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HomeMy WebLinkAbout0083 NORTH PRECINCT ROAD - Health 83 North Precinct H = 148 - 134 Centerville No.2453LOR UPC 12534 smead.com • Made to USA cy I, w f�fR 11 �J ilk FeTa6uiY Utz S F I t? n sou ti NHaUUPFhIEttlfS CERIIFlED SOURCING i"yv^OMMOSkARGA3 Ca TOWN OF BARNSTABLE LOCATION Fa(�cI m cr- o SEWAGE # VILLAGE c�K' v� ASSESSOR'S MAP & LOT�� 3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY (QO LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 .LId ,v Bk 29474 Pg102 #9146 02-26-2016 @ 11:31a; DEED RESTRICTION a� WHEREAS,Emilios Riggs and Anastasia Rigas of 208 Elliott Road, Centerville, MA 02632,are the owners of 83 North Precinct Road located in Centerville, MA, and being shown as Lot 16 on a plan entitled"Subdivision Plan of Land in Barnstable,Mass. (Barnstable County)Owned by:Peter G. Sheaffer December•8, 1973, Scale 1"=40' by Cape Cod Survey Consultants, A division of Boston Survey Consultants, Iyanough Road(Rte. 132),Hyannis,Massachusetts," which plan is duly recorded in the Barnstable County Registry of Deeds in Plan Book 291, Pages 73 and 74. WHEREAS,Emilios Rigas and Anastasia Rigas, as the owners of said lot have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre- ' condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.00 State Environmental Code,Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code,Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document. NOW,THEREFORE,Emilios Rigas and Anastasia Rigas do hereby place the following restriction on the above-referenced land in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. 83 North Precinct Road,Centerville,MA may have constructed upon the lot a house containing no more than two(2)bedrooms. Emilios Rigas and Anastasia Riggs agree that this shall be a permanent deed restriction affecting the house located on 83 North Precinct Road, Centerville,MA,and being shown as Lot 16 on the.plan recorded in Plan Book 281,Pages 73 and 74. l For title of Emilios Rigas and Aanastasia Rigas, see Deed recorded with the Barnstable Registry of Deeds in Book 28285, Page 287. Property Address: 83 North Precinct Road, Centerville, MA 02632 Executed as a sealed instrument this a?5 day of February, 2016. }Y) Emilios Rigas Anastasia Rigas COMMONWEALTROF MASSACHUSETTS Barnstable, ss. ' On this ah day of February, 2016, before me, the undersigned notary public, personally appeared Emilios Rigas and Anastasia Rigas, and proved to me through satisfactory evidence of identification, which was a MA driver's licenses, to be the persons whose names are signed on the preceding or attached document, and acknowledged to me that they signed it voluntarily for its tated purpose. IL i r Lb Vic. Notary Public: c(b ct My commission expire . 7 ( 5�oZ01 (p Town of Barnstable P Department of Regulatory Services ,. a XMwar"L%I Public Health Division Date `� L7` MAM �A rd». �� 200 Main Street,Hyannis MA 02601 � lilt MKS A . E Date Scheduled Time v' t11 Fee Pd._ / f Soil Suitability Assessment for Sew ge Disposal Performed By: �./a�11� C�O��/j�jyf/t -110� Q r Witnessed By: � 1A7Wt K-1 Locatlan Address )) ( 1L,,OCATION�i.GENERAL INFORMATION Owners Name ?9 4 1 t Address Assessor's Map/Parcel: �. �'3�` / Engineer's Nam Dc,I'I C8 voel n o —. NEW CON UCTION REPAIR �/ Telephone# O Land Use r Slopes(96) / Surface Stones n D Distances from: Open Water Body 100 t ft Possible Wet Area ip1(9 ft Drinking Water Well wo t ft Drainage Way �� { ft Property Une V `1 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands in proximity to holes) • � �i P_t. der. , Parent material(geologic) ro 61CI-1 Wu Depth to Bedrock Depth to Oroundwater. Standing Water in Hole: t9 VLQ Weeping from Pit Face U`'d h Estimated Seasonal High Oroundwater } DETERMINATION FOR SEASONAL•HIGH WATER TABLE Method Used: / � Depth Observed standing in obs.hole: In, Depth to soil mottles. Z _In, `��ne a Depth to weeping from side of obs.hole: In, Groundwater Adjustment 14} Index Well-# Reading Date: Index Well level Adj,factor, ,q„� Adj.draundwater Leval.,v PERCOLATION TEST Dattl �2-i i� Pm Observation Hole# I Time at 9" Jq Q Depth of Pere /t7 t/ t h Time at 6" h Start Prc-soak Time® 0-0D Time(9"41) End Pre-soak WOO -"O Rate Min./Inch �� I Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) ^� Original: Public Health Division t Observation Hole Data To Be Completed on Back---------- �Y ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTIWERCFORM.DOC 1/� t DEEP.OBSERVATION HOLE LOG Hole# I Depth from Soil Horizon Soil Texture Sdil Color Soil- Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. tsiste�lcy 96 t3ravell 0-10 a fr►0bJp 