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HomeMy WebLinkAbout143A MAIN STREET (CENT.) - Health 143A Main Street Centerville A = 208 154 No. 42101/3 ®RA pa@ mfO duu 11 111�mmaml 10°l° (o 0 0 0 0 �G TOWN OF BARNSTABLE LOCATION ,5 A IM A /,A! 1 SEWAGE #iZ 0-0O" 7- ;. VILLAGE C eAZ-,re J! VzIle ASSESSOR'S MAP & LOT �S INSTALLER'S NAME&PHONE NO. M A C Q A Al i?,f, $ � SEPTIC TANK CAPACITY Z XO a LEACHING FACILITY: (type),Z- /9 4) W eZI S (size) ,/_3- ' A S NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: - Xdv f Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ��;� � v � � m� � � � ,��\ _` �' '� - O _ �- �. - � °� 0 z� , �� ,� y ., a .� �� � .. r ' aog-i,� Commonwealth of Massachusetts �m Title 5 official Inspection Form {�I i 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . � 143A Main Street i�a Property Address David Nelson Owner Owner's Name information is required for every Centerville Ma 02632 6-14-19 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. Inspector Information on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 Q Company Address Sandwich Ma 02563 aff City/Town State Zip Code ,m (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑Q Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey ...•Oaie:ID18.O8.1808:50:39-0IYp 6-14-19 Inspector'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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts 911 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r; 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-1,4-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and.6. 1) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: 0 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. ❑Q Y ❑ N ❑ ND(Explain below): Tank was only half full when viewed. Tank is leaking. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street u- Property Address David Nelson Owner Owners Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts �o Title 5 Official Inspection Form ±= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street V� Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. I Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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. ❑ ID Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. El 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 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? ❑ O Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts �y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/GPD Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes ❑. No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes RI No Seasonal use? ❑ Yes [E No Water meter readings, if available(last 2 years usage(gpd)): See below Detail ***2017- 1,000gallons 2018- Ogallons*** Sump pump? - ❑ Yes ❑■ No Last date of occupancy: 1 year ago Date t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form ?= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes X No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 11/26/2001 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 11911 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 18 i c Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 911 Depth below grade: feet Material of construction: X 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 1 Dimensions: 500gallons Sludge depth: "Tank leaking" If 11 Distance from top of sludge to bottom of outlet tee or baffle If It Scum thickness to of Distance from top of scum to top of outlet tee or baffle n of Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? 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 was only 1/2 full at the time of inspection. The tank is leaking. