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HomeMy WebLinkAbout0508 MAIN STREET (CENT.) - Health (2) 508 Main Street (Cent.) Centerville P , A = 207 108 No. 42101/3 QRA poncokol-Toz 10%' O O p ;e No. �® r dc) `� Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpprication for Th000l 6pacm Conf�truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 50 IR MIA(Ij 57 G+ %v'f(—LJ Owner's Name,Address,and Tel.No. -TaTL-c L--L z Assessor's Map/Parcel PO-7 102 Pia 13() R3• soard bUjZC-zU&tom, V Installer's Name,Address,and Tel.No. -5 0,J—4 zZ� �� Designer's Name,Address and Tel.No. 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) gpd Design flow provided 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) .TNS'r4CL IUEZ J H—a® 1> 4y i 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 BoardqPkalth. Signed Date C�© 1 Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued r r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mt5po5al 6p5tem Cou6tructiou Permit Application for a Permit to Construct( ) .,Repair.(.) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components i Location Address or Lot No. J U S- MAW 57r e r L/(( L& Owner's Name,Address,and Tel.No. -r,'CC Assessor's Map/Parcel PO-7 102 pQ I3UX CU Soc rrw 0U, RL.( A6--T0 -) V—r Installer's Name,Address,and Tel.No. S 0�'4 ZZ� Y7 Designer's Name,Address and Tel.No. 1" �o Type of Building: ' Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 5 µ Design Flow(min.required) gpd Design flow provided 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) —T 025 Ti4.L 1> —.Fj Date last inspected: y Agreement: ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in a` 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 o..H, alth. Signed Date V of Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( ) Abandoned( )by ,ItMAmc— (;,&7a?AU5E�,, at SQS MAi,A) � e�Cl� .��«C, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a0�7 ' dated ^`� Installer CAPG&^JtaG /`I( EZQQI$CS Designer N #bedrooms A11A= Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wil funcai n-as.designed. Date `7 Inspector 4 }� Zvi v� ---- ---.------- - —.---- — _-- — — No. Fee THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS '=i5poga1 6p5tem Construction Permit Permission is hereby granted to Construct ( . ) Repair ( /� Upgrade ( ) Abandon ( ) System located at S Q S k,4/?V S and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date (O^ Approved by ` 4 'TKEr Town of Barnstable Barn Regulatory Services Department 1�'��j IA�NSCABM I 1639. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 6193 June 16, 2017 TJLC LLC PO BOX 9344 SOUTH BURLINGTON, VT 05407 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located.at 508 Main Street, Centerville, MA was inspected on 05/15/2017 by Raymond Dumas, 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: i • Distribution box needs to be replaced. You are ordered to repair or replace the septic system within two (2)years 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 ORDWcKean, R.S., ARD OF HEALTH -s O Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditionall y Passes Letters\508 Main Street Centerville MA.doc of 1�rqy, Town of Barnstable R&RM" U, ; 6 � Regulatory Services Department �Ep►AA'l� Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-8624644 Richard Scali,Director FAX: 508-790-6304 Thomas A-McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES TO'REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding.of effluent to the surface of the ground Y . ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool o Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA 9 Single Cesspool- y"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) ❑Leaching pit or cesspool with high liquid level, <12"below inlet (per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) . OTHER El Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massach"setts , _ Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^ 'l 508 Main St. w� Property Address TJLC LLC Owner Owner's Name information is 7e' nterville Ma. 02632 5/15/2017 required for every Ce 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:When filling out forms A. General Information on the computer, '7� use only the tab 1. Inspector: key to move your cursor-do not Raymond Dumas use the return Name of Inspector key. Dumas Landscape Const. �y Company Name 564 Old Stage Rd. Company Address Centerville