanks Robert Diamond Founding Director, Fernbrook Partners Email: robert@fernbrookpartners.com Mobile: 07801757518 On 7 Mar 2017, at 17:30, Sousa,Vanessa <Vanessa.Sousa@town.barnstable.ma.us>wrote: Hi Mr. Diamond, Please see attached letter regarding your septic system located at 489 Main Street, Centerville, MA 02632.The inspection of the septic system showed that the system "Conditionally Passes" due to rotted distribution box and install outlet tee on septic tank. I understand your mailing address is in the United Kingdom. I thought it would be best to send letter via email,for you will receive this notification in a timely manner. If you have any questions, please contact Town of Barnstable Health Division at 508-862-4644. Thank you,very much appreciated . Vanessa Sousa Town of Barnstable Health zoo Main Street Hyannis,MA 026oi <image003.jpg> <489 Main Street Centerville.doc> 1 COMMONWEALTH OF MASSACHUSETTS 24 4. .-. ExEcuTrvE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONME TAL PROTECTI_ ,. W ' i3+ B E 1 " .tSE,pk`2_� A4`1 : TOWN0 BARNSTABLE TH© HEAL TITLE 5 �:� ::, � -_-_ / OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM' `FARM ®� PART A PARCEL 5 CERTIFICATION �-----� LOT s Property Address: 489 MAIN ST.,CENTERVILLE,MA. Owner's Name: CRAIG JANNEY Owner's Address: 489 MAIN ST.,CENTERVILLE,MA. Date of Inspection ,28,2004 Name of Inspector.(please print) LLOYD"DOUG" SIME Company Name: Mailing Address: 396 SOUTH ST.,BRIDGEWATEK MA.02324-2431 Telephone Number. 508-697-6663 CERTIFICATION STATEMENT I certi>v 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: XX Passes Conditionally Passes �~ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: July 31,2004 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 DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of I I , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 489 MAIN ST.,CENTERVILLE,MA Owner. GRAIG JANNEY Date of Inspection: July 24,28,2004 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: YES I have not found any information which indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 3 10 CMR 15,304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not det d"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether me r not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent stem will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Boar Health. *A metal septic tank will pass inspection if it is structurally sound,not leaki and if a Certificate of Compliance indicatin-that the tank is less than 20 years old is available.. ND explain: Observation of sewage backup or break out or high tic water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven ' tribution box. System will pass inspection if(with approval of Board of Health): broken pipe are replaced obstructi is removed dirt * 'on box is leveled or replaced ND explain: The system required ing more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with a oval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: I rage s or i i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 489 MAIN ST.,CENTERVILLE,MA Owner: CRAIG J Date of Inspection: July 24,28, 2004 C.Further Evaluation is Required by the Board of Health: Conditions exist which require ftirther 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 ' 310 CMR 15.3030)(b)that the system is not functioning in a manner which will protect pub ealth,safety and the environment: Cesspool or privy is within 50 feet.of a surface w _ Cesspool or privy is within 50 feet of a bord ' g vegetated wetland or a salt marsh 2.System will fail unless and of Health(and Public Water Supplier,if any)determines that the System is functionin ' a manner that protects the public health,safety and environment: _ The stem has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surf water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water su ly. The system has a septic tank and SAS and the SAS is within 50 feet of a priva ter supply well. The system has a septic tank and SAS and the SAS is less than 10 et but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,perfo at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates t the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate ni gen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the