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0079 OLD FARM ROAD - Health
_ 79 OLD FARM`_ROAD, CENT ER,IL LE A=231 024 IlII RECYc(f� pka © UPC 12643 �� . l• 40.53LOR �,��COhSvy` HASTINGS,MN TOWN OF BARN,Rd LOCATION ` iA J`^ R�^ SEWAGE# a0t;y_�It VILLAGE Cep Z"-2r V I I 1 ASSESSOR'S MAP&PARCEL Z I oa INSTALLER'S NAME&PHONE NO. &()U r-C o . c 64` SEPTIC TANK CAPACITY jS00 LEACHING FACILITY. (type) (size) /oC>0 NO. OF BEDROOMS q OWNER P e.-i v PERMIT DATE: / l 1 q I ILI COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility C1 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) X1 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ,, /� AJhA—Feet FURNISHED BY �' b'1 �� � o i'A� � Q C r Y � 3( 30` 3(o No. G I14—I?3' Fee 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21ppfiration for Misposal *pstrm Construrtion Vrrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. '>4 Owner's Name,A ess and Tel.No. 1,1 OGO FAttM tCO&h efrNIrC-f't-JIL'Lt M4, Mf tjji ) 4 r'i4(.09e--K /i4t4ISC- Assessor's Map/Parcel 'L3 i Z ®'L 5' ` ( y5 P r G Kt-v I Gft k Se I AA Installer's Name,Address,and Tel.No. c9V lj e fCq Designer's Name,Address,and Tel.No. 4,0 9 j � 30l_ Type of Building: Dwelling No.of Bedrooms A- Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures q— Design Flow(min.required) T� gpd Design flow providedA/A_ gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil — JA o1'e- "A > O E Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction d maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro tal Co and not to place the system in operation until a Certificate of Compliance has been issued by this Board ealt Signed f/%% (% Date /` Application Approved by ..,= - Date Application Disapproved by Date for the following reasons Permit No. C2 0 I LI —rZ 3 1 Date Issued � Y No.r. G I 1 0? Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppticatlon for.lDisposal 6pstern Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name A res ,and Tel.No. OLW FA �20Avi /t-Nf6VLVlLt� AA,1 Sf�l'Nrcti1 a tern MKSC' Assessor's Map/Parcel 2$1 O 2 S `�"l a 5 fTA o f yL w f(" c N.t-v`(e-0 A SE M b Installer's Name,Address,and Tel.No. 37Y d7 C4' ,--, R Designer's Name,Address,and Tel.No. ti i (��e�. f3•o�2 Cam. /� -<< ��• ����� Type of Building: ..� - Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) l 4 Other Fixtures .-Des�►gn Flow(min.required) /� gpd Design flow provided * gpd t �A Plain'' Date Number of sheets Revision Date Title o,Size of Septic Tank Type of S. S. `I Description of Soil Ole- \ Nature of Repairs or Alterations(Answer when applicable) Date,last inspected: Agreement: 4 fThe undersigned agrees to ensure the construction d maintenance of the afore described on-site sewage disposal system in r accordance•with the provisions of Title 5 of the Enviro ntal Co t~and not o place the system in operation until a Certificate of Compliance has been issued by this Board Vealt Signed Date Date Application Approved by . T - Date Application Disapproved by Date for the following reasons + Permit No. 6 '� 7 2 Date Issued --------------------------------------------------------------------------------------------------------------------------- s- THE COMMONWEALTH OF MASSACHUSETTS + BARNSTABLE,MASSACHUSETTS (Certificate of Complianre THIS IS TO CERTIFY,t at the On-site ewag isposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by t(/f X at 1 01 G b l=A P_M CL►7 C F n/TC-RV f LLC- M+1If has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.d0/9-d 3I dated Installer Designer #bedrooms ® Approved design"lio�w gpd The issuance of this pe 3t shall bt ,/e oo~nstrued as a guarantee that the system will nct/�on 4d sikh Date 7 �`/ 4 Inspector fJ 1 ✓ � -------------------------------------------------------------------------------------------------------�------ --------------- ------ No. 901L( p9 3/ Fee �y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Misposat :�Ppstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) K-System located at I O U yl F Q 2 M it V A W , to Nrt*V/1.l M s? and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit __,__� —7 IS- t• Date ( " Approved by C� ILI 2- 31 qpk TO IN 4 nor p A r4�t:,`TnQr. PERCENTAGE OF LOT COVERAGE 10f AIErAI (� k;, 1�3.74S.F. ISTING'STRUCTUFiES 6.4%� MAP & PARCEL 23 1-026 J rde.aew.omt P4 ce �,r I / MAP 231-025RCEL ^� P � Do � o - f � LOCUS MAP PARCEL 2 , a \ —_-- --- PLAN REF: 305-98 53— / 'oo� / / O DEED REF: 10253-335 _— -----_-- / MAP & PARCEL ASSESSOR'S MAP: RD-1 4-----_-- ASSESSOR'S 1&2 231-005 ZONING: D-1 FLOOD ZONE: C m' --- PANEL NUMBER: 250001 0005 C / \ EP¶C SHOW PERO DAZED: 08/19/1985 / s Ok RECORD O _ ppana<q OVERLAY DIST. GP, RPOD, ZONE II, i �� \/ •c�. 