Ma. 02632 Cityrrown State 508-778-0249 S 1437 Telephone Number License Number I, B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in,the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/15/2017 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "`"'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 qp Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: D Box needs to be replaced 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): D-Box needs to be replaced t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): D-Box is deteriorated ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 T81e 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts. . Title 5 Official Inspection Form "Sub-surface-Sewage-Disposal-System Form -"Not`b—r Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 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: 0) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool , ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ira•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 7 Number of bedrooms(actual): 7 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 770 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts. w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2000 gallon septic tank, D-box and 3 1000 gallon pits. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2015 173000 gallons, 2016 189000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Occupied now Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) � Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachu$etts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: occupied at time of inspection Date Other(describe below): General Information Pumping Records: Source of information: Barnstable Sewage Treatment Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 2000 gallon tank, D-Box , and 3.1000 gallon pits t5ins•3113 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 508 Main St. Property Address TJLC LLC Cromer Owner's Name information is Centerville Ma. 02632 5/15/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 30 years old Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20 inchesfeet 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.): all good Septic Tank(locate on site plan): Depth below grade: 12 inchesfeet Material of construction: ®concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 gallon Sludge depth: 3 inches t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. City/Town 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 34" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? dip stick ruler Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic Tank should be pumped Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC - Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 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.): liquid at level ok but evidence of carryover in D-Box 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 t5irrs•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Evidence of carryover in D-Box and D-Box dose not look structurally sound, needs to be replaced 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: All pits inspected by camera through d box pit#1 water 30 inches below pipe, pit#2 (middle)36 inches below pipe, pit#3, 48 inches below pipe t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Precast Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): All good Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 TdJe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 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.): all good 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.): t5irs.•3113 TrHe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Properly Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 19 ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: obtained from most recent inspection ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 5/15/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LOCATION_gCQ&� 7— `_SEWAGE#_ I VILLAGE Ij' ASSESSOR'S MAP& LOT O INSTALLER'S NAME& PHONE NO. .