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HomeMy WebLinkAbout0009 MAY LANE - Health 9 May Lane Centerville A= 147 - 107 f t i SMEAD "i No.2-153LOR UPC 12534 smead.com Made in USA R R f Massachusetts tllf /i,/ -/�Commonwealth o as 5. - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 May Lane ` Property Address Robin Furlong Owner Owner's Name/ Uri information is required for every Centerville ✓ Ma 02632 8-14-15 page. City/Town State Zip Code Date of Inspection t~= t'11 Q11 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer,use only the tab 1. Inspector: (S TY /1�?i� key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation reb Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 Citylrown State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-14-15 Inspector's Sint , 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. �0�# Vs t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. Cityrrown 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Fora o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Z 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. City[Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 ears usage d see below 9 ( Y 9 (gP ))� Detail: 2014- 156GPD 2013- 104GPD Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 2012 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. El Other(describe): L15,n. 13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 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: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1'3" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order with no sign of leakage. Septic Tank(locate on site plan): Depth below grade: 33"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon H-20 Sludge depth: 3" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.). At time of inspection septic tank appeared to be in working order,baffles present with no sign of back- up.Liquid level equal with outlet invert. Tank is not in need of pumping at this time but should be pumped every 2 years for maintenance. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in working order with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-4'x8'flow diffs. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Flow diffusers show no sign of back up. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owners Name information is required for every Centerville Ma 02632 8-14-15 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: Z hand-sketch in the area below ❑ drawing attached separately fie- 3`3 i A i 0 j z i 3 =, l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 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: No Gw 6' below SASfeet 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: 4-4-84 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file at BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 May Lane Property Address Robin Furlong Owner Owner's Name information is required for every Centerville Ma 02632 8-14-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMO-NW-NW O ,?• F -ASS kCH-t SEWS EXECLTI4 OFFICE OF E ��ROlti',tIE?!t Viz. FIRS DEPARTMENT a-v Eg„-zoh OFFICI.�L INSPECTION FOR--VI T\OTT FOR VOLL` -TARP ASSE SUBSURCE SEN ACE DISPOSAL SYSTEM FO&NI- F A EN7TS PART A CERTIFICATIOI Property Address: � e- L4-5�- Owner's name: �,. 1 1�� Owner's Address: � ® � � l n L1� � �L71y deN Date of inspection: ' 'Name Of Inspector: (please OS@i i print) C!Y t9 r�, Company Name: ' vi ® u Hailin Address- el Telephone Number ve - ,e rn CERTIFICATION STATENJENT I certify that I have personally inspected the sewage disposal system at this below is true, accurate and complete as of the tune of the add s _ ` ` or anon reported training and experience in the proper fr nction and of thena�fm site inspection was�o�d�`d on my approved system inspector pursuant to Se n 15.340 of Title 5(310 C_MZ I y_ �e sv3teirl ant a DEP passes Conditionally Passes Needs Ftmher Evaluation by the Local App o y-mg Aulhorlty Fails Inspector's Signature: ° Date: The system inspector shall subr.,it a copy of this ins e DEP)with in 30 days of co letina t ' inspection.P If the s repo�L to the A;oproding Autl3Qs-iiy gpd or greater, the inspector and the syste owne1 s sub stem is a shared s (Board°� or DEP. The origi��al should be sent to the system oc�ter and co ies r ��or has a design�0-% Q, i0.000 mil the report to the "PPropria,regional once o-rhe autho::ty. p seLt to the bu er, if a I fi pp icable,and:*,e a-ppr©, g Notes and Comments ***"This re . port on1v describes condition,at the time of i t►me. This inspection does nat address how the system,wiil h spection 2l{1 1ncer the eol2dirian5 of use ai!tti conditions of use. perform is the future under the same or ditTerent Inspect;ori Fob 6'I5 2000 Map 7 Page 2 of l l OFF ICgAI,7p"I SPECI'ION FOI 'Vj—NOT FOR VOL L7,, ,�SS�SS����S SUBSURFACP -qEi�!