30 �� I,ou�i� Stiff to `'iP. 13 Fr. 9 1e" =* 30- [;Z L, 4kedi'm �q 4.4 l0 y� S/4 L.00 s•e ° DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, p -�0 AP Svtd (0 `i' �- zlD �(`►a b LP 0 -3 0 LDa UY SC,a 4 R 30 -�26 C 9ed.,vi� �a o RSA os� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) MotUing (Structure,Stones,Boulders.. Consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Solt Color Sall Other Surface(in.) (USDA) (Munsell) Mottling (Structure,SSopes;Boulders, consistency. I � ' Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No,,�I_ Yes Death of Naturally Occurring Pervious Materlol Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on qJ A V (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me cons the requir trainin xpertuipa a experience described in 10 C1vM 15.017. �` ASs9e DAVIG� yGN Tan Oq Signaturel� Datt; -- 6 .. ;) D. . COUGHANOWR 0/ �CENSf- EVALUP QASAF n0PBRCFORM.DOC �y'T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name information isrequir Centerville MA 02632 07/15/11 9e. for every Cityfrown 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 and of the form. Important:`"hen A. General Information filling out forms on the computer, use only the tab 1. inspector. key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections �y Company Name P. O. Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 S13742 c..,s r n Telephone Number License Number 1.4 :R 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 sewab Aisposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of r Title(5�(�10 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation,by the Local Approving Authority 07/19/11 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 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. uc� /� l t5ins•11110 Tiue s official inspeow Forth:Su Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 North Precint Road Properly Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 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-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cost_): ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. Cityrrown 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 El ® 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 t5hs•11/10 Tdle 5 Official Inspection Form:SubsLirface Sewage Disposal System-Page 4 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 North Precint Road Property Address John Saegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. City/rown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system.is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 16.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 TWO 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 83 North Precint Road Property Address John Szegda Owner Owner's Name Information is required for every Centerville MA 02632 07/15/11 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 t5ins•11/10 TNe 5 Oftial 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 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 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 0 No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No 09/10 Last date of occupancy: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 o►17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. CitylTown 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection,records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe). t5ins•11/10 Title 5 Official inspection Foim:Subsurteee Sewage Disposal System•Page 8 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °yc 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: 20 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.2 feet Material of construction: ❑ cast iron 0 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): Depth below grade: 0.4 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: yeas is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 3" r ' t5ins-11110 Title 5 Of6d8l Inspedion Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" 211 Scum thickness 511 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" 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.): The tank was sound and tight with tees in place and liquid at outlet invert. 