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �- Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street u Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0'r 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2)500 gallon chambers ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts ,lp Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f; 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Chambers were dry with no evidence of past back up. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street u Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately VILLAZ ljdde!°L.l.GT ' _ASSESSOR'S MAP& LOT' t - INSTALLEKS NAMt, PHONE racy ✓IS1 14 C C ,�%# ' S SEPTIC TANK CJAPACC"Y. f EACt3 hlG FA. i]LTI'Y_,tr3£x}2- (size3' NO,OF,3EDROO is Ht3l MER,Ok OWN tR PEAlvlrrbA't'E: !1 a __COMPLIANCE DATE: ov_ Scparauntt ISistance k�ctweeat.tYtec' Nfazimum AdJusted Groundw•aterTable tet the f3rtt6m Of T.'aching Facil4y Fcet� Prixdw'Water Supply Well and L,eaehing,Facility {11any wells exist On site Or wtdiin 200 feet of leaching racility} Fr�r Edgw'ar wetland aiid Leaching Facility(If any+vetlaruls cxist. within 300 festoClcaclung faeility) _....._.._�___�Feet tw�_..... ... ......:.:._.��.___ 5 X t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 1 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ❑■ Surface water ■❑ Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @12'feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed: 11-10-01pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 143A Main Street Property Address David Nelson Owner Owner's Name information is Centerville Ma 02632 6-14-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: F■ A. Inspector Information: Complete all fields in this section. F B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppIicatiou for Misposal *pstem (construction Permit Application for a Permit to Construct( ) Repair(u-<Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. 143 A mo j r, g} ect-A cl'V's Il Owner's Name,Address,and Tel.No.�0.Ujd 0 SOYA Assessor's Map/Parcel ow V43 A ^4MO s-1 (2cn4cr 0; 11C_... Installer's Name,Address,and Tel.No. J3 Aj 0 EXCatV0A i0A Designer's Name,Address,and Tel.No. 114`rco.Sc.rry L#J FIoresida-lc 4417- 0653 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) SC, A;c'rn� �zalaCcrnL�1'� �t�OU 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 th. Signed Date - Z- 19 _ Application Approved by Date Application Disapproved by Date for the following reasons. Permit No. C�q 4 / Date Issued r� ag -s No l� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zippl catlou for,-Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(v<Upgrade( ) Abandon( ) ❑Complete System dividual Components Location Address or Lot No. Iy3A mo.;n 5.1 CtMcrv�1) Owner's Name,Address,and Tel.No._D0.Vid Assessor's Map/Parcel � 03 A rAA tQ 5'4 CCn4_-r v; if e—z ,• Installer's Name,Address,and Tel.No.,0¢. CXCa Vc_a;o✓\ Designer's Name,Address,and Tel.No. JL4-r<o.SCT-ry LQ Fo rc:$44-I C. Type of Building: Dwelling No.of Bedrooms V/�/ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures J Design Flow(min.required) Jj gpd Design flow provided A �/1 gpd Plan Date ' r Numbe of sheets Revision Date / Title Size of Septic Tank Type of S.A.S. Description of Soil ;J Nature of Repairs or Alterations(Answer when applicable) t5na Ole-) Date last inspected: Agreement: w 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 Health. Signed Q4,0 .2 Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. / r� 1-� Date Issued P --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS �r✓ BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(VT Upgraded( ) Abandoned( )by at 43 Antra , ^ !4 , Cr LSA�•�+ "� I I C has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N . — Y dated Tom_ 19 Installer Designer #bedrooms Approved design flow Ai gpd The issuance of th}'s pe it