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HomeMy WebLinkAbout0111 OLD POST ROAD (CENT.) - Health (2) 111 OLD POST RD., CENTERVILLE A=209.063.004 IIII �QEEVClFp�p J 2�, O _x llll UPC 12543 No. °pncoNS� HASTINGS. MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 111 Old Post Road Property Address Ed Leslie Owner Owner's Name informarequired ion is Centerville MA 02632 4-9-14 required for every - -- page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. ImportarK:When A. General Information tnt ng out forms o the computer, ��OF use only the tab 1. In Or: I •� 9�' �� key to move your `off- yG cursor-do not James D.Sears = JAMES m use the return Name of Inspector s v: key. :# CapewideEnterprises,LLC Company Name :,��� •.,• Tif, •�� ``�: 153 Commercial Street Company Address » Mashpee _ MA 02649 Cap town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 J310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority � � � 4-9-14 -- pectoes 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. tSf13 3I13 Tile 5 OfAdel Inspection Far:Subsurface Sewage Disposal System•Page t of'7 Apr-11 14 08:34p p.2 ,a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lull 111 Old Post Road Property Address Ed Leslis _ Owner Owners Name informations Centerville MA 02632 4-9-14 required for every • — page. City/Town 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: 13) 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): tNns 3n3 Tile 6 OAidal Inspection Fom SVbw lace Sewage Disposal System-Pago 2 d 17 Apr 11 14 08:35p p.3 1 a Commonwealth of Massachusetts Title 5 official Inspection Form �+ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road _ Property Address Ed Leslis Owner Owners Name information is Centerville MA 02632 4-9-14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational_ System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are'replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool.or privy is within 50 feet of a surface water ❑ Cesspool or.privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ms-3/13 Title 5 Official Inspection r-arm:Subsurface Swags Disposal System•Page 3 of 17 i Apr 11 14 08:35p p,4 r Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Oki Post Road Property Address Ed Leslis Owner Owner's Name information is Centerville MA 02632 4-9-14 required for every 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 ❑ Z 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 magaM Is less than 6" below invert or available volume is less than Y2 day flow.Z 6: tSlns 3l13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 at V Apr 11 14 08:35p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road Property Address Ed Lesfis Owner Owner's Name __.....__—. information is required for every Centerville MA 02632 4-9-14 page. City/Town 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 ilow of 2000gpd- 10,000gpd_ E] ® 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. 15ins;3113 Title 5 Official Inspection Fonn:SubsLafaoe Sewage Disposal System•Page 5 of 17 Apr 11 14 08:36p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road Property Address Ed Leslis Owner Owner's Name information is Centerville MA 02632 4-9-14 required for every Cityrrown page. 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? El ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available 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)1310 CMR 15.302(5)1 D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual). 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 I t5 ns•3/S3 Title 5 0mcial inspection Form:Subsurface Sewaga Disposal System-Page 8 of 17 I Apr 11 14 08:36p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road Property Address Ed Leslis Owner Owner's Name information is MA 02632 4-9-14 required for every Centerville page. CityrTown State Zip Code date of Inspection D. System Information Description: The system is a 1500 Gal Tank D Box four infiltratrors. 