alysis must be attached to this form. 3. Other: 3 rage 4orii OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 489 MAIN ST.,CENTERVE LLE,MA. Owner: CRAIG J Date of Inspection: July 24,28,2004 D. System Failure Criteria applicable to all systems: You must indicate "yes'beh'tb each of the following for all inspections: Yes No N Backup of sewage into facility or system.component due to overloaded or clogged SAS or cesspool N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool NA Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped N Any portion of the SAS,cesspool or privy is below high ground water elevation. N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ N Any portion of a cesspool or privy is within a Zone I of a public well. N Any portion of a cesspool or privy is within 50 feet of a private water supply well. N 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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 forma NO (Yes/No)The system fails.I have determined that one or more of the above failur crit ria exist as described in.'I 10 ChIR 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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"ot Wto each of the following: (The following criteria apply to large systems in addition to the criteria abov yes no _ _ the system is within 400 feet of a surface drinkin ter supply —_ the system is within 200 feet of a tribu to a surface drinking water supply — the system is located in a ni en sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone H of a public wat pply well If you have answered" to any question.in Section E the system is considered a significant threat,or answered '�etiin Section D ove the large system has failed.The owner or operator of any large system considered a Significant at un er Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR 15.30 -system owner should contact the'appropriate regional office of the Department. 4 'OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 489 MAIN ST.,CBNTERVILLE,MA. Owner: GRAIG J Date of Inspection: July 24,28,20o4 Check if the f011owing have been done.You must indicate' es"of&as to each of the followine: Yes No Y _ Pumping information was provided by the owner,occupant,or Board of Health _ Y Were any of the system components pumped out in the previous two weeks, Y — Has the system received normal flows in the previous two week period Y Have large volumes of water been introduced to the system recently or as part of this inspection 9 Y _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back up" Y — Was the site inspected for signs of break out') Y — Were all system components,excluding the SAS,located on site Y _ 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 sludee and depth of scum 9 Y _ 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: Yes no Y _ Existing information.For example,a plan at the Board of Health. Y _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 4 J 5 i ar,b V Vl 1 1 , OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 489 MAIN ST.,CENTERVILLE,MA. Owner: CRAIG JANNEY Date of Inspection: July 24,28,2004 RESIDENTIAL FLOW CONDITIONS — Number of bedrooms(design): Number of bedrooms (actual): 4 DESIGN flow based on 3 10 CMR 15.203(for example:I 10 gpd x#of bedrooms): Number of current residents: 3 Does residence have a garbage grinder(yes or no): Y Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 110.95 GPD AVE. Sump pump(yes or no): NO Last date of occupancy: current CONI ERCIALANDUSTRIAL Type of establishment: Design flow(based on 3 10 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.)- Grease trap present(yes or no):._ Industrial waste holding tank pre yes or no): Non-sanitary waste dischar o the Title 5 system—(yes or no): Water meter readings ' available: Last date of oc ncy/use: O (describe): Pumping Records GENERAL INFORMATION . Source of information: Owner said it was pumped about 1-1/2 years ago. Was system,pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM N 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) Tighttank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: AUGUST 15, 1995 DATE OF CERTIFICATE OF COMPLIANCE FROM BOH Were sewage odors detected when arriving at the site(yes or no): NO 6 I ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 489 MAIN ST.,CENTERVILLE,MA. Owner: CRAIG JAIVNEY Date of Inspection: July 24,28,2004 BUILDING SEWER(locate on site plan) Depth below grade: 20-22" Materials of construction: -cast iron 40 PVC X other(explain): Distance from private water supply well or suction line: Comments(on condition ofjoints,venting,evidence of leakage,etc.)