_'IGE DIS�'POSAI SYSZEsi-T SP C�-ASS SS-V E PART A FORM CERTIFIC4,TION(continued) Property Address: lei? 4 ti v, Owner: aj Q Date of Inspection: if 9 O Inspection Summan-: Check A,B,C,D or E/�,L_u:��-g co"plete all of Section D A. Sys ns Passes: � I hav � f e not found any information which indicates that any of the failure criteria described in 310 Cl 15.303 or in 310 C'NtR 15.304-exist.Any failure criteria not evaluated are indicated bellow. Comments: B_-/System Conditionally Passes: V One or more system components as described in the"Conditional Pass"s, repaired.The system,upon cosxspletion of the replacerr�nt or ewon need to be replaced or �p approved by the Board o�Healtb-w?JI pass. Answer yes;no or not determined(Y,1N,.ND)in the for the fotloving st2temenfs.If"not determined"please explain — The septic tank is metal and over 20 years olds or the septic tank(wtedler metal or not)is strocturaLy unsound;exhibits substantial infiltration or enfltration or tank failure is ienf Sys vl pass inspection if the existing tank is replaced with a complding septic tank as approved by the Board of HealdL *A metal septic tank will pass inspection if it is structurally sound;not leaking and if a _t'ffieate 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 distr�ution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box Syy� pass on u(tip approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is ieveled or replaced \D explain: The system required pumping more than 4 times a year due to brokers or obsn-uct�d C. a pass inspecron if(with approval of the Board of Health): p`pe�s! The broken pipe(s)are replaced obshuction is re?noved ND explain: r>rlo Pace 3 of 11 OFk-TCIA.L INSPECTION FORM-NOT FOR VOLUNTARY SSESSN SUBSURFACE SEWAr-F DISPOSAL SVSr��,�sJpp 4u- UENTS PART A CERTIFICATION ION(continued) Property Address: v Owner: % 62,L19-e Date of Inspection:_ y C_ Further Evaluation is Required by the Board of Health: V'Fu / Conditions exist which require father evaluation by the Board o:`PIealth in order to determine is failing to protect public health,safety or the environment, he`` 1- System will pass unless Board of Health determines in accordance with 310 C IR I5.303(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 wed or a salt marsh 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,safetp 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 systerz has a septic tarts and SAS and the SAS is within a Zone 1 of a public grater supply. — The system has a septic tack 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 coliforrn bacteria and volatile organic compounds indicates that the well is free from the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than lhrdonm that facility and th failure criteria are triggered.A copy of the analysis must be auached to this for-tr, m.pro��dedt no other 3. Other: 'nnn Page 4 of I OFFICIAL mSPECT' o FoR-M—NOT FOR'VOLUt SUBSURFACE SEWAGE D.NPOSAL sYs ���SSESS�IF��S TE-N' r PART A CERTIFICATION(continued) Property Address: 9 nvv;!�! Owner: ®Qec C2 Date oflnspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes \o/ �/ cloip cf sew aye =t,fac City or system coonent due to overloaded or clogged SAS o*cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool !! Static liquid level in the distribution box above outlet invert due to as overloaded or cloyed SAS or esspool =quid depth in cesspool is less than 6"below invert or available vo_�e is less - - t/ Required pumping more than a, times in the � s�%�y.0 last veal 2jOT due tic clogged or obstructed pipe(-,)-��her i6f times pumped , ny pot lion of the SAS,cesspool or privy is below high,-,,round wad ej atfo� L,** .Any pot-ticn of cesspool or privy y is widin 