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2012-4,000GaI's g ( y g (gP ��' 2013-1,000GaI's Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.R., 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: 15ins•3113 Title 5 Ofrdal hspedlon Fong SLbsurface Sewage Disposal System•fege 7 of 17 Apr 11 14 08:36p p.8 { Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments UV 111 Old Post Road Property Address Ed Leslis Owner Owner's Flame information is Centerville MA 02632 4-9-14 required for every ......... page. . City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: 2008 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/Altemative 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): Elm•3n 3 - - Tilla 5 Official Inspe:ion Form:Subsurface Sewage Disposal System•Page 8 of 17 Apr 11 14 08:37p p.9 t Commonwealth of Massachusetts 9'a _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road -- Property Address Ed Leslis Owner Owner's Name information is MA 02632 4-9-14 required for every Centerville 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: 1998 Permit # 97 - 677 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan)` 3' Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): 22" Depth below grade: feet Material of construction: ® concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast 3„ Sludge depth: t5in6•3113 We 5 Official Ilspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Apr 11 14 08:37p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments - r5 J` I I 1 Old Post Road Property Address Ed Leslis Owner Owner's Flame information is Centerville MA 02632 4-9-'14 required for every _-_ page. cityrrown 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 27" 011 Scum thickness Distance from top of scum to top of outlet tee or baffle W Distance from bottom of scum'to bottom of outlet tee or baffle 1 S" Asbuilt-Tape How were dimensions determined? Sludge-Judge 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 at working level. Tank and covers at 22"below grade. In and outlet tees. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feel 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,•3113 Title 6 Oflic'el Inspection Form:Subsurface Swyag9 Disposal System•?age 10 of 17 Apr 11 14 08:37p p.11 Commonwealth of Massachusetts Title 5 Official l.nspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road Property Address Ed Leslis Owner Owner's Name iiore is dequired for every Centerville MA 02632 4-9-14 -- — page City/Town 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 Wns•3113 Title 5 Offical Inspecticn Form:Subsurface Seivage Disposal System-Page 11 d 17 Apr 11 14 08:38p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road Property Address Ed Lesiis _ Owner Owner's Name information is required for every Centerville MA 02632 4-9-14 •- page. CityrTown 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 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.): D Box is clean and solid. Camera out to box. D Box is 5' below grade. Did not open box. _ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* i Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Min•31i 3 Title 5 Official Irepeclim Form:Suoswfaw Sewage Disposal System•Page 12 o`17 Apr 11 14 08:38p p.13 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road _ Property Address Ed Leslis Owner Owner's Name information is MA 02632 4-9-14 required for every Centerville - page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ® leaching chambers number. 4 — ❑ leaching galleries number. Cl leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is four infiltrators 10'x30'x2'. Ck leaching at inspection port dry and clean. No sign of over loading or solid carry over. 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 tSris•3113 Title 5 Orficial Inspection Form:Suosurface sewage Dispose,System•Page 13 of 17 Apr 11 14 08:38p p.14 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road Property Address Ed Leslis Owner Owner's Name information is for every required Centerville MA 02632 4-9-14 -- page. CitylTown 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•W1 3 Trta 5 Office Inspackn Farm Subsurface Saaiage D#essl System•?age 14 0!17 f Apr 11 14 08:39p p.15 ply , Commonwealth of Massachusetts Title 5 Official Inspection Form a. Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 111 Old Post Road Property Address Ed Leslis Owner Owner's Name informationis required for every Centerville MA 02632 4-9-14 page. City/Town State Zip Code Date of Inspedion 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 e_3 ,Sv REAR ' _D £CK To C -�f,s3 -G ,v 151ns,.3n 3 - - Title 5 OlNdal Inspection Form:Subsurface Savage Disposal System-Page IS of 17 r f Apr 11 14 08:39p p.16 ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Old Post Road Property Address Ed Leslis Owner Owner's Name information is required for every Centerville MA 02632 4-9-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar Q Shallow wells N Estimated depth to jigh ground water. 