- Joints appear tight, leakage in pipes or fittings in the celllllaarrr SEPTIC TANK: X (locate on site plan) Depth below grade: 15-23" Material of construction: X concrete metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5'X 5'X 5' Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2-3" Distance from top of scum tc,top of outlet to-e or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 5" How were dimensions determined: TAPE MEASURE AND MEASURING STICKS Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- INLET TEE IS INTACT, RISER OVER TEE PROVIDES VENTING.OUTLET BAFFLE INTACT.RISER OVER OUTLET END OF TANK.OUTLET COVER PARTLY UNDER PAVEMENT.TANK SOUND. GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: concrete metal fiberglass_po ylene other (explain): Dimensions: Scum thickness: Distance fi7om top of scum to top of outlet to baffle: Distance from bottom of scum to botto outlet tee or baffle: Date of last pumping: Comments(on pumping,re mendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet i ,evidence of leakage,etc.)- 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 489 MAIN ST.,CENTERVILLE,MA. Owner: CRAIG J Date of Inspection: July 26,28,2004 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 hylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/ Alarm present(yes or no): Alarm level: Alar working order(yes or no): Date of last pumping:"- Comm 7> ion of alarm and float switches,etc.)- DISTRIBUTION BOX: XX (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 inio or Gut of box,etc.)- D-BOX IS UNDER THE DRIVEWAY PAVEMENT. INSIDE VIEWED AND INSPECTED WITH A VIDEO CAMERA,BY SOARES ENTERPRISES.LIQUID EVEN WITH OUTLET INVERTS,NO LEAKAGE P . XX PUMP CHAMBER. (locate on site plan) Pumps in working order(yes or no): Y Alarms in working order(yes or no): NA Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.)- PUMP IN THE CELLAR FOR THE LAUNDRY&DOWN STAIRS TOILET. PUMP WORKED WHEN THE CHAMBER WAS FILLED WITH WATER FROM TOILET&SINK,DRAINS INTO PLUMBING TO TANK 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 489 MAIN ST.,CENTERVILLE,MA. Owner: CRAIG JANNEY Date of Inspection: July 24,28,2004 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type XX leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.), THE PITS ARE LOCATED UNDER THE PAVED DRIVEWAY. NO SIGNS OF HYDRAULIC FAILURE OR 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 constructio Indication of r water inflow(yes or no): Commen ote 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 o raulic failure,level of ponding,condition of vegetation,etc.)- 9 Page 10 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 489 MAIN ST.,CENfERVILLE,MA. Owner: CRAIG JANNEY Date of Inspection: July 24,28,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. t�"1 40 d' t All If 10 rage i i or i i OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 489 MAIN ST.,CENTERVILLE,MA. Owner: CRAIG JANNEY Date of Inspection: July 24,28,2004 SITE EXAM Slope 0—k— Surface water Check cellarShallow wells wells y�;l Estimated depth to ground water 15 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) XX Checked with local Board of Health-explain: RECORDS ON FILE, 10-19-02 Checked with local excavators,installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 1)HIGH GROUND WATER COMPUTATION RECORDS OF 10-19-02 RECORDED GROUND WATER AT 22 FEET.FTUFF R METHOD CALCULATES HIGH WATER TABLE 15 FEET. 2)STANDING WATER IN A POND AT THE BOTTOM THE SLOPE IS OVER 15 FEET BELOW RARE. II LLOYD D. SIME 396 SOUTH STREET, BRIDGEWATER, MA. 02324 508-697-6663 FAX: 508-697-6456 2004 CERTIFICATE OF CONDITION ON THIS, DULY 28, 2004 I HAVE INSPECTED THE SYSTEM AT 489 MAIN ST.,- CENTERVILLE, MA. AND FOUND THAT THE SYSTEM APPEARS TO BE IN GOOD WORKING ORDER. THIS CERTIFICATE DOES NOT CONSTITUTE A GUARANTY OR A WARRANTY BY THE UNDERSIGNED. INSPECTORS SIGNATURE: 4LL4115S- 2E D.E.P CERTIFIED,TITLE 5 INSPECTOR 1 C-O-MM WATER DEPT CUSTOMER STATEMENT ACCT 11 7,082 7/22/04 JANNEY,CRAIG LOCATE 489 MAIN ST CEN LOT: L30 MAP&PARCEL : 208085005 Consumption History DATE READ CONS 06/30/04 426 0 426 --- 32-- -- 06/30/03 394 22 f f�• �� � 12/31/02 372 37 06/30/02 335 _ 17 -12/31/01 318 39 06/30/01 279 15 12/31/00 264 31 TRANSACTION HISTORY .E DESCRIPTION 0 to 30 31 to 60 61 to 90 Over 90 00 S-f xRTING BALANCE 0.00 0.00 0.00 15.00 00 pA,yMENT 0.00 0.00 0.00 -15.00 !