HomeMy WebLinkAbout0067 NORTH PRECINCT ROAD - Health 67 North. Precinct Road
Centerville
A= 148-133
S M EAD®
No.2-153L®R
MUM
smead.com • Made In USA
TOWN OF BA,R,NDSTABLE
LOCATION �fl 7 Worth�/'eGr'•'rGf !�f SEWAGE#✓I sF
VILLAGE T,9i-0 AQ ASSESSOR'S MAP&PARCEL
Imo 'S NAME&PHONE NO. ►^N-k C 0)l m y
SEPTIC TANK CAPACITY 1006
vc9
LEACHING FACILITY:(type) (size)
J
NO. OF BEDROOMS
.OWNER. e S.
PERMIT DATE: CAE DATE: -710?1 t6a
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
28
40
19
28 42
...
24
ater
ervire
North Precinct Road
t4az rdous Materials Inventory Sheet Checklist
f- Date
Physical Street Address-Check database to ensure it exists
orking Phone Number
Actual Amounts.-( ie. gas being used:to:=fuel machines, thinner to
clean brushes.all count as hazardous materials-no.blanks)
-location of storage, how. long is storage for?
Storage Information
If none, note that. -
f�Disposal Information ..where and who?.If no_ne,:note,that
Applicant Signature.-,understand what is listed and.noted
taff Initial -.any.questions, know who to.ask
Vehicle Washing/Rinsing?, -,:give`a vehic.le.wash.ing policy and
explain-A. .:...
Attach the Business Certificate'with your sign off and comments
nsists of and the procedures
"The i�tory form should explain what the business co
they are doing. Notes need to be left to explain.what you discussed with them.
Date/o/ /��-
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: :e,� 010
BUSINESS LOCATION: off, ooyY Precinr-L if-A • en-kmIu my INVENTORY
MAILING ADDRESS: ,COI:yyu_ TOTAL AMOUNT:
TELEPHONE NUMBER: - 1-1H 83 to L/
CONTACT PERSON: .1 0
EMERGENCY CONTACT TELEPHONE NUMBER: -1-1 q R; (o - Sl 6`I MSDS ON SITE?
TYPE OF BUSINESS: La hdls(a 121 M
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers v hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers -----------------
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials%�nnj
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) ou must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: � a— Fill in please:
APPLICANT'S YOUR NAME/S: .-T f rn o4 V1, Cs--rQ ( e_
T t�
BUSINESS YOUR HOME ADDRESS: (p-1 l�n -}Y1 ��P r n 4 c(-
�h+e" IIte ma9 0.i\Q�-4
y TELEPHONE # Home Telephone Number `I-1 ul-S 3
NAME OF CORPORATION: rO\cf3cca e s
NAME OF NEW BUSINESS L TYPE OF BUSINESS �.cf/�r�l,Ic<x r�is2a
IS THIS A HOME OCCUPATION? ✓ YES NO md* 0-(03
ADDRESS OF BUSINESS t (o o i'i,\n P r e c- )►'1 G t 2 rA Q p4ery 1) i AAp/PARCEL NUMBER (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
This individual ha n 'nform o h�per it r quireme s that pertain to this type of business.
41
Authorized Si ature/*
COMMENTS:
3..CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
4
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate �O!
Owner Owner's Name
information is required for 167 Lovell's Lane, Marstons Mills MA 02648 July 21, 2008
—
very 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.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell c_ _
cursor-do not use the return Name of Inspector
key. Septic Inspection Services Co. t _
Company Name
r� 189 Cammett Road ,;
Company Address --,
Marstons Mills MA 648
Cityrrown State Zi Code r ;,
508-428-1779 SI 12855 `'J_
ry
Telephone Number License Number c n ry t
B. Certification
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
fm af —
July 21, 2008
Inspector's Sig ure 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.
08-195 US 8ank.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate _
Owner Owner's Name
information is required for 167 Lovell's Lane, Marstons Mills MA 02648 July 21, 2008
-
every 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 CM 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Tank is not in need of pumping at this time, leaching pit was found empty at time of inspection with a
high stain line indicating pit has 2' of effective leaching.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is.removed
08.195 US Bank.doc•08/06 'Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
iCommonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate
Owner Owner's Name
information is required for 167 Lovell's Lane, Marstons Mills MA 02648 July 21, 2008
-
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed -
ND Explain:
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
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.
08-195 US Bank.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate
Owner Owner's Name
information is 167 Lovell's Lane, Marstons Mills MA 02648 Jul 21, 2008
required for y
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria 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_day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
® tributary to a surface water supply.