26� /y v>�t. sc;.,a'r,•Qa MASS ESTUARIES o �` �� S��`�"`` PLOT PLAN OF LAND \ ' r. LOCATED AT: 79 OLD FARM ROAD %"'° `4 CENTERVILLE, MA LOT 1 PREPARER FOR: k FARIDEH & STEPHEN MUSE OCTOBER 15, 2013 MAP & PARCEL \ 231-006 REV: REV. REV: GRAPHIC SCALE YANKEE LAND SURVEY I 30 �s w B, CO., INC. 119 ROUTE 149 MARSTONS MILLS, MA 02648 —5553 1 inch = 30 tL LOT 2 MAP & PARCEL YAANK�URVEYOCCOOM O�SNETFAWWYANKE4'E2SOURVEYCOM 231—008 SHEET 1 OF 1 JOB JM S , m „ W o i. E6JPL EpVAL T - � o 0 .. _. _ .. ... I I� I I -0 � 164 C y > 9june 2014 -1--__— FIGW INTCWOR Y'YN VYYI Fpnc(. �i1�''I4TING LI' IFIG ri 1�14.iT 1.1441 Nt ¢I/LL•( {y v I hl w/1 �IvRoT W uso p.RcN -. N14 CR. �' EaVnL% @i3VN.0 C'iR Q P,QUW IN MIIDRY 1'a Y4Y QLW'1 � F b NGw /-i'N 07 R:U�T IoN �$XIhTIF=1G GONG`7RU�T Io hF" -- ol� O n Flew ver,FY M 1 III I I r 1..��- IRST_ Fl:obs2 PLs�N I I I cn � Vie L� m� FHy w rW' U j I 1 i a'.6 ,c I r N s i I 15 M�y ezol 9 Jun 4 i i I j 1 ft"o Ve�'IPY EkI S'fINU G6rl'+TKIX+TI o.I I Q { U i � I, I A2 3 ° ' o I•y p w V R % W L L L�m V w Gm .. ... ¢m r. rW kV �r1 I .. .. - I. 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II j .. � : � '_,__ ____ _ PSGMEnIT?V•t� V—5EE B i tN FoR FPonrkr a I , � 0 FcXKi T7NGI R-FS OWCi � � � PSI'AGO AOU�11o^I :1';'b•f.v, - m, iN cW d F �0 CIm"O.C, V O . P�h Gf11nNFit—�-\ � ,O V . I Ruor SMInXaLNa OJE{t � - i ICEvnM HEHKMNE. a ez— ovrlc Uo u;rr*5 F 6E;t?Fat1.3f, - May y 20 14 16„0,o i I'{ - roiR!P�Y✓crN I 9 Jane 2014 t h�F.LVW AI 2xp'9 %ELnU . PRW iMyt Y-K 96 WNI.�I 62�O.o, KI�E£WPU. � _ I s v IPL wti�o.d r 4xi's � i 'a ITc L. R' M1 r � � •/�x�ti� JFc i I w ��, —... _._.. _ u. fl t_..i ..�.—_ FPeEMLN1 CFJNYy ff -__ w �fys f/sE%E .. HProx Ex15i•4fIN15:11 � _ - � G1U`� _ Ca HIL YIPaC 0P�'RIE,c�-_ - - U�AIG,POOYI N •.__. nP�Emexr rapt - - A. I GROSS �7 TON � a.s li s Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Old Farm Lane Property Address . Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, 1 use only the tab 1. Inspector: I �� key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. C y e Enterprises �y Company Name 153 Commercial St. Company Address f Mashpee Ma 02649 City/Town State Zip Code 508-477-8877 SI 4522 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 16.340 of Title 5(310 CMR 15.000).The system: rz ®�Passes ❑ Conditionally Passes ❑ Fails 01 Needs Further Evaluation by the Local Approving Authority CM 11/15/2012 C3 Inspectors Signature Date b Th E stem inspector shall submit a copy of this inspection report to the Approving Authority(Board -- of ealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Su rtace Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Old Farm Lane M Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 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: The dwelling located at 79 Old Farm Lane is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 1000 gallon precast leach pits. The system was found to be in good working condition at the time of inspection. 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 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 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•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 M 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 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 ❑ ® 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 '/z day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Old Farm Lane M Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 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): 4 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes E 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 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 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. City/Town 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 Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): r Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 2.5 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: 1500 gallons Sludge depth: 6" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 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 3' Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be soon and again every 2 years for proper maintenance. Outlet baffle was intact and in good condition. Water level was even with outlet invert, tank was not leaking and was structurally sound. Risers should be installed at the covers to make access easier. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Old Farm Lane M Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 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 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.): Distribution box was video inspected and found to be in good condition. Water level was even with both outlets. 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: t5ins•11/10 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 ^M 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2x1000 gallons ❑ 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.): The system consists of 2 precast leaching pits. One pit has a riser and cover to grade, this pit was found to be dry with no visible stain line within 3' of the inlet pipe. The other pit was video inspected through the distribution box and also found dry with no sign of past hydraulic overloading. 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I mc) -r�� 2 -r 33'(. 1-7 A-L 310 5 9-L zs ` o4 _ 4 1Y-7 (.c^u c Q r�s A-q 5-Y N 3 t5ins•11l10 Tide 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 page. Cityrrown 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: 40' ( at system location) feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Dwelling overlooks Wequaquet Lake. The location of the property where the system is located is elevated considerably compared to the water surface. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Old Farm Lane Property Address Kathleen Armstrong Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2012 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 l _J.. "d- Farm Road PROPERTY ADDRESS: 7�9 01 Centerville ,Mass . / 02632 On the above date, 1 Inspected the septic system at the above address. This system consists of the following: 1 . 1--1500 gallon septic tank. 2. 1-Distribution box. 3 . Z-100.0 gallon leaching pits . Based on my Ins action, I certify the following conditions: RECEIVED 1 . This is a -title five se;)tic system. ( 78 ' Code ) JUN 2. The . septic system is irr proper working 7 1996 o'rde.r `at the present time . HEALTHr--• $T. 3 Nq repairs needed at the present time . 70`�`"^d E_.,� -r LE SIGNATURE: Name:—J. P.Macomber Jr... ----- ,--------------- Company; J. P.Macomber & Son- 'Inc ----------------- ---- Address:_ _��,______,�___,__ __Cente�rvill.e LMass__0.2632 Phone:---5Q875n3338__-•-THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY � III JOSEPH P. MACOMBER & SON,. INC. Tanks-Csupools-Leachflelds Pumpsd & Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 U 1 commonwealth of Massachusetts Executive office of Environmental Affairs Department of Environmental Protection WUllam F.Weld Trudy Coxq 8-aotary Govemof David B.Struhs ArQ•o Paul Uluccl coffvr"4o«,.f u.Gowmof • SUBSURFACI:,S).WAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddresa. 79 Old Farm Road Centerville ,Mass Add,ressofowner,P. Suneby Date of Inspootlon: 5/3 1 /9 6 (If different) 16 Glenbrook Road Name of Inspector: Joseph P. Macomber Jr . Wellesley,Mass . 02181 Company Name,Address and Telephone Number. J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fads Date: Inspector's 9lgtrature: � � � The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 ll apartment of Environmental Protection. The original should be sent to the system owner and c,pies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15,303. Any failure criteria not evaluated are indicated below, BI SYSTEM CONDITIONALLY PASSES: 1*V?6 One or more system components aocA to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If'not determined",explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfrltration,-or tank failure is imrt. ent. The system will pass inspo,:tion if the existing septic tank is replaced with a Foaforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One W1nUr SV•et 9 o 556-1049 • Telephone (617) 292.5500 ) Boston, Masaschu wtts 02108 FAX (617 •� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) PropertyAddresa:79 Old Farm Road Centerville ,Mass . Owner. P. Suneby Date of Inspection: 5/31 B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or huh static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): . broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /E)? Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT`. aLQ Cesspool or privy is within 50 feet of a surface water /9-14 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. '? The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 9) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: 79 Old Farm Road Centerville ,Mass . Owner. P. Suneby Date of Inspeotion: 5/3 1 /9 6 D] SYSTEM FAILS: • I have determined that the system violate,one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. / Backup of sewage into facility or system component due w an 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 ees&p94is less than 6"below invert or available volume is less than 1/2 day flow. �-C Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tunes pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy vs within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. kt" Any portion of a cesspool or privy is within 50 feet of a private water supply well. �u Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large sysu:ms in addition to the criteria above: f The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following condition, exist: the system is within 400 feet of a surface drinking water supply Al' the system is within 200 feet of a tributary to a surface drinking water supply l�9 the system is located iu a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shaL bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE: SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddresa: 79 Old Farm Road Centerville ,Mass . Owner. P. Suneby Date of Inspootion: 5/3 1 /9 6 Check if the following have been done: ,••4-1?umping information was requestw,i of the e Winer, occupant, and Board of Health. None of the system components have b:. n pwnpcd for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not txen introduced into the system recently or as part of this inspection. built plans have been obtained and esammed. Note if they are not available with N/A. The facility or dwelling was inspectud for signs of&ewagv back-up. /he system does not receive nou-sanitary or industr-izd waste flow ZThe site was inspected for signs of brvakwut , All system components,� , A te eludute the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 2The size and location of the Soil Absorption System on the site has been determined based On existing information or approximated by non-intrusive methods. ZThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Su))- Sur"Disposal System. (revised 11/03/95) ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 79 Old Farm Road Centerville ,Mass . Owner: P. Suneby Date of Inspection: 5/31 /9 6 FLOW CONDITIONS RESIDENTIAL 1 Design flow:�/ ops Number of bedrooms: Y Number of current residents: Garbage grinder(yes or no):� �} Laundry connected to m (yes or no): Seasonal use (yes or no): J Water meter readings, if available:44�/ -.`J! Cc� % f/? = /✓� ✓�, i -'� ��-� �/A Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: K h Design flow: /1;'1f gallons/day Grease trap present: (yes or no)/lr 14 Industrial Waste Holding Tank present: (yes or no). Non-sanitary waste discharged to the Title 5 systea-,: �y8s ur 11o)Ak4 Water meter readings, if available: Ai 19 Last date of occupancy: k1 -- — OTHER: (Describe) _ Last date of occupancy: GENF:ILU,, INFORMATION PUMPING RECORDS and sour e of t rornuitiG::; System pumped as part of inspection: (yes or nu;;Gi If yea, volume pumped: ) or.s Reason for pumping: TYPE OF SYSTEM _ 1,,"' Septic tank/distribution box/soil absorption system Single cesspool /' - Overflow cesspool —X",It,�— Privy Shared system (yes or no) (if yes, uttzen previotu uu,.ection records, if any) Other(explain) -- _ ROXIi ,TE AGE of all componenu, date inst"&a (if lmown) and source of information: A `, Sewage odors detected when arriving at the site: iyuz or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 79 Old Farm Road Centerville ,Mass . Owner: P. Suneby Date of Inspection: 5/31 /96 SEPTIC TANK: I`/R11i1 AV, I� (locate on site plan) V Depth below grade: Material of construction: zoncrete _metal _FRP ._other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:.% Scum thickness:_ _Cl— Distance from top of scum to top of outlet tee or baffle: ) Distance from bottom of scum to bottom of outlet tee or baffle.