/00 MININIUM BILL 0.00 0.00 0.00 15.00 !/00 PAYMENT 0.00 0.00 0.00 -15.00 01 MIN EX 0.00 0.00 0.00 46.90 01 ITT 0.00 0.00 0.00 0.55 01 1VIIN INT 0.00 0..00 0.00 15.55 '01 PAYMENT 0.00 0.00 0.00 -47.45 5/01 PAYMENT 0.00 0.00 0.00 -63.00 101 1\41N 0.00 0.00 0.00 15.00 1/01 MIN 0.00 0.00 0.00 . 15.00 '02 M11,;EX 0.00 0.00 0.00 70.10 Balance Due: 35.00 Sent By: CAPE COD LAW OFFICES; 1 600 771 8288; Sep-24-03 10:14; Page 17118 . 8t�T By, dOATOLOTtI WRIT; 5eAa289�00; ACP•1d-09 aa:ag; rAM= • `ie6i{+e flJ.ftrCfYvA i<'f1 LEOFL,MMOLMA1016N 'A Allfmw 8i�1 l,oei�mn• �' ."� � C LCr fu'tl� . r r 9?!fJ�' t yre do'iti.-W& wb4 j 'aaepirsR.171C ... ........ Z.E`- 2Utir�.l�tr:�a�•rr}t Range Zeno ' Lt"i fil,�'i� ��atr�'ma�+yr.re?pR."'C��auusg � � � ,' `•;:'. � .r • Wef"er F�c'��on'Ca�ndltlonc" �, :, � • nrllty F�vti 4ar:,tdcri wsl9.,.. � � � � � • 00. i. *%p,��1 1.et-rasa. lal1 A4Plz�o+�r 1^Y ' qof l 6ph—gaff wrr 4l, euzrim diatr P�, eo wmrJeMet*A Woo we mj-o at 1 . • , i f�f!7LI�!•T\a'1�'N,1 ,�1•t1r�1111_•rW IN•_.�rrr•.u.r��.._._.•„w.....r..r...• ' , ' ' �': o- Eeei:flP.O•L`'41F9A fP:'l��h wK.sP i ' aw;edt+�f�t' n' a� f • ' • i:s�R+�o"tret.di p�ro rweir+} ! � ,f .. - Mn'�f 3tp�.41e�°:�fr..w__.. i-w-•w_..�..p_ rnP. .�.�ru...e__..•�..._.. ..�.. ..n,n.. �n� F'7.6i$ 1,1, U�0(fa CfX'!C1ifOrr iCn:S: / P I a a ' 3L o:o o od3w - - N a a4,K m N _ m ti m _ Indw -.. — CJ W O O M Q w o 4 .ram CO _ C d C!! �y � � �$� " - ' w �� �"� '""� ������� t , TOWN OF ARNSTABLE Ilk LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LO_ 4cc-j'4�•r�Lv � L,LE � INSTALLER'S NAME 6r PHONE NO. SEPTIC 'SANK CAPACITY_ + LEACHING FACILITY ype) M>15 SOX aZ(size)_ NO. OF BEDROOMS_ PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER INN DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED• S— ! �� VARIANCE GRANTED: Yes No Af loss bid lob . 3t 14 y I _.. - GOP t 7�tf►Cl. CnA Yll- ...... ASSESSORSMAPN 0? y PARCELNO: FEBZ THE COMMONWEALTH OF MASSACHUSETTS K BOAR® OF HEALTH l ogS TOWN OF BARNSTABLE 4 e 0� vv tra iott for Diripaiial Work,i Tottstrnrtiun famit Application is hereby made for a Permit to C'orlstruct ('v�'or Repair ( ) an Individual Sewage Disposal ' System at Locatio -Address or Lot No. `z1.. .... o ............ -----------•---------............. ------3 .�,4�.1 �1.I7. ... ......�:... pf� O cn Address Installer Address Type of Building sk IF Size Lot.`�J zZ_........Sq. feet .. Dwelling— No. of Bedrooms............ --------------------_.Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of ersons.......................--... Showers — a g p � ( ) Cafeteria ( ) d Other fixtures ......... ---------•-----•-------------------------------- W Design Flow...............................�r-�---.-.gallons per person per day. Total daily flow.-- -.--j ....�` ..gallons. 9 Septic Tank—Liquid capacity-150w..galIons Length..40_.4.... Width..S:4----- Diameter.......... Depth..S n.4...... Disposal Trench--No. .................... Width.................... Total Length...--............... Total leaching area....................sq. ft. 3 Seepage Pit No------------Z..... Diameter......//- .... Depth below inlet......¢.......... Total leaching area..` Llr.....sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.-2Z¢/,.,e...C c F�=act.b............................... Date-J.?_ ................... Test Pit No. 1 ZX5$.—_-minutes per inch Depth of Test Pit.....1.Z'-...... Depth to ground water........................ 44 Test Pit No. 2................minutes per. inch Depth of Test Pit..............--.... Depth to ground water........................ a' .....--••-••---------,- ---........................•--------•-••-•-----••------------------*--------•--•-----••---............-------• ".'•.......... ....... Description of Soil 7 5..........,�"�",-���iv�•-----•-f�` V .....-•--•-•--•••-•••••-••--••-•-•----••••--•••-•.....