��f7?Q,ey,1,,,e*5nn Ti76• SEPTIC TANK CAPACITY D L. LEACHING FACILITY:(tW) -,#- (size) O NO.OF BEDROOMS_kj PRIVATE WELL OR PUBLICWATER �. BUILDER OR OWNER jkc ,Q p, ,,p, r DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: '7 S 7 VARIANCE GRANTED: Yes No v �16 ct . ' 13at litt:p;i�v,:^r4v.io�szzs barnstabf�,usJAssasssnciiHy,ciispfa .t,s "n�a�r�ar=i0`1t�� :ery=7 4i23,1171 4:49 PM Fags I of YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$.30.00 for 4 years]. A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. -it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main.St. Hyannis. Take the,completed form to the Town Clerk's Office, 1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. gam. DATE: Fill in please: A APPLICANT'S YOUR NAME/S: ,�- BUSINESS YOUR HOME ADDRESS: 5,08 MAin Sf- S a 8 3 4 S D0(oE3 C� fe-k-o ll e met- 6zjai ;L TELEPHONE # Home Telephone Number So 2-- 395-oob8 NAME OF CORPORATION: ,Uo6- 9'06V-_5 NAME OF NEW BUSINESS f31rOf.J,j /poc,- e'�ol7e TYPE OF BUSINESS QC 7'5 IS THIS.A HOME OCCUPATION? X YES NO ADDRESS OF BUSINESS S68' *Ia-;n ;5-f ' ;7?W;lTe MOL 02Z 03 Z MAR/PARCEL NUMBER_ (Assessing) When starting a new business there are several things you must do in order to.be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. —(corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMIIITSSI ER'S OFFICE MUST COMPLY WITH HOME OCCUPATION This individuO s n ia#o nled f any permit re uirements that pertain to this type of business . FAILURE TO RULES AND REGULATIONS Au o d Si ature** COMPLY MAY RESULT IN FINES. 9� COMIC/IENT , �._ rJ ,'C < 2. BOARD OF HEALTH This individual ha een infor d of.tble per t requirem nts that pertain to this type of business. Authorized nature* c6mMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This.individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: f � f COMMONWEALTH OF MASSACHUSETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION? PARCEL, ; �(JA TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION .ic A Property Address: Owner's Name: Owner's Address: Date of Inspection Cj Name of Inspecto lease print) - Company Name: � fL� r .. c Mailing Address: d Telephone Number: C—�� '� 7 �G?��j CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that he information se;ned below is true, accurate and complete as of the time of the.inspection. The inspection was per ormed based on 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: ` V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority '�-ails V Inspector's Signature: Date: ciy L -Z-- 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 treater,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. 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 pale I Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property ress: ... / -� . Owner: Q, Date of Inspection � .... 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 15303 or in 310 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 determined"please explain: The septic tank is metal and over 20 years old"'or the septic tank(whether metal or not) is structurally. unsound,exhibits substantial infiltration or exfiltration or tank:failure is imminent.System will pass inspection if the existing tank.is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain; Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 r 1 Page 3 of 1'l OFFICIAL INSPECTION FORM —:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) o Property Address: Owner: Date of Inspection- ) 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 priNry is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail un less the Board Y of Health (and Public Water Supplier, if any)determines th at 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 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 form. 3. Other: Z Y t, Page 4 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued)- Prop erty y Address: e OwneOoi JJ pit- ' Date of nspectio ZD. �U D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each.of the following for all inspections: Yes N 71 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool V 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 V Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day flow Required pumping more than 4,times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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 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 form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as. described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 a the system is located in a nitrogen sensitive area(Interim Wellhead Arotection Area IWPA)or a mapped Zone IL 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. 