100 feet of a surface water supply or tributary=o a surer water supply. wry cc y portion of a cesspool or privy is within a Zone i of a public well..Any portion of a cesspool or privy is widrin 50 feet of a private water supply vweLl —_ Any Portion of a cesspool or privy is less than 100 feet but greater than 50 feet frown a paivate water ' supply well with no acceptable water quality anal ysis.fThis system passes if the weill water performed at a DEP certified laboratory,for coliform bacteria and v a© � organic com ap�dsis, indicates that the well is free from pollution from that facility and the pence of armnonia nitrogen and nitrate nitrogen is equal to or less than 5 ppane peed that no other failure criteria are triggered.A copy of the analysis must be attached to this forret.l (Yes/No)The system fails.I have determined that one or more of the above described in 310 C'VIR 15.303;therefore the system fails.The fah re Mena exist as Health to determine what will be necessary to correct the m owner should contact the hoard of E. Large a Sys tems: b ra],S: To be considered a large system the syste aPd- m must serve a facility with a design now of 10.000 gpd to 15,000 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 d.uhng Rater supply the system is Iocated in a nitrogen sensitive Zone II of public water supply wellarea(Interim Wellhead Protection Area_M-o If you have answered"yes"to any question in Section Ee system is Yes"in Section D above the large system has failed.The owner or as considered considered a si�nicact-1 tea' or ate; -� situ -cant threat under Section E or failed `-'� 15.30 t_ -F v under Section D of any urge s S em eon-ider,-a s_stern owner should contact the a shall up9'ade the system in a-cz _ - PPropriate regional el ice of r` "c „i=-'; i the Depa,�eni. - T � �� ncncrt.nn � Page 5 of I I OFFICIAL ENSPECTION FORIM-NOT FOR VOLUIN-TAR ASSESS-VaNTS SUBSURFACE SEWAGE DISPO-SAL sysTr, PARS'B CHECKLIST Property°Address: e6A vP Owner: Date of Inspection: d 9 D� Check if the following have been done.You must indicate'),es"or"no"as to each of the fo3owL: Pumping information was provided by the owmer,occupant or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received rormal flows in the previous two week period? -- Have large-volumes r - ofi water been introduced to the system recently or as pa_�t of thasinsm-cdon? Were as built plans of the system obtained and examined?(If they were not available -- ble note as X,_A) Was the facility or dwelling — g inspected for suns of sewage back u-p? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? v — Were the septic tank manholes uncovered,opened,and the interior of the task_ ted for the of the baffles or tees, material of construction,dimensions depth- of L of }anon f � quid,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 d $-ned based on: Ye no Existing information.. For exanTle,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?i - . is unacceptable) [310 CVLR 15.302(3)(b)] s.2nee pit vnnnn Page 6ofil OFFICIAL INrSPECTIO;1i FORM—NOT FOR VOLUTNTARY SUBSUP-FACE SE«VAGE Drsp®s4.L Sy—STEM TvSPE4CTj0-N F€jRFr-%'1's PART C SYSTEM A�TORNLATIO Property Address: CeR dr/y Ci � Owner: 00� 6L�� - Date o:`Inspection: FL C®\TD O?iS RESIDENTIAL �[ \umber of bedrooms'design):-7- .\umber of bedrooms(act ial):--? e14° / DESIGN flow based on 310 C'_VFR 15.203(for example: 110 gpd x=o: Number of current residents: Does residence have a garbage grinder ) �® (yes or no Is laundry on a separate sewage system(yes or no)-,-FV °if es separate Laundry system inspected ye t y inspection required] Seasonal use: (yes or no): �� W ater meter readings, if available(last 2 years usage(gpd# Sump pump(yes or no): �_ Last date of occupancy: e-(4en-.e4- C 0 NLNIE RC I ALILN-DY;STRIAL Type of establishment: Design flow(based on 310 CIAR 15.203): 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 LV-FORIMAITON Pumping Records Source of information: v't 00 J\ r ej i�,,ku s, Was system pumped as part of the inspection(yes or no If yes,volume pumped: gallons--How was r Reason for pumping: `ty Pad determined? �OF SYSTEIM v 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%altemative tec_hrrology.Attach a copy of the current operation and maenance conLa-cr= n obtained from systerrz