•--••••-••-••-•--•--•--••••-•....-•-•----•---••------•••--•••-••---•-••-•••-----•••--•---••---••-•.....--•...........................••--•-........ W ------------------------------•-------- ------------------- ....---------------------------------- .----------------------------------•---------------•-----------------------------*......------......... U Nature of Repairs or Alterations—Answer when applicable...............................--...........................--.................................. ....•---•---------••-•---------------------------------------------------------------------------------------------------------------------------------------•-----------------------------............. Agreement:The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersign d furQr agrees not to place the system in operation until a Certificate of Complia e has be iss ed by the bof hed�lth. pf b' J'if .�I� Signed - - .�.. d ` I:-..y...�........- --c .. lj-..% .. 0_11 , / Dare Application Approved By ...... ..... ..... ... .................... .-�.:Z...� � ................................. Dare Application Disapproved for the following reatons: ............................................................................................................ ........................ .................................................... ............................................................:..... Dare Permit No. ..:.... 6''G /�... Issued ��...:.. ..�r' 'Da` Dare 9t�No............... THE COMMONWEALTH OF MASSACHUSETTS ZOARD OF HEALTH "TOWN OF BARNSTABLE yAppftrafiaufur* Di!ipmial Works' Tomitrurfiatt Vanfit Application is hereby made for a Permit to Cojj,.,truCt Vf Or' Repair an Individual Sewage Disposal System at: lc;>�........................4...69..... Location-Address or Lot No. ........... ................... ........................ ........... RAUX-11 Sine:...voa......... or Address ;4 ............ t� 1i is t al I er Address 44 U Type of Building) Size Lot. ...- .... .........Sq. feet Dwelling—No. of Bedrooms.......... --------- Expansion Attic Garbage Grinder # 0- ---------- --- 04 Other—Type of Building ------------------------ ---- No. of persons---------------------------- Showers Cafeteria 04 Other fixtures ------------------------------------------------------------------------ Design Flow............................................gallons per person per day. Total daily flow—.A#=----6.60.... W .....gallons. 04 Septic Tank—Liquid capacity-15kw..gallons Width__AS_-.4t----- Diameter-_._---__.__- - Depth..�.4n..... Disposal Trench--No. ..................... Width.......__......___.. Total Leiigth.................... Total leaching area....................sq. ft. Seepage Pit No............ Diameter-_'.//.......... Depth below inlet........5(.......... Total leaching area..`4 4t.lr.....sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by...Z ............................... Date---�a....... Test Pit No. I 2.4f:�Z�_.rfiin6t'es.'per inch Depth of-Tesf'Pit.-.---/z....... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._._...__..._.._..._.. 04 ................................................................. ............................................................................................ 0 Description of Soil_..7_J--..5...........Ae'� ........ ...................................................................................... U ......................................................................................................................................................................................................... ....................................---------------------------------------------------------------- .................................................................................................. U Nature of Repairs or'Alterations—Answer when applicable------------------------------------------------------------------ ............................ ..................................................................................................::-................................................................................................... Agreement: /11 The undersigned agrees to install the aforedescri6ed Individual Sewage Disposal Sy-tern in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned furth r agrees not,to place the Disposal y tern in accordance urth r agrees not system in operation until a Certificate of Compliance has be issTed b the bo',F)d of he Ith. Signed ----- .... ... 