shall not be construed as a guarantee that the system will ction as igned. Date 1 t GI Ins ector ( A- P 1 No. _ � ! '7 #", Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS- Disposal *pstem construction permit Permission is hereby granted to Construct( ) Repair(✓f Upgrade( ) Abandon( ) System located at A AT -t- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must a completed within three years of the date of this pe it. Date Approved by � TOWN OF BARNSTABLE LOCATION 143 A fYla;,^ SJ SEWAGE# 7019 - 2�d�1 VILLAGE CccAcru,l 0 G ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. ,[�4 3 EXcctQM) I on q') 0G53 SEPTIC TANK CAPACITY /,'OQ qca 1 H I O LEACHING FACILITY. (type) (size) NO.OF BEDROOMS OWNER .Db ykak Oc@ Sor-, PERMIT DATE: I• 2 -19 COMPLIANCE DATE: 19 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Q AZ" A3- S� A4- s� 8y- �1s 3 14 r $5 0. 0 0 Fes No. '• ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS 0ppYtcatton for Mtgoml *p!tem Conotructton Vertntt Application for a Permit to Construct( )Repair)Upgrade)Abandon( ) ,aComplete System El Individual Components Location Address or Lot No. 1 4 3 A Main Street Owner's Name,Address and Tel.No. Centerville,Mass.02632 Donald M. Hanrahan Assessor's Map/Parcel 7 /S_ Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.Nos 0 8—7 7 5—9 7 0 0 J.P.Macomber & Son Inc. Ronald J. Cadillac P.O.Box 258 West Yarmouth,Mass, 026 3 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage GrindeNp ) Other Type of Building V.0 C_ _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 9 0 gallons per day. Calculated daily flow ` gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank J sct�C� Type of S.A.S. SC'�J 1� Description of Soil: 1�{ I S` of z< Loamy sand to mcmd i um Rand 29 ' X' i Il� X 2 Nature of Repairs or Alterations(Answer when applicable) Omitting cesspools. Installing 1 -1500 tank. 1 —Distribution box and two 500 gallon leaching chambers. 29 'X10 ' 10"X2 ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issl by this argf Signed i Date 11,120101 Application Approved by ��L Date li 2t Application Disapproved or the following reasons Permit No. ,—�2 Date Issued Z l Y 40 No. ✓`� �V ( ` �' * f ; ;* y '° ""'a Fee ' � � THE COMMONWEALTH OF MASSACHUSETT,S Entered in computer: i. Yes PUBLIC H,EALTHDIVISION -TOWN OF;_BARNSTABLE., MASSACHUSETTS ZippYici Lion for Misspozar 6potem ctConitruction Permit Application for a Permit to Construct( . )Repair O Upgrade V)Abandon Complete System ❑Individual Components Location Address or Lot No. 1 4 3 A Main Street Owner's Name,Address and Tel.No. Centerville,Mass.02632 Donald M. Hanrahan Assessor's Map/Parcel • G /S` Installer's Name,Address,and Tel.No. 5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No 5 0 8—7 7 5—9 7 0 0 J.P.Macomber & Son inc. Ronald J. Cadillac P.O.Box 258 West Yarmouth,Mass, 026 3 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage GrindeNp ) Other Type of Building c No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 5 0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank SC:C, Type of S.A.S. Cn Q_uc, R 1 Description of Soil Loamy sand to medium sand- 'T ?_`'j , >( I Nature of Repairs or Alterations(Answer when applicable) Omitting cesspools. Installing 1-1500 tank,;.1—Distribution box and two 500 gallon leaching chambers. 