o��er) int _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all cornpon s. datf Installed 'f known)and sours ofinc`ormuon. co c 60 s3'ere sewage odors detected when arriving at the site(yes or no):o): Thin� incr�n . l Page 7 of=i i OFFICIAL INSPECTION FORM_'SOT FOR VO>l LINTARY ASSEss-Ni��-TS SUBSURFACE SFWACE DISPOs�'Y_sYs�'E�gL�sP� �'€���� PART C SY STFTIVI ANF'ORMATION(continued) Property Address: 4 �� X �/ C�vP v. � Oymer: � a Bate of Inspection: a��pZ� ®' BUMDI_VG SEVER(locate on site plan) Depth below grade: l / Materials of construction: .ast iron v10 PVC_other(explain): Distance from prig ate Ovate.supply-well or suction line: Comments(on condition of ioims,ve,,Lug,evidence ofleakage,etc.): SEPTIC TANK:_a✓ i ocLLrP on site p?an) Depth below grade: �J Material of construction:_concrete_metal fiberglass._polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Cer incate of Compliance(rein or no):_(attach a copy of certificate} ��� - Dimensions: Sludge depth: Y-1 Distance from top of sludge to bottom of outlet tee or baffle: c2 .9 Scum thickness: X-4?XS / 11� del from top of scum to top of outlet tee or baffle: G Distance from bottom of scum to botto r outlet to r baffle: How were dimensions determined: o/e X` Comments(on pumping reccmmendations,inlet and outlet t.�2 or baffle condition,structural integrity,liquid ley.els as ated to outlet invert, e ence of le�Qe,etc.): GREASE TRAP:A�61oeate on site plan) Depth below grade:_ Material of construction:_concrete etaI fiberglass_polve`,hyiene offer (explain): — n 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 baf le: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle rendition s, r;��sTaiFz - i 4 as related to outlet invert. ek idence of Ieakage,etc.): Page 8 of i 1 OF'FTCI_AL INSPECTION EOR'YI-NOT FOR YOLI,T:s-,TARY ASSESS fE c SUBSI,�RFACE SEWAGE DISPOSAL SYSTF-m ������� NFLE PART C SYSTEM n-EORMATITON(continued) Property Address: 9 4 ,v e� ry Owner:��� E Date of Inspection: zl" T GFfT or HOT DINT=T_•F. i�., _,P �{d •.,_.._iiC ll�.i r'�'37I)E(} =_f f i irt�:_01�' -aeonsite p;a-) Depth below grade: Material of construction: concrete rnetal__"berglass_ polyethylene o`d,er(e-plain): Dimensions: Capacity: QaLons Design Flow: gallonsiday Alarm present(yes or no): Alarm level: Alarm'M­07`,fin`order(yes or no): Dace of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: � resent must be opened)(locate on site plan) Depth of liquid level above outlet invert: klo/-" A L Comments(note if box is level and distribution to outlets equal any evidence os solids eairyoder,any evidence of leakage W toryo�r out of box,etc. PUNI::P CHA_1MER:o!V(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., ew c.): T;rlo i (nc^crYinn �n,r 41, C Page 9 of I I OFFICLA,L INSPECTION FORM-NOT FOR VOLL�T_ARY_tSSESSNff SUBSURFACE SEW-AGE DISPoSA_L SyS-UEVj-rVSp'EC-1-1C),V _NTS PART C SYSTEM INFOR1MATION(continued) Property Address: 07 Owner: Date of Inspection: SOIL ABSORPTTON SYSTEM (SAS): (locate on site plan,excavation not reqUir ed) If SAS not located -,r Type leaching pits. mi--r- leaching chamn'--'. nd—mber: /1 /0 leaching gal; 0 leaching trendies. 1i'mmber, leaching fields- niumber- dirl-lerlions: Sf overflow cesspool; number: R&I Typpe/name of technoloo C-4(not.innovativ I I gy. Comments(note condition of'so-11, signs of hydraulic failure.-i etc.): evel off pondmp damp soil,condition of vegetation, ,C>94 d so� cy CESSPOOLS:&(cesspool must be pumped as part of InsPection)(locate 0 1 n site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions o1 cesspool: I Materials of construction: Indication of groundwater—mr1ow(yes or no): Comments(note condition of soil,Signs of hydraulic failure,ie-%Fel of Ponding,condition o f,ea.lion_ etc.1: PRIVY:k(locate on site plan) Materials of construction: Dimensions: Depth of solids:71 Comments(note condition of soil,si-RUS of hydraulic failure,level 0fPonding;Condition o---,eqe-,-2 orL Page 10 of 11 OFF'ICIAIL INSPECTION FORM—,NOT FOR VOLUNTARYSS_ �E I T S SUBSURFACE SEWAGE DYSpOSAL SYs7w ASSESS-NI �-ASS � PART C SYSTEM INTORMI A ION(continued) Property Address: Ge Owner: /'a 6��$ Date of Inspection: I SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the se;vage disposal system including ties to at least taro permanent reference landmarks or benchmarks. Locate all :-ells °ic: n 100 feet.Locate where public water supply enters t$e building. 