7 ... - --------- ---------------- ..... ------------- .... ApplicationApproved .. ................................................ ........................ 'Dm Application Disapproved for the following reasons: ................... ...............................)...... .............................................................................. ....................................... 1 D, ------------------------------------- --------­­----- -------------­­---*---------------------­----------­­... ....................................... br ........................................... Issu'ed ----- Permit No -------------------------------------- -------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .4 '4:A) TOWN OF BARNSTABLE Zertiftrate of Tompliattre THIS IS That th�jndividual Sewage Disposal System constructed or Repaired by ..........................N__at .................................................................................................................................... ------- ....... --- ....... 04 --- ---------------- ----------------*------- ------- ..............*-- I a r has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT Bf CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFAC DATE.......... .......:_....... ................................ ............................. --------------------------- .............................. ------------------------- ------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No... FEE.A� Phipmat-Workii! amitrurtion rantit A 7 .................... ........................................................ Permission is hereby granted__.-_, . - ..._..... ........... to Construct (I-l"or Repair an Indiv ual Sewage Disposal•S st .................................................................. at No - -------- eA--- . .. 7 Street as shown on the application for Disposal W P orks Construction Rergiff No,3.--- �i e ...... ...... ..................... DATE..... Board of ealth ....................................... -_------------------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS &OTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Turk Tonstrixrtiutt Hermit Application is ereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sysl at: �o Ad dr 6 ......•.... ` ......................... -� Owner •Addresa • Installer --- pq ddress VType of Building Size Lot......_..f..�2:2:..Sq. feet ±' ., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures . .. . ... ........ ............ .....•- W Design Flow...........................��.----.gallons per person er �ay..... Total dail flpow........�.��....._..--•---.--_.�lops. WSeptic Ta quid capacit gallons Length.V 1-... Width._!1'. 5.. Diameter................ D th-.?!.��... Dis sal p No........9 t _.---- Width `.._.... Total Length....��. . Total leaching 2 x po .- - --- •--•-- n8 area..... .. ... ....sq. ft. 3. Seepage Pit No..................... Diameter .............. Depth below inlet.- .e.:Zel-.... Total leaching area.................sq. ft. z Other Distribution box (� Dosing tank ( ) t~ e ll`t I GH►J G--z J t�1NtiJ�n�G a Percolation Test Results Performed by._ '...--••--•-.-••-.---.-.--.-•- ----...--f. Date....------------------------•------....- Test Pit No. I....fl-.....minutes per inch Depth of Test Pit.....1.2-..... Depth to ground water........................ LL, Test Pit No. 2......2...minutes per inch Depth of Test Pit.....1_'2:-::`..... Depth to ground water........................ O Description of Soil......................•••._...•...�._. .......� -- .-.. ..: - --• ........_....... �...... W UNature of Repairs or Alterations—Answer when applicable............................................................................................... .........................•---....-----..........----••-•----........----•-------...................-•--••---------•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIEI 5 of the State Sanitary Code—The under urtler agr not to place the system in o�eration };iI ' ` Cer ' ca of Compliance issued t oard of healtly ,. . Sign d ..... . r . `� ... ...........