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-1 Ill 0 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) 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•11/10 TIUe 6 Olfidal Inspection Forth:Subsurface Sewage Disposal Sys•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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 box was level and tight 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•11/10 Title 5 Official Irmix-don Form:Subsurface Sewage Dispo§al System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name Information is Centerville MA02632 07/15/11 required for every page Citytrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: 1 ❑ 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.): This System has a 6'x6'precast pit surrounded by l'of stone. There was a puudle in the bottom with stain line 30" up from the bottom. 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•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. Citylrown 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•11/10 Titie 5 Official tnspection Fomr.Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts v Title 5 Official inspection Form Subsurhmm Sewage DNOMW System Form-Not for Voluntary Assessments 83 North Precint Road Pmperty Address John Owner owners Name 07/15/11 inforrrration is MA 02632 required for every Centerville state zip Code tie of Inspedion Pap• c ityrrom D. System Information (cunt.) 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 a� 'r5b 5� Faa+c 8abmelaoe6'awa9� fi�•�i5 of l9 t5ita•1tn0 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page, City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 30.0 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: Dare ❑ 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: USGS maps show an elevation of over 30.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. thins-11/1 D Title 5 Official Inspection Form:Subswface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 North Precint Road Property Address John Szegda Owner Owner's Name information is required for every Centerville MA 02632 07/15/11 page. City/rown State Zip Code Date of Inspection E. Deport 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 L-77Dt . 73 � ...... �... No.. ....----•--• ✓ Fug.. . QTHE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HE TH I�L�J'i.,.t........OF........� ........----- Appliration -for Bhipoiitti Workii Towitrurtiutt Vamit Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System t / ®� / /'"/ � �.!`✓r/ ............................. ........................................ Location-Address or Lot No. 40 .I s ------------ Installer Address � d Type of Building Size Lot... C................Sq. feet U Dwelling—No. of Bedrooms... ........................ ...............Expansion Attic ( ) Garbage Grinder ( ) 1:14 Other—Type of Building _..�fv-------- ----- No. of persons..-____----- ___._--_.-- Showers ( /� — Cafeteria ( ) P4 Other fixtures ...... ----------------------- W Design Flow............6�?.......................gallons per person per day. Total daily flow---- ------------------...........gallons. WSeptic Tank—Liquid capacitv_�o P? ..gallons Length_8_*;O------- Width-. .../C?.�'-- Diameter................ De1 ptli_d-----`/ x Disposal Trench—N o. .................... Width����.--_--.-_-. Total Length....P............ Total leaching area..--.-.-_--..W.�-.-.sq. ft. Seepage Pit No...._.-_........._.. Diameter_1__5/_ ________ Depth below inlet_,,...,7.......... Total leaching area.::_ _..____sq. it. Z Other Distribution box (kl� Dosing tank ( ) Percolation Test Results Performed p:'=-5'.P ....._. Date... _______ _ �l v,vBe.-rP - -- a Test Pit No. 1..._ ._...._minutes per inch Depth of "Pest Pit._//S____-. Depth to ground water...%---'S__ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ------------------------------------------------------------------------- ---------------------------------- 0 Description of Soil__/il. _ a_ '^__ c _c•/" nse_ alb= 5�-AP --- :ra:C.- - - io�= Go,G, ;` /y✓�-A v— oA�l. - . icy- .��� ' ;:-- --• ---------------------------------------------------------•--------•--------�•--- U � �1�..__ .... . . .•• �L --•-••............ .•••-• ----/ -=--`---••- /n•"..., �,�/ W .- - UNature of RepaiP_s__or Alterations—Answer when applicable------------------------------------------------------------------.--------_------..------- ---------------------------------------------------------------------------------- .... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee su by d of health. .007 Sig Date Application Approved By•-- . ,_,1- ----•--- •--•-• ••.... •• .0 A-k -7- 7-- Date Application Disapproved for the following reasons:----•----------•----------- ----•--•--•----------------•-------------------------..-.-..--•-.--•------------•--- ---•----•--------------•------------•--------•--•.....-•------•--•---------- -------------------•-••-••------------------------------------•----..--- Date PermitNo........................................................ Issued........................................................ Date 77 T 1 ,No.------•----- -----• FEE lI " ..... THE` 0M NWEALT�i{OF, MASSACHUSETTS BQ' F HEA `T ,Ajiphrativit -fur l tt u rttrtiutt rrutit Application is hereby'made for a Permit to Constuc ' ep r P�i an Individual Sewage Disposal Sys em k � . r � � ow� -------• --- .....................................------•---•-•-----. �--------------------------------- Location Address orL�1Vo ---------- O nerCss Installer r,.Address - UType of Building �: ; Size Lot_.'�V'_ "`1.....Sq. feet r-__- -E�, Anson Attic.. Garbage Grinder ` Dwelling—No. of Bedrooms.:; ( ) g ( ) 04 Other—Type of Building --. 1'"._... �,=�To: of pci sons s ShowersCafeteria ( ) !f QOther fixtures ------------- ` ... = ----------.....----------------.....-------------------•--- g ....................:......gallons per person per day. Total,daily flow:-------------------------------------------gallons. W Design Flow.:.............. WSeptic 'lank—Liquid capacity-._.-------------- Length---------------- ...... Diameter................. Depth---..-_--_..._.. x Disposal Trench—No:..........---------- Width..................t_Total Length.._-_-_-__--_.._-_--- Total leaching area--------------------sq. ft. Seepage Pit No______________________ Diameter.................... Depth belQW1i inlet__......____.__:_.__ Total leaching area______..._.____..sq. it. z Other Distribution'box ( ) Dosing tank Percolation Test Results >e,:r Performed by— e= :.. Date Y..... a Pest Pit No., 1-----------------mmutes.per inch Depth of Test Pit-_____--___-- -_. Depth to,ground water.............:............ G4 Test Pit No. 2____•_.__-__.:.minutes per inch Depth of :.rest Pit-------- .......... Depth to ground water-_---------_._.-,;-_-- IYi --------------------- -----------------------------•-----•--------• a--------•--- r D Description of Soil-------------- -----------------------------------"=-"i = ----- --------------------------------.` x U Nature of Repairs or Alterations—Answer when applicable ............. .... ..... ............................................._............ . -- --•-----------•--------•----•------•------------------- -----------••------------------------- Agreement The undersigned agrees tor install the aforedescribed Individual Sewage Disposal System in accordance with the:provisions of Article XI of the State Sanitary .Code—The undersigned further agrees not to place the system in Operation until'a Certificate of Compliance has bee •ss by o d of health. i .S _. --- -------- Dal Agpllcatlon Approved BY- : - 1 ' = _. `° +------------------•- ` Date Application Disappfoved for the following reasons--------------------------------------------------.................................................. ------------------------------------------------------------------------------------------------------------------------------------------------------ P Date Permit.No. ...........-.. Issued.......................................... •---------•------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD PF HEALTH . .. Tutifiratle of f'lairi 1141trr T.IIS.IS T RT�'_ p�,']that the Individual Sewage Disposal System constructed or Repaired ( ) byt a--•- ...................... � r � In ler°' at. _w ----- --------f."_�".. ..e- N++ ? °4 ._. , ----------------- has been installed in accordance with the provisions of . t5e XI T1 State Sanitary o Ie s �les�cridt the application for Disposal Works Construction Permit N ..--- ._______ dated. .0 ,_. :. f_ _______ _ _________ THE ISSUANCE''OF THIS ,CERTIFICATE SHALL NOT BE CONSTRUE®wAS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTO Y. DATE =------------------------------------- - .............. Inspector----------- ..----------------------- ` r THE COMMONWEALTH OF MA SSACHUSETTS BOARD,`: F HEALTH ...............O F... '..::.:........ No.------ FEE .................. s %X11pu ttf luum rurtion rrtatit Permissio d ereby granted•_ t ...... to Cons uct r Repair Individual Sewage spos Sys at No' a p- ' � " �Y ' 71 Street - 14 as shown on the application for Disposal Works Construction r ted:.� ... - ___--- Bo d#ofHp • DATE,_L ll --- --- --- ----- ------------------- � � � t; � � � � J PUBLISHERS.FORM 1258 HOBBS & WARREN. INC.. �._� , x .V Y ',r: •a i1 , `o oc -+, .- Z y,O'a �L•9 •.,v^ „q)."t4. h` 4' o a rc 'r ..,,- ;r'. ,T; ,h� C d h ,'';. d.fs. .'er�,•',%aG ' its, r, j,,. ..L .f,�,t ,t,.s :+ 1r _,r.• y '�g•r �`. _{,+' :.�k..7 .. o ," "• r' ,:'t .-'". - r. '^t-r✓ �i<?:'"` y'•.>lt ..f...�:,.r -:W ':.F"' ,fry ` •-i'..S%nh ap4s-t_ r♦,,: .,,.f, a tt�XA:: " .),,,i F 7 J r, fit. „c 4r r1 <• Sq�'r y c +t ",::� ° )f. fir: f' r. 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