10' 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. 7-23-96 Date ❑ Observed site (abutting propertylobservation 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: Th. on design plan 7-23-96 no G.W. at 10'. Before filing this Inspection Report,please see Report Completeness Checklist on next page. 151n5-3113 Title 5 Official Inspecilon Form:Subsurface Sewage Disposal Systern-Puge to o1 17 Apr 11 14 08:39p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Old Post Road Property Address Ed Lestis_ Owner Owner's Name information is Centerville MA 02632 4-9-14 required far every page. Cityrrown state Zqp 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 i 151ns•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal system•Page 17 of 17 s i ,] T Commonwealth of Massachusetts W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a �f o 111 Old Post Rd. 4 G„M Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name VQ P.O.Box 763 Company Address Centerville Ma. 02632 Cityrrown State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/24/2008 Inspector's Sign ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use, at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 111 Old Post Rd..doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. City/Town 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 septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed I I I Old Post RdAoc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank•and soil absorption system (SAS) and the SAS is within I 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. . 111 Old Post Rd..doc•03/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ® or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less El ® than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 111 Old Post Rd..doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ry �M 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No . ❑ ® Any portion of a cesspool or'privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 t system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 111 Old Post Rd..doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of'construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 111 Old Post Rd..doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 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? E .Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:129,000 g ( y g (gp ))' 2007:65,000 Sump pump? ❑ Yes ® No Last date of occupancy: 4/24/2008Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): I I I Old Post Rd..doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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 r n if s attach previous inspection records if an Shared system es o o e ❑ Y (Y ) ( yes, P p Y) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1998 s Were sewage odors detected when arriving at the site? ❑ Yes ® No 111 Old Post Rd..doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma.. 02632 4/24/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 15" feet Material of construction: ❑ cast iron 2140 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through Infiltrators Septic Tank(locate on site plan): Depth below grade: 16"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 6" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 26" 311 Scum thickness Distance from top of scum to top of outlet tee or baffle 6" ' 12 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured 111 Old Post Rd..doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every 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.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to bestructurally sound. Grease Trap(locate on site plan): Depth below grade: feet . Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): . Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 111 Old Post Rd..doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is level.Box has one outlet lateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No f Alarms in working order: ❑ Yes ❑ No I 111 Old Post Rd..doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I I I Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS).(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4-Infiltrators ❑ 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.): a L 1 {•`. Sandy dry soil.No signs of hydraulic failure.There was 2"of water in infiltrators at time of inspection. t .. t . 111 Old Post Rd..doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 111 Old Post Rd..doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G7 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 00 7 Ja� 1f� z 111 Old Post Rd..doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Old Post Rd. Property Address Ed Leslie Owner Owner's Name information is required for Centerville Ma. 02632 4/24/2008 every 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: Bottom of leaching 25' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 1998 If checked, date of design plan reviewed: Date Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As.Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2annual ranges of groundwater elevations. 111 Old Post Rd..doc•03/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 15 THE Town of Barnstable �p Tp� - �'' " Regulatory Services Thomas F. Geiler'Director • BARNSrABIA Muss. .. g Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. No. 07 7 0 »...... ., Fee �c THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for �Xgpo5al *pgtem Construction permit Application for a Permit to Con tact( i Repair( )Upgrade( )Abando ( ) O Complete System 0 Individual Components Lv �s ✓1'u-� Location Address or Lot No. 1/ Q P�5T R A Owner's Name,Address and Tel.No. CXNT£2V1 i Assessor's Map/Parcel a 0 9/O L 3 , G O Y 864E T U57 Installer's Name,Address,and Tel.No. �/ Designer's Name,Address and Tel.No. b0R7oLL 6771 - 771- q3 9q 4AT 9i31 Type of Building: Dwelling No.of Bedrooms Lot Size 161 720 sq.ft. Garbage Grinder(/ 4 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3349 gallons per day. Calculated daily flow 6 6 gallons. Plan Date Number of sheets ©;Z Revision Date /f W Title Size of Septic Tank l Type of S.A.S. Description of Soil I)A &P, 4=.� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmen al Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is Bo d-raf Healt Signed Date 1/ f Application Approved by Date Application Disapproved for the following reasons Permit No. 7—6 1`I Date Issued 7 .., .' •+ v _ ` !'Y -..-....., + � � .fir�'. � F ' No. ( 7— Ci-7 y .- � t. Fee / a� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: e Yes PUBLIC HEALTH DIVISION -TOWN OF'BARNSTABLES MASSACHUSETTS 01pplication for dig ogal * stem Construction Permit Application for a Permit Co struct( ✓)Repair( )Upgrade( )Abgndo ( ) El Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. �gCG`rNT IZV/ 1,46 � y�,�. Assessor's Map/Parcel 0.9f/U 0 0 y �^.�r� ` ' �. ll�•' 1� L/-t (JKj Installer's Name,Address,and Tel.No. �, Designer's Name,Address and Tel.No. -` P30270LZ_0 7T / - 77/- q3 rq qAF_- 9/3 Type of BMilding ,_/ 7 ` -—DW-blling�^-- No.of Bedrooms Lot Size /be 70�0 sq.ft. Garbage Grinder(IUG} Other Type of BuildingiZh FED &kA- No. of Persons Showers( ) Cafeteria( ) Other Fixtures s Design Flow 3 3U gallons per day. Calculated daily flow 6 6 o gallons. Plan Date / l� Number of sheets vA Revision Date 11120 q7 Title ¢ P Size of Septic Tank /S Type of S.A.S. Description of Soil 4-,04 A Nature of Repairs or Alterations(Answer when applicable) A Date last inspected: •. j Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issue this B ar. f Healt Signed Date Application Approved b e, Date /�Z Application Disapproved for the following reasons Permit No. 2 7-6 7'7 Date Issued l/- 2�e THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded( ) Abandoned( )b 'g Q R 7644-0771 i at 67b PO 5T Ab. C-F-V 7F-R V l LC Fr has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 r"77 dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector NJ'7""677 --------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'Wi!gpOal *pftem Construction Permit Permission is hereby granted to Construct(✓)R-•epair( )Upgrade( )Abandon( ) System located at �� 042) PG ST K.D. CFN764 V I L.1•-0 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this ermit.�-+ J J ' Date: �/ �� g 7 Approved by� " �uFE� OF 2 -5Iw6LE FAMIL`{ 3 43EDR.oI tE PLA I•l- OtJ BAGK. uE do GAVP3A4-,-- Grz11.r17 E$. G Ent T'E►��i t,L� 17AIL-y P.ow = -, x 110 �oT l ol� po-Srr fib. S�T1G TAN - 53o x?OO uS� 1500 GAL• t.