�...1`�1 Date i Applic�Un Approved By....�i.�,�L_ _._.__.._��/fy................ (� .,�•�--------- ----------------------------_ Hate Application Disapproved for the following reasons:..........................................................................................................--- ........................•-•--...-------------•-••-•---......................--------------......----------.....---••--•----------•-----•-------••••----•--••-••---•-•-•-•--•--•-........-••••..__.._ Permit No..� _.._11,3 ) ��1.. Date ......._....___ Issued......... S- ......__. a ..- " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I Trrtif iratr of Tomplionrr e THI I,S_'O ER IFY, That the Individual Sewage Disposal System constructed ( �) or Repaired ( ) b f e.�l ger i�crc�v ti�-`t �.. /CQlnstaller ............................••---.... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod as described in the application for Disposal Works Construction Permit No........... .�l...y3.1............ dated.....Y/V, te....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................:.......................................•---••-•••_. Inspector.................................................................................... -- - -- - --- ----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No........................31 Fse.I L)n.... Disposal Works f9pnstrudion rrrmtt Permission is hereby granted......f '-••3...... v, �C.f oz(.---••--••-----•--•-•..................•-----............................ to Construe ) or Repair ( ) an IndividualC ewage Disposal System at No.................J M��n---`�`t' ��...�..............•---•-------------...........•...--• ....... '........................... ....._ - Street as shown on the application for Disposal Works Construction Permit No.9..q..y.•....J- Dated......7./34y........... t. Board of Health DATE................................................................................. t� K �, �,''' n �".+x' 'N!!Ftf ��'.' ..� �,�_R.tr � r #'�'7 sr{ � '�•.�r,.�skh'�.'k�p- ;r'?°�..df!'ifi'�f.�s,.%.tit+"",` 1 76r*��„ '�f IV, {,� Q ce 1 •,. t Na_ --.L�3 f' �" _�}//,y�"a.� Fss'- 1 Q© � r COMMONWEALTH r E:C WEALTH OF MASSACHUSETTS <; .r�JB� LOA R DO F HEALTH AppKiraa#iun for Elio s�at. lurk Cnunstrurti,aat Vomit ' Application,is*hereby made for Permit to` Construct (~ ) or Repair (. ) an Individual Sewage Disposal lob __ ion->Addr .........__....... ...................../........._.. "L.__ ...._....... �................... _... G«. �: --- 1J`�-_f���.0:SJ " ...._.....__„or Lot No.. .. .... ... ' AdM Installer Address Type of Building Size Lot........f._ A-�A=..Sq, feet t Dwelling—No. of Bedrooms.............. ..........................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building .................. No, of persons............................ ( .) Cafei'eria __......... Showers _. Other frxtures•. :......:...................:................................. .._....... r,.WW Design Flow................. .............„ .6--....gallons per personyer flay. Total dail flow.......'-��./__Q....................-gallons. WSeptic Ta —Liquid capacitgallons Length.1a!+_ft" ..... Width..: �1.. Diameter________________ D th..r1e.1?7.' .... Width..__.UP'___._.. Total Length Total lea area.__..___ __. .sq. ft. x Disposal —No.......... .. g � �- 3 Seepage Pit No................... Diameter .............. Depth below inlet.` ... Total leaching area ....... ..sq. T-�.. _. x Other Distribution box (� Dosing tank ( ,. - .. loll,. - Percolation Test Results Performed by----�--- •-•...... .........� a • 4 '� Test P•it No. 1..q.'' ......minuie per inch Depth of Test Pit.....l-� 1.__.. Depth to ground water........................ w G>4 Test Pit No. 2........:.:....minute per inch Depth'of Test Pit_____ ' s.... Depth to ground water........................ a Description of Soil. --•--- ..-: ---- �� ." ................ ............ .... U. -• ....... .............. _......................_ x ................................• -.... .-.......•--- ---------•-.........--- ---- ••------............._.----........_........•--•••-•----..........,...-•---- =;i U Nature of Repairs or Alterations—Answer when applicable.................................................... y -- --- --•--••--••...........................