4 y Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property dress: Owner Date of Inspection: Y 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 ? i/ Have large.volumes of water been introduced to the system recently or as part of this inspection ? V Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of breakout V _ 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: Yes no Existing information. For example, a plan.at the Board of Health. 61-/_ 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(3)(b)] s + 4 Page 6 of 1 l OFFICIAL INSPECTION FORM—P40T FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE=DISPOSAL SYSTEM INSPECTION_ :FORM PART C SYSTEM INFORMATION Property Address: (g /�L' V ¢' � �w� Owner: Date of Inspection: �. FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . Number of bedrooms(actual): rl '� DESIGN flow based on 310 CM 5.203 (for example: 11.0 gpd x#of bedrooms): �-7V Number of current residents: Does residence.have.a garbage grinder(yes of no): Is laundry on a separate sewage system (}'�s or no): [if yes separate inspection required] Laundry system inspected(yes or no)/6 Seasonal use: (yes or no):-WO... Water meter readings, if av ilable(last 2 years usage (gpd));pz I1�0OD Q✓ Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIALA Type of establishment:. Design flow(based on 310 CMR.15.203):. gpd Basis of design flow('seats%persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the ins ection(yes or n : If yes, volume pumped: = gallons--How was-quantity pumped'determin 8?- Reasori Tor pumping: TYP�OF SYSTEM Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system.(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP.approval _Other'(describe): Appro it to age of all o pone ts,date installed nown) and source of information: Were sewage odors:detected when arriving at the site(yes or no):A.--16 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: t";u Date oflnspection: 0 BUILDING SEWER(locate on site plan) ( Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: V (locate on site plan) Depth below grade: � � Material of construction: (/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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: b " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions determined: , Comments (on pumping recommend tions,�nletand outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of leakage, etc.): he GREASE TRAP, locate on site lan Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): y �L 7 Paee 8 of I l OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property dress: Qaz Owner: � Date of Inspectio TIGHT or HOLDING TANK /0 (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: i1 (if.present must be opened)(locate on site.plan) Depth of liquid level above outlet invert: � Comments (note if box is level and distribution to.outlets equal, any evidence of solids carryover,any evidence of. akage into or out of bo ): PUMP CHAMBER:kt )(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):. ' Comments(note.condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,C SYSTEMS INFORMATION(continued) Property ddress: A Owner - GG (.� Date of Inspection:_ o SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits; number: leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comm e eAnts (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation. t _ v O r LD. 'tea C/� a aee1, CT31 e SL CESSPOOLS: cesspool must be pumped as part of inspect ion locate on site plan J � � p Number and configuration: l 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition.of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 35„ 9 e Page 10 of I I OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property.A ess: {� Owner:Inspection: :� Date of InsP y 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. i 2— a+ y , �... o Iwo �1�n 1 NCO api�Ij I l�n o,��,I l of P..+ C�� i ` 0 1- P C Page l l of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Aqress:,'Sb� doj 11 AZ-A-Pd Owner: Q L(.+ Date of nspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 7 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) 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: ® © irr j l 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location:�5 Lot No. Owner: Address: Contractor:/y791O 1? 