1 V A/ - s ICA Titla G T+,cnor ' P22e 11 of I I OFFICIA-L IITSPECTION FORM_NOT FOR�'®I I�-TAR ASSESSNIENT[S SUBSURFACE SE'44'AGE OISI�OS�L SySwE'$ _�—racy ,vria.� PART C SYSTEM UNFORINLATION(continued) Property Address: 4,V C H cry Owner: lQ�. Date of Inspection: 9 �! SITE EXA_'iI Slope Surface water Check cellar Shallow wells Estimated depth to?round wa_-er feet Please indicate(check` P m--sheds used to determine he high ground water elevation: Obtained frees: :; -m�csi_zn plans on record-if checked,date of design planre'rieH-ed: Observed site = Tna proper<y/observation hole within 150 feet of SAS) Checked Lit toed' Board of Heal`h-explain: Checked«'th iccal z�xcav-awrs-ir15'iallers-(atlich documentation) Accessed liSGS database-explain: You must desc. ' e lhov you establiss ®jcd the lug a ouad wa r el tio i BARTER & NYE, INC. Registered Land Surveyors and Civil Engineers 7 Parker Road/ Osterville, Massachusetts 02655 / Tel. (617) 428-9131 WILLIAM C.NYE,R.L.S.-President RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E. -Vice President-Engineering November 19, 1987 Town of Barnstable Board of Health 367 Main Street Hyannis, Ma 02601 RE: Lot 24, May Lane Centerville Gentlemen: In accordance with your request I have inspected the septic system for Lot 24 . The system has been installed as per the approved plan. Very truly yours, Q Peter Sullivan, P.E. Baxter Nye, Inc. PS/1 F'° 0' p H OF P'ir;R J�r� S:JLL1C:iN R t4o.29733 'a . jy S T c MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING • Town of Barnstable �p 1HE Tp� Regulatory Services sAxrsrnstE Thomas F. Geiler, Director Qj 16.39. Public Health Division ArED��p Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE Lod -11 ll, . N LOCATION ®�jyj�}�/_ / . s /� SEWAGE VILLAGE 0 '�y%�12( 1 L-� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.1�iYt� ,� A .Pd.-tj SEPTIC TANK CAPACITY /t9 d .�LEACHING FACILITY:(type) ; "NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Sj DATE PERMIT ISSUED: ,. DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes "� No _-!,. . i, � � � �7 � . � �� �� f • 7,57 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH E ..----....1.Q.W.1 .............OF... ApplirFa#inn for llhipoii al Works CTnnitrnrtinn rrmit Application is hereby made for a Permit to Construct ( '1 or Repair ( ) an Individual Sewage Disposal System at: .................._..... --- 1.,�.►------------------------------------------ ------------------------------------------------ ............4......................... �/�']/�,� y Locatio - ddre/s --•or Lot No. ......................----•-•-• ... V-'.S�r��..1 , 5.. _................ .. ........ Owner Address Ia --- �'?- ••••--•......... .....•••-•••--•--••...---••-•.._..-•---------.....................................•--•--.......... Installer Address Type of Building Size Lot...... ���_Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) ...----.... No. of persons............................ Showers — a Other—Type of Building ......:.......... p ( ) Cafeteria ( ) 04 Other fixtures •----•----------•--------------••---••--•••••••---•---.-------•-••••--------------•--------........-------•-••••••-•••----•-•••-•-----••.........•---- W Design Flow..................: �_................-gallon er person per day. Total daily flow......................�55�?........gallons. W Septic Tank—Liquid capacity_ Lallo ength................ Width................ Diameter-----........... Depth................ i s x Disposal Trench—No._...:e3t......_.. Width_._._.. _........ Total Length..... 'C...... Total leaching area...... ---sq. ft. Seepage Pit No---------_---------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (✓) Dosing tank ( ) %-. f� / '—' Percolation Test Results Performed by. X .}.N : . _.._�.� ..AT Date......_/��1_ Ae a ,.� Test Pit No. 1................minutes per inch Depth of Test Pit.--................. Depth to ground water.......--------......... 1z, Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water........................ ------•-----------------------------•---•----------•---•--------...-----.....--•-••......-•-••-..............................................................O Description of Soil.............