29'-"X10 ' 10"X2 ' Date last inspected: r Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on- n'site_ sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Iji6ard Signed Date 1 2 0 0 Application Approved by Q�a Date i 2 t Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Qtompriance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )UpgradegXXX Abandoned( )by J.P.Macomber & Son Inc. at 1 43A Main Street Centeryille,Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.7? ' -_721 dated I I / Z l 1 C) Installer J.P_Macomber &d:Scn Tnc; Designer Ronald J. Cadillac The issuance of this permit shall not be construed as a guarantee that the system will function a&designe� Date 120 .1 bU I Inspector y�Ank i r — -------------------------------------- NO. ��e / \ Fee $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogal *pgtem Con!6truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade JKXXAbandon( ) Systemlocatedat 143A Main Street Centerville,Mass. 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 th�is--pe "'t. Date: f ' 7 ( C�I Approved by j5z-_.,,.,_,� ' :fi�.3T.wY fys�, .nF-iSX^r+.`Ry.,Sy tx. r .v'. •-©, �� i'`�$..e- :iR i��. .�>,cfd�.^^sa } s .;.:'coo-, .t �k ..: .,.a h y3.{,e+ti. #it�Nrt ;gR.R it{b �y ,r � ^� >U r. gE .r�•5 �.. --e,F' -., :`� .,.:" ``..,.�e't� • i. Y 'k�„f t1t'^fb.�,'3`.•,� ,i �,zf SE�VAGZr ttJ'� �� ti y� r # t s A1P !! P S $SC?R S AS E MAP & LOT l S .INSTALLER'S NAME:Bt PHONE NO:: SEPTIC.TANK CAPACITY �SO a LEACHING FACILITY: (type),Z ART el %s (size) NO:OF BEDROOMS BUILDER OR OWNER PERMITDATE COMPLIANCE DATE: ;� :2ov;. �' ""'»w7f ' ?s(Xr .✓ x 'S1atd cC,.�}. ' s ->r7a�. r rt t �'" SeparaLlon'Dlstance- ClW8eI1 k is n _ � c ?... , Maxitnu'm Adjusted Groundwater Table to;the Bottom''o€Leachtng Factltty. FEtt:. Pnvate:Water Su 1 We11 and.Leachiti Facility. If any wells:eztst P on site.or within 200.feet of.leactung�factLty feet; ry ( ). , Edge of Wetland and Leaching.Facthty(If any wetlands exist r- leaefung facile swtthtta�30Q feet��of p .... Furntshe ty)' d by. ' eet. I . ,- .. 5 .: .'� r 7 £v r,(• 'till�ijt ° 1 . _ t $ It r , t . t � ....-. `� ..,..; ,_,. � .- ^� t •' �r3;,may y4 i"+.� r�' •- .� t r -• f f » 3 ;S x,t tE r -+� P � 2 F r � f f 1 •r J h _ T w NOV-20-01 10 : 13 Ate R. J. CADILLAC, PLS, RS 508 775 9700 P. 01 Sup-14-01 06:07 BARN5TAULE HEALTH DEPT 508790004 P-02 sre,sro� NOTICE: This Form Is To Be Used For the Repair Of Failed septic Systems only. f PEI2(-0LATION TEST AND SOIL E"VALt;ATION EXENIPTION FOR-M A dj - hereby cer:fy that the engin=%d plan sibiled by me dated a/ 6 L _„_, conceerang the property located at 143A / *gA mccts all of the following criteria: This failed System is connected to a residential dweiling only. 'there are no commercial or business uses associated with the dwellin;, The soil is classified as CLASS t and the percolation rate is less char. or equal to S rriautes per inch. The a,p:icant may use histoncal date to corcludc this Fa::or may concuct pretirr►nary tests a:the stce w:thoa: a healt:, agent pmsan:. There is no ine:eest Nw-and/or char.;e in t;se proposed /. There are no var4ances request:d or:icesred. • h oet o` a opo d: *hin ci!iry il. be to ted ss an en c a e na im-• ad t ed.4; rdw :tab It • do . LA us he gro dw er !e .in ,e F6 .ptor thod en 1plic le, Please complete the following: A) Tap of Ground Surface Elevation(using GIS information) J J a) G,W. Elevation 2�'� +ad us:rrren( P,)r hi oh G.W. -4-7 W7. DUTEEZt E BEL E:EN A and B 8 ` ----- NO TI C E i i$i,ee up,.n the a�_—ove in:'ermauon. s rerair perrmt w,a be ,ssued for_2— bedrooms i maKirr.Lim. Ne add:tienal bedrooms are aLt;todzeC in the utu:e wttr,ou:erginee;ect Lsutic 5 'stem plans. q nea.n Fulacr occo%raL, NQTE5' B Cj'I-21 RTE 28 Hanrahn.dwa 1. LOCUS IS A.M. 2018, PARCEL 154. 0. 2. ELEVATIONS SHOWN ARE TOWN GIS ±10. N/F 3. LOOCCUS IS. IN FLOOD ZONE C ON FIRM DATED AUGUST 19,1,98,-r>. LONG CH 40, AND PITCHED AT 1/4- PER FOOT. (UNLP NOTED," POND, MEYER 4. ALL PIPES TO BE 4" S V 5. MUNICIPAL WATER IS, AVAILABLE. LOTS WITHIN 1011,-)' ARE ON TOWN WATER. JOB N(C'. 28 7 ND 6,. C"MPONENTS TO BE AASHTO H-1(;,, UNLESS NOTED. 7. INLET TEE TO PROJECT DOWN 13", OUTLET TEE DOWN 14". 