1� D�/�/�7, Address: AYYESr Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. .............................................................................. .Date month/day/Year i STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well......................................�/ . �9 OWater-level range zone ...................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to g�0 yJz water level for-index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 26) --� determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to 'high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ............................................................................................................. Figure 11--Reproducible computation form. 15 i � t 1 I i 7 ua C\Ose- x f A I t { h _ t 1- Hi9 L Jr � s /, � _l .,.a L1p o0 &,L Ro oy `TOWN OF BARNSTABLE / q� LOCATION p QkMolljj�! 3r SEWAGE VILLAGE �,�/,�(/'r/i �� ASSESSOR'S MAP & LOT p-7- 10 INSTALLER'S NAME& PHONE NO. �� /7 a,,;, 7Aenay CjG SEPTIC TANK CAPACITY 2 _® L LEACHING FACILITY:(type) L (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 9��✓. BUILDER OR OWNER & , Cs,e�Y DATE PERMIT ISSUED: _ /7 S : .DATE COLIPLIANCE ISSUED: a 7 7 ', VARIANCE GRANTED: Yes No ✓ 7 r . ._ i i v t R13•IOVEE T.WMDCJW- LANDING , EXIST. t RE-FRAME TO INSTALL I RFt10JE EX'5T.DOOR Z OTB-1P. I J 1 NBx DOOR PATGN TO MhTGH E)�T _ I J. M ui -z i x' m r < r m 2 X b RAFTER a 16"O.G.(TYP.) O Kitchecette L �� v r movc -- ]X b HIP RAFTBL rtYPJ ml %•X 36'F.6. NJGN m KET RED. e�110NER� Ox . F • G _-_-m _ I 3vG�Wm%A34'D.� 56 T.T.T 4 N � / I I m � ♦ a � • � '>¢ O m -1 x b FASCAA BD.W/}ln' � + - O�� GARNETS E%15T. - A - 00 - iB-,P.bLA55 OF xUNP7Nt BBLJW - -- p• Typ.Roof Framing @Entrances _ FJUST.DOOR BI CI BELOW Q SCALE:114"=1'-0" - �b+ Bath o• _ � 24 36'x 96'F.b. r,� N r SHOWCR - O . FXtST.DOCJR o n - C O tIN. O •� r� OA I1B"W x24'D. -SO'W.xla'D. L '0 . O PEDESTAL 51NK EXISTT., SHGYER DOOR M RI�LILE I MEN GA9MEr I R�LACE 1 Fy,•t E)aST. WINDOW SCHEDULE LEGEND 5'-4 B 3.4• T-z.i- ( s•-r./- 3.4. RQiARKS - . _ rA T. MODEL WTIIFEMXH)NO. TYPE (WxH)EWST.WALL TO REHAM NEW2 x4STUDWALL•16'OG. AND9LSEN TM,] 2 DOUBLE HUNG T- vb-X 4'-4 VB" 0 3 LOCATIONS REOD.,l/B'SDL bRILLFS MSEGT SCRFFlL>, ^i " - VTILIIY AYW Wb SE£PLA 5 HARDWARE SFJ_ECTI]J BY O/PIBZ,EXTFSXIOR 4/ Second Floor Plan First Floor Plan 4D0 5ERr5,VtNTL E%TBXIOR.HIGH PERFORMANCE �.-� ; �A^ _ . SCALE: 1/4"=1'-0" LOW-E4 bLA55,PROVDE EXTFNS'ON JAMB5IF -1•� _°A'C�1 \) l ✓ SCALE: l/4"=t'-�" - - B ANDWR AND52 a^MMG z-a l/B•x z-a l/0• s NO RF2SD.,HARDWARE SM bRILLES,N5ECT SCREEN5, 5ELEC F BY OWNER,EXlFR10R NB $ GOIOR-WHnE HDv,I T1,.-/ I PROVIDE 32'W.X 40'L MBJUTED.HMGED ACCESS - 1O1�/r�� ~' PANEL TO CRAWL 5PACE.GOORDMATE LLr.ATION WITH Oe m iB•_S'./_ T-tn"./-O.H. - MATCH E%BT. -T T. HATCH Ex15T. (Fx15T.) MATCH FXEiT. B'-B ln" B'-5 t/2' MATGN EXIST. fEWSTJ a-11B a-1 tn' - �1�1' 5'-11 1/2' 1-5 x b LOCI<l\ff i 2 411 t2 I '� may/ F HATCH EXIST.RAKE BOS. MATCH EXIST.RAKE BDS. P HATCH EXIST.RAKE BDS.� I MATCH Ex6T.RAKE BDS. 2 X 01O6T5 H11_..JOIST Q < 1 CR MLD'b. <CRO✓<•I MLD'G j i 1 CROYO•I MLD'G. J _ s GROY9.HLD'G. I - �t 17 !RIPPED TO 5DFJ HAN6ER5 T'P.) - I _ ___ -._. .•_ _ __ DOYOi •� SmE OF RIDGE EFAM '-I f2)3 x i0 (/] -- 10 _ _ _ __ 4xmOF FROM LND@I-I ., -------- __ _ ------- TO -� FOUNDATION rlY J ppyp•I TO HEALER � I I I r` (2)t-3/a•x a • d mll Y L J �T LVL HFJ.DER - ; - - - --- - -- (2)2XB(RiFPm TO 51IFJ' U __ ___ n_ Y ---�----- ----------- ------------ - I o i ------ -- I o �^ w� I� � ml II Is p"I 12 X 12 LEDGER °xl 'a Ij L�i, fi yl _• J --- ul !"'•� y by m i ins q• a� ___ - U F U •m\ I ----\- Gu�mI- -------- z �o----- - (2) 1?i � O -3/4'z4l/4' �I .h I 'L ______I___ry• - __ __ � I afar+ LIO x ' II t. ILVLHEAVER ''_. X ----------- n -----------� --gym - .— -t � - - -- -� - m1 Ii4x4P05T. 414 FCr1T - UIID6t I I - Bl1JCK SOLID RDWI I SIDE OF RIDGE BEAH I �'' . (y 2 x 10 G I ins m I ---- - -- -- - �n.a--x---- I TO FdJ1IDATION(tYPJ , DOYPI TO NEADBt .; _ _(2)2 x 1D - _ - ° a -- - 5 s MATGN EKBT _ RAKE Ori. , ` HATCH EWST.RIJCE BOSS IRGWI . m EXIST.RAKE BDS. E T. B RAKE DS. [CROVH HLDG. L • 1 GRd"M MLD'b.T13 Rt7a/•M 1 CROWN MLD'6.TO RBHAM _ <�Z �10 110� FJ05T.LOOKITJr QI ZZ 12 I U B._5�. �J TO REMNN < +/- (FJCSTJ IB'-S'•/_ O.H. T-1/z'+/-Olt. MATCH FX6T. A� o MATCH E.ST. (FXISTJ I'U`Tµ AFT' MATCH EXIST. 4J . Upper Roof Framing Plan Second Floor Framing Plan Lower Roof Framing Plan o - SCALE: 1/4"=I'-0" - SCALE: I/4"=l'-0" � SCALE; 1/4"=1�_0" - - _I A.l I CONTiACTOR SMALL REMOVE E105T.ROOF. •a ' bABLE END WAI1510 RENAM. I t. 1 I