•--- ..-•-•- •----•. --•--•---••••••••--------•••----•----------------•-•-•-------•-•---•----•-----------••-••-----••...._.....••..--•--- v —Flaw-.....a ----------------------------------------- W U _ Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------•-•-------------------------------•------•-•----••-•-•-•-----------•-••---------........----------.....---------...---------------...------••-•---------------------------------...----........ Agreement: The undersigned agrees to. install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT 4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boardof health. Signed--- ...... .. ............. Application Approved BY ... .. . . .......... ......................... Date Application Disapproved for the following reasons:----------•-----••-•---•--------------•-•-------•-----•---•---•-••--•-•-----•-------------...--•-----....._._. ...............••------•----------•---•---••--•-•--•----------•--•---•---••------••----•••-••---••--......-...------------.....•-•-------••-------••---------•--•--•-----------•------•-----•--•-••.••--- Date Permit No......S:?...::J? Date No................_....... Fizz......Z i...'"':.`.'.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......[0.W__0_.........OF.... _........... ......................................... .............•----._......-•--•--- Appliration for Biiipos al Works Tom1rnr#ion 1hrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at .. - __.......- 1• • ........ ............. • ..._....... ............ ----...------........------ Locatio dress .or Lot No. ......................-- ! lr:...... .f ................................. 'fi:T ----------..... --•---..........•---- •- .......................................... Owner Address ........................... = � .I............... -------•-•------...--------•---.......-----•--•-----•-----•-------.....------....••............... - Installer Address U Type of Building z Size Lot......'6 fR�� -Sq. feet, �-, Dwelling—No. of Bedrooms__...._..v............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixture�...........................................................................................................................-- •-----•-•.............. W Design Flow....................'.S.................gallon er person per day. Total daily flow....................... -� .......gallons. WSeptic Tank—Liquid capacit Jallonepgth................ Width........._..... Diameter................ Depth................ x Disposal Trench—No...... ....... Width......,14._._.. Total Length.....'y..L2...... Total leaching area.....`ZE d_.sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box Dosin tank '-' Percolation Test Results Performed by.. K:jTE-n-..�.. . ?._.�'._JA�4? .. Date........ �s W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....................... fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ..---•--•--•--...._---•. ..................•---•....---......-•-•--•.....----..............-----•--....-•--------••--•-----•-----•-•-•-----......_•---....-- O Description of Soil.................... ?-•-------•-----••-•...--------•...-----••----•-•••-----------•-•---...---••-------------•-•---•--•-----•-•--•--•---•-------.._.. chi ..................................................... . i f !J�''•-----............-•-•-••---•-•-•-•--•-•----•-•-----•----•--•---••--•-----•-----•--•--...---•--....-••--•--•---••--- W x •-••------•------------•---------•-••-••----•-•-•••••----•---------------•--•••-•-------•-•••--------••-•-•----...-----------••-•----•-•-•--------------•--•----•--•--................................. 0 Nature of Repairs or Alterations—Answer when applicable............................................................................................... ••.-•--••------•---•-••-•--••••--.......•--•------------------------•--•--......--•----•-••--•-••-----•---•-••-•-•---------••---••--...•-••-------••---•-•--...........•---....-•--.................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed• • '': ':r ....................... ... �, Date Application Approved By...........(yle,M .:. .::, Date Application Disapproved for the following reasons:-------•--•---•••----•-----••---•--•----•--•-----•----••-•----...