- Cj Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle, depth of liquid !Pvel in relation to outlet invert, structural integrity, evidence of leakage. etc.) GREASE TRAP.A,40A;&_ (locate on site pian) Depth below grade:( Material of constrnrtion;4..oncrete _metal _FRP _other(explain) A1 A Dimensions_ Scum thickness. iN Distance from top ut scum to top of outlet tee or bah;e:_(1r1 Distance from bottom of prom i- bottom of outlet tee or bafue k'l% Comments: (recommendation for pumping, condi—n. of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity evidence of leakage, etc. f � -P �^t12:�^t'xr! �� •s 5� (revised 8/15/95) 6 v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) PropertyAddreaw 79 Old Farm Road Centerville ,Mass . Owner. P. Suneby Date of Inspection: 5/31 /9 6 TIGHT OR HOLDING TANK&/,( . (locate on site plan) ' Depth below grade: Material of construction:11,20oncrete_metal_FRP _other(explain) Dimensions: Capacity: �i�ons/day as Design flow: Alarm level: kh Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: c, Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out if box, etc.) Distribution box is level with equal flow;No evidence of solids carry over ;No evidence of leakage in or out of the box No repairs needed a, i a time - PUMP CHAMBER.-XAP"e_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 S1ISTENI INFORMATION (oontinuod) �� ) ProportyAddroaa: 79 Old Farm Road Centerville ,Mass . owner. P. Suneby Data of lwpeotion: 5/31 /9 b 901E ABSORPTION SYSTEM (SAS): (locate on site plan, if Possible; excavation not rvquu� but uwy t e upproYin'"tod by non•intrwi,a i.uethods) If not determined to be prosent, explaiii: Type: leaching pits, number: leaching chambers, number: n leaching galleries, numher:_ _ leaching trenches, number,length: e..'� leaching fields, number, dimensioiis:__L __ overflow cesspool, number: Co-menu: (note condition of soil, ¢imu i hydr.utlic fajiun, ;,ri of ;vending, condition of vegvta(ioa,etc.) Soil;Loamy sand to sand & gravel to fine sand.a .o signs of hydraulic failure or bonding. Both 1 eachi n g_pi tS :qrP dr. c_.. G normal No rppgirc npedPl at_the present iima,r- CESSPo0Ls:Z (locate on site plan) Number and configuration: — Depth-top of liquid to inlet invert:_A X Depth of solids layer: — Depth of scum layer: Dimensions of cesspool: %1 .----._...._.. Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of uwpc,:tion)_�/� _-- Comments: (note condition of soil, signs of hydraulic f"um, level of ponding, condition of vegetation. etc.) PRIVY: i�'�. (locate on site plan) Materials of construction: � —.._Dimensions: Depth of solids:,,'/4 Comments: (note condition of soil, signs of hydraulic failure, level of poading, condition of vegotat-ii:A etc.) (revised 11/03/95) b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Add.. 79 Old Farm Road Centerville ,Mass . Omer P. Suneby Date of Inspootion: 5/31 /9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: ' include ties to at leant two permanent refemnceu landnuir" or benchn3arks locate all wells within 100' Centerville Osterville Marstons Mills Water Company 428-6691 53 �Kt\ I-1,5ao t �-� jot zi A7- V ;:. - .........--- --- — .. J DEPTH TO GROUNDWATER Depth to poundwater.2 I + feet tuet.hod of determination or approximation: Installed new septic system 9/7/9 4 Zr) Wntpr Pnnount.Pred at 141 . See page (revised 11/03/915) y A6 -Z// THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q TOWN OF BARNSTABLE 3linpniial Nnrkii Tomitrnrtian Vantit Permission is hereby granted...J . P.Macomber Jr . .. to Construct ( )) or Repair (XX) an Individual Sewage Disposal System at No....7g...Old...Farm.._Ro.ad.... en.t_e.r.vil_le_.._____..._ Street as shown on the application for Disposal \Yorks Construction Permit No.. - I Z Dated...... ........... ......................................:'� , .i ..•. ...................................... �i c uo�ii� c DATE. 1...". ..-........... ..7................................ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -� TOWN OF BARNSTABLE Gor'tifirMte of ('����TT omplian e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired �CXX ) by ....J . P .Macomber Jr . ............................................................................................ 79 Old Farm Road Centerville at ...................................................................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...