•------_-•-- , ' R ----•--.......... 1.......------........- .........__- -_-•-• ... ... Agreement: x The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of: the State Sanitary Code-The under ' urtlier agr not to place the system in o peration a,Cei ' ca of Compliance has'been issued by t oard of cti S 4.h eal y: i Ll c - .... "j •... .._.... Sign d... , . th 4 wry C Date Applian Approved By... _ Date t A .............pplication Disapproved for the f ollouring reasons . ............................................................ ....___ .. .... ..-- .... .................................... ---. __.._ Date `Permit No.... .... I .�.�.� S`�............. .. _—•-_ ate ..._.......... --------------- --------------J-- ---•----------------•------------------------------`------- ------------------_------------- - - -------•- rar THE COMMONWEALTH OF MASSACHUSETTS BOARD OF -HEALTH '""ar . } Trr#ifiratp ,af Tnntpiinnrr ram' TH ,f 70 ER IFY, That the Individual Sewage Disposal System constructed ( X ) or Repaired ( ) by. -1 • 6�± ____. ....�-/c5' . �� � Installer . .. M at. `.__•__•...................... ... ��----_----.___--------- _-____- ....... ----------------------_-__........_................. ......... .... 4 has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code.as described in the application for Disposal Works Construction Permit No...........q.�!___.1!_&_l._..-....... dated_....�1�A ........................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................ --•- --... Inspector......................................................_... ................... �- THE'•.COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, :�.• .'No......................... Disposal Marks T no#rUdin `trrmit R - Permission is hereby granted.. .......... �' $C: 'I........................................................ -- to Construct or Repair ( ) an Indivfrlual eewageDisposal System -_._. - Street as shown on the application for Disposal Works Construction Permit No. � Dated..: _ 39.`1 .. --• .... . : _ - -_. .... Hoard of Health DATE................................................................... ... _....: ...w:. b 3 D40 PROPOSED 18'X 28'IN-GROUND Ir Opp `SS (MIN),WITH 5ELLFL. FENCE TOBLATCHING O APN 208-085-005 `�o\ GATES. �� O DOOR ALARMS TO BE INSTALLED 43,934±SF AS NECESSARY. 0 CA EXISTING GATE o O O (TO BE REPLACED) �h� to -Q c9 rn s31`3)�,8 S2203 S No. 489 J 2 S`36�\ 01 12 STY. \ 3y 06i .o EXISTING GATE WE). FR. (TO BE REPLACED) �7 O F O O LL, 110 }O ( 1 o trj � O o� O � � O 24.99' 10'St-= `-y) N0000010011E Ot7 b9 I=?J o m CO z a MAI N 5TREET N I HEREBY CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, AND IN MY PROFESSIONAL OPINION, 0 THE FOUNDATION 15 LOCATED ON THE GROUND AS SHOWN HEREON, AND ITS LOCATION 15 IN CONFORMANCE WITH THE HORIZONTAL SETBACK REQUIREMENTS OF THE TOWN OF SANDWICH Z ZONING BY-LAW. 0 l SITE PLAN JOB No.: 12134 N DATE: 18oct 12 N 3 BAPMTABLE (CENTERVILLE) MA. SCALE: i" = 40' PREPARED FOR OF '�qs N STEVE 5ENNA RICHARD sgcy� o s ^' J. rlchard j. hood, P15 No 00031 land surveyors - englneer5 0 i� e22 deep Wood drive - fore5tdale - ma 02G44 LAND S Ph: 508.533.7100 i U TOWN OF ARNSTABLE LOCATION U 9 SEWAGE # C 1 VILLAGE ASSESSOR'S MAP & LOIAOT-41',' INSTALLER'S NAME & PHONE NO. OI� . SEPTIC TANK CAPACITY /f8 C� c� LEACHING FACILITY:(type) Jbaa �� o��(size) NO. OF BEDROOMS— PRIVATE WELL O PUBLIC WATER BUILDER OR OWNERS i ��5 (--6 KN DATE PERMIT ISSUED: a-13 ' D-- DATE COMPLIANCE ISSUED: /10 , VARIANCE GRANTED: Yes No a 1 zis � C � 's S`v im Qoe 7 ' s _ 4 1 ' T LOW(, h� 'Ted J j .T .r VIA 011. C E rZ e �.ea� 2 +►•�, t"i_- � �� ':�^'' G+'4iL� �Il,l MILE le, WAIL �#4 / T T I P�t�r�►..�Lt T�tME.r.t51ULJ�, ��;, � 1 r� � � -rtz�cTlo� �1 _� WAT>={Z 4vvee4�' a % �Ca t.�E�S - _ _ Doti �?L' - I c t.o vj 7CU C Tor ' , ,\ 1 Pia c, /a, / 9�} i rl,'t. /' r L ' #'L 6!A: �tA ��pa�4 �\ \\ C • �E ( I 1 GjlUC1 �iA Ll-l%t�.l tom' UM �" c' b 4M P;�►� , I�t �, F a�� T. Ipl IN `C> 1 '� }--- I %,� .` -#m r r -� o = 2-�a �•�/D I I `c - I A�. - C -- � LJTILIT� 2e1D/ I ` a� L,i•f'11�. TL111fC / , U5E (Gj > �} �'4 x -4 lrEfic l-C-`� S 1N� � 0� W w.nrtg� cF �.• _ r `, , p ,� y 5Tt2Nf—� ' /`p•-- v / 4,�v ! 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