---•------•---•----------•-----------•......... -••--...-•----•---•-•---•-••-•---•---•--....-••---•--•---•-----•...............••-••-•---._....--•---•-----•--..........----------••----............................................................... Date Permit No....... 'f /'.-=�� - Issued................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............� ...........OF......... '. .e7r I.:b..... %rrtif iratr of Tomptianrr THIS 15 'C CJ TIFY That the Individual Sewage Disposal System constructed (i or Repaired ( ) . .........1;. i --------------------•-------•--•--••--••--•----...-----•--•---..............•-------........................................-----•---...... at. Installer - -----------------•-`------ // • -- %'J- �--*-- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_....__....__..__......_____....._......... ._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS,A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... ..~.. .> ' .�... Inspector.... --------------------- .. .�...� THE COMMONWEALTH OF MASSACHUSETTS BOARD QOF HEALTH T( .�J............OF.........�J �I �I� L ............................... -� .............. No.................... .. r_ �. Disposal lgorkii Tons#rndion ramit Permission is hereby granted......... .................pa.:............. . to Construct (X) or Repair ( ) an Individual Sewage Disposal System at No.. Street as shown on the application for Disposal Works Construction Permit No.?_ -.A-,`:_ DATE.................................. .............................................. 1J 3 Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS BAXTER & NYE, INC. Registered Land Surveyors and Civil Engineers 7 Parker Road / Osterville, Massachusetts 02655 / Tel. (617) 428-9131 WILLIAM C.NYE,R.L.S.-President RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN, P.E. - Vice President-Engineering November 19, 1987 Town of Barnstable Board of Health 367 Main Street Hyannis, Ma. 02601 RE: Lot 24, May Lane Centerville Gentlemen: In accordance with your request I have inspected the septic system for Lot 24 . The system has been installed as per the approved plan. Very truly yours, Peter Sullivan, P .E . Baxter & Nye, Inc. PS 1 OF is P kn SULLIt'. PJ � ? No. 29i33 wY .� MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETPS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS of7NETo� TOWN OF BARNSTABLE OFFICE OF i BABBLE,MM& i BOARD OF HEALTH MAE& 1639 367 MAIN STREET ATE MAY�. HYANNIS, MASS. 02601 July 16, 1986 4/'� v+lens• . Mr. Richard S. Burling 3217 Main Street Barnstable, MA. 02630 Dear Mr. Burling: The variance granted Alden Homes, Inc., on June 20, 1984, to install septic leaching flow diffusers 89 feet from wetlands with the reserve area located 78 feet from wetlands, in lieu of 100, on Lot 24, May Lane, Centerville, is extended to "expire July 1, 1987, with the following conditions: (1) All other requirements of Title 5, of the.8tate Environmental Code, and the Town of Barnstable Health Regulations must be strictly adhered to'. P (2) " The designing engineer must be on site to supervise construction of the system and certify in writing to the Board of Health that his design has been complied with before the issuance of a certificate of compliance and an occupancy permit. (3) You must receive approval from the Conservation Commission. This ext ension of time is granted because a site visit was made after a period of heavy rain. This visit did not reveal any significant wet areas that contribute to any marsh, swamp, river, lake, or other water course. V y truly 41lds ober L. Chi Chairman BOARD OF HEALTH TOWN OF BARNSTABLE JMK/mm cc: Conservation Commission - _ --- t - i R t Z7 5`•9` U'rs 7DweLj-jjJU DIAAGW17(L G A�fl � aJ Pufi' PLC. W 6-OIL - �' 05 ��•� - _zf r ''fl 5�'AGE ,� � n " _. of s T I { o f t �-- / l 9y WT CO2er:G770A,1 ,4IW 230, 3 -13 - - _ -rV zw �--'- 4 Z -3� . �r."'"""« ^� .r/"tI� �j/ ;-!: IT 4. G—/ rr/ ."Y i..' . J >..<..t"r ya t ,( ��./� J� ,,r,+� �-/..♦ ( J / �� / / '+ JC.+c„` .. JJ 1,.- /�,,, ✓ si:..sw f� /I /A / A1A OF Pd,1 a `�H O f;yfao /, ' /Lt� �'� r�t 's '�5'� L��/T'r+ry� �TJ�i " s° + ' �i�/` '-- NJ-•' o� Wit LIANI N �� DAVlD / C. C. �' N ',� a te' •' `' �0 lYl�i�TS s r 7'"/7`- TW%' G�'f�✓° '3 r `o THULI r AA a N Y E 9?76 ' No. 19334 O \ ® ' 10/_�{5 ST su "AL