08-195 US Bank.doc-08/06 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632 _
Property Address
US Bank C/O Ann Quinlin Remax Real Estate _
Owner Owner's Name
information is required for 167 Lovell's Lane, Marstons Mills MA 02648 July ,21 2008
_
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
- system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ El Area
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.
08.195 US 8ank.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632 _
Property Address
US Bank C/O Ann Quinlin Remax Real Estate _
Owner Owner's Name
information is Y ,167 Lovell's Lane, Marstons Mills MA 02648 Jul 21 2008
required for _
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner.(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
08-195 US Bank.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
I: Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632 _
Property Address
US Bank C/O Ann Quinlin Remax Real Estate _
Owner Owner's Name
information is Y ,167 Lovell's Lane, Marstons Mills MA 02648 Jul 21 2008
required for —
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2 —
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 _
Number of current residents: 0 —
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): —
Sump pump? ❑ Yes ® No
_
Last date of occupancy: March 2008Date
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: —
Last date of occupancy/use: Date
Other(describe): —
08-195 US Bank.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 67 North Precinct Road, Centerville MA 02632 _
Property Address
US Bank C/O Ann Quinlin Remax Real Estate _
Owner Owner's Name
information is required for 167 Lovell's Lane, Marstons Mills MA 02648 July 21, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: None
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
El Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-195 US Bank.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.,Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate _
Owner Owner's Name
information is required for 167 Lovell's Lane, Marstons Mills MA 02648 July 21, 2008
-
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1 —
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.):
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
.----------------------------------------------------------------------------------- ---------------------------------------
Dimensions: 8.5' long x 5.2'wide- 1000 gal. —
2
Sludge depth: —
Distance from top of sludge to bottom of outlet tee or baffle —
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle —
Distance from bottom of scum to bottom of outlet tee or baffle —
How were dimensions determined? Measured —
08-195 US Bank.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of:15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate
Owner Owner's Name
information is y required for 167 Lovell's Lane, Marstons Mills MA 02648 Jul 21, 2008
every page. Citylrown 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.):
Baffles intact and clear, liquid level was found 2-Y below outlet invert due to evaporation. Tank is not
in need of pumping at this time.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: —
Scum thickness —
Distance from top of scum to top of outlet tee or baffle —
Distance from bottom of scum to bottom of outlet tee or baffle —
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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):
08-195 US Bank.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate _
Owner Owner's Name
information is 167 Lovell's Lane, Marstons Mills MA 02648 Jul 21, 2008
required for Y
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0.1
-
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.):
No solid sor high stains present.
Pump Chamber(locate on site plan):
Pumps in working order: ❑. Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
08-195 US Bank.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate
Owner Owner's Name
information is 167 Lovell's Lane, Marstons Mills MA 02648 Jul 21, 2008
required for Y
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: Two 6x6 pits. —
❑ leaching chambers number: —
❑ leaching galleries number: —
❑ leaching trenches number, length: —
❑ leaching fields number, dimensions: —
❑ overflow cesspool number: —
❑ innovative/alternative system
Type/name of technology: —
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching pit#1 was empty at time of inspection with a high stain line 2' below inlet pipe. Pit#2 is
located under fence and was not opened.
08-195 US Bank.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
1 Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate
Owner Owner's Name
information is 167 Lovell's Lane, Marstons Mills MA 02648 Jul 21, 2008
required for y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration —
Depth—top of liquid to inlet invert —
Depth of solids layer
Depth of scum layer
Dimensions of cesspool —
Materials of construction —
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
08-195 US Bank.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate
Owner Owner's Name
information is 167 Lovell's Lane, Marstons Mills MA 02648 July 21, 2008
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
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% 19
\ \ \ , \ \ . ♦ \ , \ \ , . , , \ \ \ . \ , \ 42
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24
Water
Service
North Precinct Road
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 North Precinct Road, Centerville MA 02632
Property Address
US Bank C/O Ann Quinlin Remax Real Estate
Owner Owner's Name
information is 167 Lovell's Lane, Marstons Mills MA 02648 Jul 21, 2008
required for Y
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: pate
❑ 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:
USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el. 35 and topo map shows property at el. 50.
08-195 US Bank.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
THE Town of Barnstable
�pF Tp�
P o Regulatory Services
LIRNSrABM Thomas F. Geiler,Director
9Q 1639.
OpTfpM,�A Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
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 or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations 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 Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC
LO CANON SE�WA E , PERMIT N0.
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VILLAGE
I N S T A LLER'S NAME & ADDRESS
BUILDER OR OWNER
11 La
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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