`�L/..-...5./... ............ dared ............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ......................-_ �� =..::.......�.'�:-v.:.J...l . iL �': .Inspector ...... :...:.. t. .. V i THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the q qualifica tions ualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the "or, •ion of Water Pollution Control -w aN OF Barnstable BOARD OF HEALTH SUBS011FACF SFHAGE DISIUSAI, SYSTEM INSPECTION FORM - PART D .- CERTIFICATION -TYPE OR PRINT CI,EAnL)'- PROPERTY INSPECTED STREET ADDRESS 79 Old Farm Road Centerville ,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER ' s NAME P. Suneby 11111el' V - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Tour or City State LIPP COMPANY rELEPHONL ( 508 ) 775 - 3338 FAX ( 508 ) 790 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding Upgrade , maintenance , and repair are consistent With Illy training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : XXXY_= System PASSED The inspection which I have conducted has not found any information which indicates Lhut-. the sYstell, fails to adequately protect public health or the environment pis defined in 310 CHR 15 . 303 , Any failure criteria not evaluatc-d are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I hsive COMILICted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . ol Inspector Signature Date 6/4/96 11 E) copy of this Cert.ification must be provided to the OWNER, the BUYER where applicable ) and thc 130AIZE) 0jr I I EA LTJ I If the inspection FAILED . the owner or operator shall upgrade the system within one pear or the tjcjtc- of the inspection , unless allowed Or required otherwise as Provided in 310 CHR 15 , 305 . t , No.._. .. �- Fxs......$....30:.00 ._ �..... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 3 1y Appliratinn for Uhripitial Workr, Towitrnrtiun Urrmit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 79 Old Farm Road Centerville ...............•----------•--........................-------•-•-•--------------.........---------- -•----•----------------------•-----------._.....--•---------•-•-------------.....----------------- Location-Address or Lot No. Thomas Wetmore ......................_.......................................---------------------------•--•--- •--•-------•-----------•-----------------•---•------•---------------..........----------......--- Owner Address J...P._Macomb-er...Jr------------------------------------------------------- ------------------------------•--•----•---------------------------------------•---•--------•------ Installer Address U Type of Building Size Lot............................Sq. feet DwellingX— No. of Bedrooms._--_•_-_____4----------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons-.----_...__-____:-____._.-- Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ _ _ ------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter---.------------ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- ----------------------------------------------•------------------ Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.--._.-._-_____-_----- Li, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ pi ------------------------•------------••-------------------•--------•••-----•-•--•------------------•......................................................... 0 Description of Soil........................................................................................................................................................................ x Sand & Gravel V ----------------------------------------------------------------------------------------------------------------------------•-•------...---------------------------------•-••---......------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---- U Nature of Repairs or Alterations—Answer when applicable._..-.-------.9mi_t----cessp.Q.Qls......1.na. al.L................ 1-1500 gallon_. tanKI-distribution box- 2-1000 gallon leach pits packed Agreement: in stone. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n i ued by the boar of h lth. Si ne .... . .. .......$ -31 9 4 g /....,�%'/..'... .. ........... ................... / e� Application Approved B -... ,..-4.c.f.... pP pP Y - .... ..... `T ..� ................---------------...............---.........