�Ac4� c,1G 5'YSTr= t P"" v 2' Trzewz t5S --F •4rTUGATIOF•J A E-A 2�GPD. -- — ---- T — — --- — d 33a GPD 4 11,14 /5F =444 5f ApuGx-roN A¢� ��51bti1 511;EwALL AAA= (p 0',1 2vc'L= 24�0 IF t)eFAI L of LE"IWI TrZW,4 IoTAj- AMA s 4-130 IF i,oil �� ~• 3• M.6JC• , PEZ1 -oLATlOW sradr. 9TEPHE,N ' �tIp1ARL# ALLYN — A WILSON bs �?O� -' -ION Or I cg 9AXTER No.30216 `'Wl 11 T jig/97 F4-- 101 TA-Ho ry 3d / A sa>b{ Loa,, s IM '�- - - ��, so 1Nv : l07 LOAM A#6 L 1u4 '1tzE►�c►-�1 'u� ' oaf log. t oa.•8 z �,. lot, to, fVK 5�1'IG , G� GoA�E �'7►►� , SpuD T 9d, 'PENS FtUc-- Na ►�' E�= a CECIRGD ROT P.At l do waTE2 J-ctG4Tloll GeuTerz-v1t_LE i(•2v 17 i�o Foss 1 GF-zTi PY T- 4AZ- rH E �o v i�n a'�'I o►J S I loyvN PLA►J �Z> 1?E I�1GI✓- 4}rtz�vN �w1 Ft`15 w lTu 4E SI DELI hI AF J to K\ d- z;M-5AGK. 2QuIZEMG T OF 1116 TOV/N of MAP 70 pAP1�L G3 �- $04AU'Ma A►�1V l 5 1�rr l-G�G1�T W I T'�41 N A Sp6GJAL FLzCV ►iAZAzj:> Z01-4E. B/� 7Z NyE II.tG ,_ G /1 1��� LAI,1D Sll¢VE7'�S • �J�1�.16�¢S 4✓• w/1991 L 05TE2�/I Md55. OFF5ers-1 '"ZoM 15uILDl0&5 -is;00( D NOT g6. use "rt, 6S-ABcasy Pwopsa-ry FIT; AY41 M ROIOiNG Co 19 AAA Pas T Qo i \v. Tarmac •1 _ PaNsIoN i ,0 ffwn 3 �a TMIL . , c I N 7 ,ii, 14 �Or UWEu`ia I p Nl- 1 1 1av� t k ` In1 , I 100 41 �� \\ L STEPHEN BAXTERA. , ALLYN ' Vo 8101at i WILSON � No.30216 17 U~ 511�16LE FAMIt.`{ 3 F3EDRct✓vK r E ILA t.l oN BAGK u o GAa!UA`>= G¢Ia.tD r� G ErJ vl DAI PLOW = -1, x III =33D G� LvT 1 oI D poh•r fin. -5iGmc- 'iANL ' 33a x boo = G[oa ( - usa✓ ISoo GAL. 2 - 3a �c 4 � 2' '('a�n1c►4Es � -----f �----------- QTU CATION AMA 2G4P'D. -- - ---- - - - -- 33a GPD s a lh /5F = 4dG 5f AppUG1aTDN AVE D�516'� 51t;r-WA L- AtzFA= too',r Z�Z.= Z40 IF 'l�x---`4,1 L aT= LEA641VJ4 TOEX 4 #�OTTOM Al = 3D x d-x2= Z 4 0 9F 1= -TOTAL �, s kop 5F r,fl� �- -� MdJC pE.RCoLA7lOIJ �dT� �- S'�I��It•!Gi-1 Z. '�8-� sc'o� 4` SOIL UMY, OF 2 a/4-I'�z sTa�s .0 0f STEPHEN wy 404ARD ALLYN A. WIL"I py; � --;5c `1014 Ors c� EWEA '^ No.w@216 Vo 24048 � UAI) � t" •• Zv/97 r&=ll0 Fc-- 10� ( Tgv"o "i�ti' L-Iac.E- EL-,off �.�, —7r.�T �• �� �.. 17KG �"'� "� oa.•8 s LVXPA ZE►.IGI-1 io.'c lSofC ��0'� IoG. 1=.� s' tt.=.104 S�r�c G� COAR,E 't'AW- Sa uo T 9d' CE9111^GD PLOT PL.AM �l o u�aT>r2 1 DeG.&T I oW G e NT'Er2 v I t�E �zt'pv9E� l z:rZl l r-V T"NAT 1 4 E Gov IJ D aTl O►.1 5FAN pLQ{�1 [ N� I} vN co41PL`IS .WITu Tj- a SIr->F—U. A1> l '�-aIJ bA-Tttfl g,sclC. 2WUIV-r.M&krr OF Tl.(6 To k!N PF 201 pA L G 3 �- BQ�-►�'STA�!-� A► t) t 5 1�fJf" 1.1.�1�T�rJ W l T.4I N A 15A)4i L A Hys t I.1G ,I5Pc�4L Flszav �{AZ1�/t�z.� nzvNE/� LXNV 5L72VM CZ6 • =&'WGE74 ✓• 70,lq 4"� ��J�^�-r5� G 1�a.� 05TEe�/I�L& MAS�i• oFFSBT 1=VoM $VIl.D1Nly5 SNOtXJ.;' NOT 136. Q�uGANT: l>SP_D Tb Ch'i7�Bc.1s►.� PRopEa-ry LI►JES. $P-�SIDb �Jtc.�►NG � ��G ' �.'�aysl� BIJII.�IaG Co I►+c I'� 2On 4ov,zo,Igen A7 MAP Zol FCL G3-4- Pos T 1, _- _ L PANsior%l I 0 _ Tme i✓ �Q Z �Ca j c N I %0 _ 14 nl000, iID 000, lot x I too 4-71 (co Or iafCWlRt1 �\ \\ STEPHEN j BA TER ALLYN Vo 2�Ow �\. \ WILSON 'pF � it, MoiYir0216� WD /l ta�17 TOWN OF BARNSTABLE vqC ` ► LOCATION /// Ol✓ �ar f !'�'� SEWAGE # /2-• 6 7 7 VILLAGE h ASSESSOR'S MAP& LOT o _ -®ay INSTALLER'S NAME&PHONE NO. ,Q�w ��/�jf, tJ�dai j�i�rJ yr� 5►'"r1 SEPTIC TANK CAPACITY 4rao 6 L LEACHING FACILITY: (type) . 414601 A.1hp ��1� (size) 140�.0 f®'x2 NO.OF BEDROOMS 3 B DER R OWNER PERMITDATE: / y 7 COMPLIANCE DATE:_/ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility r 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 _ .I r I e hand !hf �,�, 00 BAXTER & NYE, Evc. Professional Land Surveyors and Civil Engineers 812 Main Street•Osterville, MA 02655 Tel. (508) 428-9131 Fax. (508)428-3750 WILLIAM C. NYE,R.P.L.S., President. STEPHEN A.WILSON, P.E.,Vice President-Engineering RICHARD A. BAXTER, R.P.L.S.,Vice President JOHN R. ELLIS, R.P.L.S. May 7, 1998 Mr. Jerry Dunning Town of Barnstable y Z Q ci — 0(0 3 0 0q Board of Health 367 Main Street Hyannis, Ma. 02601 .� Re: Lot 1 Old Post Road/Centerville Dear Jerry: We have plotted the installer ties for the septic system installed for Champion Builders at Lot 1 Old Post Road, Centerville. The system was installed by Bortolotti Construction Inc. on April 27, 1998. The ties show that the system is installed in accordance with the property line setback requirements of Title 5. Should you have any questions please call me at the office. Very truly yours, R �ey cand A. Baxter,, { L. . Vice President cc: Champion Builders RAB/slg MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS k 1 .. i. __� r � � hY I � I� t 'y i