8. IF TWO OR MORE LINES, WATER TEST 0-BOX FOR EQUAL FLOW I'-BOX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEET, 0 1. . NC-T TrI; 045.74 9. DIEPTH OF COMPONENTS NOT TO EXCEED 3', R VENTING MUST BE PROVIEE(" `--CALE BUILD UP COVERS TO WITHIN 1' OF GRADE. MrRTAR CHIMNEYS IN PLACE ONE COVER OF TANK TO BE WITHIN 6" OF GRADE. BENCH MARK--TOP OF SPIKE 6.4 ICAII)Tll-ft N E R GR 0 1.)N 7- 10. STONE TO BE DOUBLE WASHED 3/4 TO 1 1/2" WITH 2" MIN. 1/8 TO 1/2" PEA STONE O ION MAP N TOP. ELECTRIC LINES APPEAR 11. IF l-NSLIITABLE SOILS, OR SOILS DIFFERING FROM THE SOIL LOG ARE FOUNE), SET FL(.).,.H = 44.,016 GIS ±,.,5 110' OFF DECK) T RUN FR( M P-0 L E TO• 45, CONTACT THE BOARD OF HEALTH, OR R,J. CADILLAC -7-,1 CALLED -1W, FILL MATERIAL FOR f5' AROIJND ANC, I.)ND'ER LEACHING 5.5 4 BAC-K OF H(JIt JSE 12. IF AN OVERDIG 15 CALLED FOR BELI- TEST HOLE 1 1 45.9 TO BE CLEAN GRANULAR SAND. MEETING SPECIFICATIONS OF 310 CMR 15.251`-�i3% 5.4 13. PI-IMP AND FILL ANY EXISTING CESSPOOLS. REMOVE ANY CLOGGED SOIL, BLOCK, AND STONE IN LEACH AREA, AND' DISPOSE OF AS DIRECTED BY HEALTH A(,-ENT. DEPTH (inches ELEV.'feei% N/F .26 14. ALL CONSTRUCTION TO MEET TITLE A N 1) LOCAL REGULATIONS. 0 43.3 A layer 1,,,-,yr 3/3 4 7 -�4 7 LITCHFIELD 45.7 TEST HOLE DATE: Nov. 14, 2001 17- sandy loarn, P PERFORME[) BY: Ron 'Cadillac, Soil Evaluator 4.8 'RADE H A N'G'E S NC., G WITNESSECII BY: Perc Exemption Form 8 layer 10yr 5/6 Z44. ARE PRO'PrISED, 'ERC RATE: layer) 0 045,68 P sandy loam 45.5 �URVEY"1199-13"ll: sand 4.0 -1 1 Ir :OIL L S Carver Coarse 5 411- GEOLOGIC M A F1 1'9 8;6%1: Barnstable plain deposits 41-1- k .................... Vyr `eC BENCH MARK-SE CORNER OF Invert 42.1C C1 layer 11- 43.1 BOTTOM STEP= 44.18 GI`.) ±0.5 s, lnvx�rt 41.'8 medium sond Exist. pipe 6 0" (2,15% grovel�� 42,8 affle x 6,5" Use Gas B .3 443 Invert 39.60' 2 DRY WELLS 4 .7 C2 layer 41.5y 6/4 42,5 S=1/4"/ft -ed N "14 3A /T70P07 ft min. rt,cver Top Conc.=40%3 -,"/ft medium sand ..................... . 43.8 3/1 Top Peastone=400-.CU x 43,1 Invert 41.8,�3 cl D-BOX x 42, LOT 2 45. 4 5 0 no water \ I Proposed 1,3n- 32.5 INLET-41-j 42.1 a 4 0,74r OUTLET-40.83 3.35 15, 0 ±S.F. 43,6 �4.83 41- -t 7. TH 1 4 4 Invert 39.77 Invert 39.f-,,O 7 2 37.5 42A 6" cir c.brnp,0Ct Proposed �os -d 1 1.. Y, 43.32 43.4 43.4 P,op e Bottom 4 --,1 El. 27.2 4 T 2' -r,.e n ,3� 4.7' A d it,j s i i 3. 0 CD Mcjsh29�--Zone, D V, DESIGN DATA June 1992 )�-)2=Z 22.F, 42.6 BEDROOMS: 3 T el-w r I noci 1-1,- Ju n, Z LEACH AREA 3.6 GARBAGE GRINDER: NoO 11-11 110 4 , 43.81 REQUIRED CAPACITY: - 33-12 i GPO; 1.1)S E 2 DIRY WELLS WITH 4' OF - SEPTIC TANK: 15"'0 GAL. T NE ALL ARK 1)ND FOR A • 4 2Z-6' CHING LUN BY By D" WIDE2.78 BOTTO R 20 N/F .- [(25' X 12.83')] B 2' I)EEP LEAC."H AREA. SIDE LEACHING AREA: 151-3 SF DAVALOS ; % [2(112.8,3'+ 25": X 2' UEEP'l DESIGN CAPACITY: 34'4) GP[) (02-,D.7 SF 4 151-3 SF') X .74 GPD/F-.,F] BENCH MARK-TOP OF SPIKE `-,ET FLJ.">H = 42.86 GIF., SITE PLAN THIS PLAN IS A VALID -c)py r)NLY IF IT BEARS FOR "D M . ANRA ' ' AN LEGEND AN C)RIGINAL REE STAMP AND SIGNATURE. D " NA L O F1 F1 TH I TEST HOLE LOCATI'.N, NUMBER j\A OF MAq, j�A OF M,18 -W- WATER LINE MARKING. \ V LOT 143A ' MAIN STREET, CENTERVILLE, MA -E- OVERHEAD ELEr%'JRIC WIRE, (IF SHOWN/ RONALL R UD -G- GAS LINE MARKINGS CIF S H 10, E S --A r r = 2r WN/ C IL NOVEMBER 16, 200 S CA L E: 1 0 9.5 x 8.7 EXISTING & 79 PROPOSED ELEVATIONS CX' MARKS POINT" EXISTING C-0-NTOUIR & 0 G/ST0k " - Ss\ , F'ROP"SED CONT,-'I)R 'INITAR\N 40 -8- , "1 0 SUR\J D P RS 1-17ILITY POLE "IF SHOWN:'HOWN", IZ 1 RONAL J. CADILLAC, LS, EXISTING DRAINAGE CATCH BASIN PROFESSIONAL LAN[) SURVEYOR & REGISTERED SANITARIAN x FENCE (IF SHOWN, NOT ALL SHOWN) P.O. BOX 258 TREE "IF SHOWN, NOT ALL WEST YARMOUTH, MA 02673 erlM 775-9701.0 HEALTH AGENT APPROVAL DATE r 11 /21/01--LEAr'HIN.- M-71VED Ft MA..-.'(.-M&.EF\ FIELD IN`:,TA1-LATI,1'-1;N BY R. 1. '-.APLLA F%A E 1 F