---------- Daze Application Disapproved for the following reasons- ----------------------- ---- --------------------------------------------------------------------------------------------------- ...... ........ ..................... . ............... ........................ .............. .............-- - - - ..... ........................................ Permit No. ...- ....... �... - Issued -------------------------------------------------------- to. Dace FEB......$....3 0..0 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ►� ; ( 6 a y Appliratiuit for Uiupuml Work,i Tomitrnrtiun jlrrmit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 79 Old Farm Road Centerville ...............•------•-------•--•-••--•--...---.....---•--•----•-•-•------•-•.....•••---•-_---•-- -•------•--•-----------------------•-•----....•--•----••••....•••-••-•••--•........-•-•--......... Thomas Wetmore Location-Address or Lot No. Owner Address J.-P.-Macam.-lhex:...LT.r.a.................................................... .................................................... Installer Address UType of Building Size Lot............................Sq. feet Dwellings No. of Bedrooms.............d-_-_-_.__._------__---_----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. t WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................ 04 --••........................•---•-•-•••---•-----•••••••••--••-•-----••......•---•--•----•--•••.••-_._.......-----------•---•-----....... . 0 Description of Soil----------------------•--------•----••--•---••------------•----...-•----•------•--------•--------------•......---------....-----------------------•-••............-•-•- x Sand & Gravel U -•--••-•--••••--•--•-------------•---•-•-••-•-•--•--•-•••-•••--••-••-••-••-----•-•-•--------•-----••--•-•-•-•--•-•••---••-•-•--••-----•----••----•--....•-•--•---•--••-••---••----------•--•-•--------•- W UNature of Repairs or Alterations—Answer when applicable--------------QMi-t---- esspools.•-•:Install................. 1-1500 gallon_ tankl-distribution box 2-1000 gallon leach pits packed Agreement: in stone . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been,issued by the board of h Ith. Signed�ll.. 1,.. A-GK�1t _ .'... $./.$t../.9.4.......... Dace Application Approved By ............ 7?" A.<..�a ..-. .. .r1. ;-------- Date `.`.` ....................................................................... Dace Application Disapproved for the following reasons- --- ---------------------------------------------------------------------------------------------------------- ..................................................... .................................................. ... ......... .......................................... ........ .... . .. .................................. Dace Permit No. ...... ...- � �...a------------------ Issued Date 1 Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ItTe>r#iftra e of C�umplianve THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX ) by J.P.Macomber Jr. ...... .......... . ...... ............. ................ ._....... .....................---------........................................................ 79 Old Farm Road Centerville Installer at ---------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ._ L1.-_. ./...a- dated "-..... ------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �/ DATE...... ...... :---- -�-�' - - - Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE.....�.__3 0•:0 0 Dispnuttl Workii Tuna# r#iun Vamit J.P.Macomber Jr. ': r Permission is hereby granted................. ..... . ................................................. to Cons t ct (( ) or Repair XX) an Individual Sewage Disposal�System at N o... /l3 Ola Fa-rm Rod Cent e ,v le •� +" Street`";'. yye4' :'.. CC as shown on the application for Disposal Works Construction Permit;No...!. -.1 Z._ Dated.......q..-. .-..q o ,•....+ ..........................S _ - ------------------------------------------------- r, j� ^' -•' t ' Boara f Health DATE........... "------.... l�-............................... = . � . . . FORM 36508 HOBBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION 7 9 --,4IfM SEWAGE VILLAGE C e.✓fPR V!//e ASSESSOR'S MAP & LOT2 3 INSTALLER'S NAME & PHONE NO. /" /m i4 C am, /S e Oy SEPTIC TANK CAPACITY /- SD o LEACHING FACILITY:(type) /�/T (size) O D d NO. OF BEDROOMS- t-y PRIVATE WELL OR PUBLIC WATER bVfEOENR OR OWNER DATE PERMIT ISSUED: 6 l .�- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No � r Oki �J g0 I