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0441 OLD TOWN ROAD - Health
441 Old Town Road Centerville- A= 248-139 J -XFS �4EADh No.2-1 S3LOR UPC 12M ..a oon, • us&In uv Ir1�Y1�1Im11QIM ZLFI OFMSRMDWM LOCATION SEWAGE PERMIT NO. Ll ql ®L40 7^V vrlk//�/ l: o. VILLAGE A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Qp � _ __ IS r No..,0.2..'��� F$ ®.................... Ot THE COMMONWEALTH OF MASSACHUSETTS I3 BOAR® OF HEALTH ............OF...... '�90G ............................. Appliratiou for Disvuaa1 Workii Tontitrurtiou Frrutit Application is hereby made for a Permit to Construct ( ) or Repair A) an Individual Sewage Disposal System at: .....4.'..........oL,� • 1 �� � •Yis----•--- -•--------------•...----.............I...........- d ..........................•--- L i n-Address o t No. � A. a _ Owner AddressA*N._ ._G�......................... (S 1/J•F.....1. - / s�R!!L/fS ........ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) ~ Other—T e of Building No. of persons......Other fixtures Showers — Cafeteria f ----------•-•---------- ••-----------•-•-•---------- 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 ( ) aPercolation 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........................ MO ...............................................--•----•-•--------.......-------------•----......--......................................................... Descriptionof Soil-----•••.. ---•........................•-----......-----------•-------------------------------------------------------------•-----------------••----• x U ....--•-----------------------••-••----••-•-•--•-••••••••--------••••••-••-----•-•-•••----------•••-•...•••-•••-••---•..........---•---•--•-.......................................................... w U Nature of Repairs or Alterations—Answer when applicable _ItiS !"9 ______.._ q® ___._._ .......... 'mac_..--17 .. ... �/3®,t. "' ------ e � f®® Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TIT!L, 5 of the State Sanitary Code— The undersigned ees not p ace the system in operation until a Certificate of Compliance h en ' sxe by the b r i -- ------•.•-- - . D ApplicationApproved By........... •-••. ........................................................................ 11 v Date Application Disapproved for t f of wing reasons--------------------------------------------------------------------------------------------------------•---•••-- ......................................................... ....-----••----....-•••----•-•-....•-----•---•-----•---•••-•-••••......••---• ......--•--------••--••------- ............................... Date PermitNo.. ............................................ Issued........................................................ Date ��' ...-- THE COMMONWEALTH oF MAssxoHussrrs ������ ���� ���� HEALTH ����""" ~�� ��" ............X&v�3��...- .....OF 00hA1V��Z/.,0N&..... . I..................... � ��~. J��~ °l ��� ���4������� ��� �������� ������ ��witrurt0on PrruKt is �� made for u Permit to Construct ( ) or Repair ' ,�) anIndividualIndividualS�� Disposal � ^ ' System at: � .... .... ....-...............---'-'-'--'-----.......---'-------'- ----'-------------------'--'------r---��---'-' Location-Address X o,"" ' � ' Installer Address Type ofBuilding Size Lot............................Sq. feet Dwelling—No. of Bedrooms........��-----------_' ( ) Garbage Grinder ( ) 04 Other—Typeof Building ............................ No of persons......�/.................. Showers ( ) -- Cafeteria ( ) ^4 Other fixtures -..--.---__----..----.-_---...-----.-.--------------------_---------- Deu6sn Flow............................................guDoue per ycr000 per day. Iobd daily flow............................................gallons. Septic Tank—Liquid*capacity............guknm Length................ Width................ Diameter-----.. Depth................ Trench--No..................... Width.................... Total Length.................... Total leaching area-.----.----sq. f t. Seepage Pit No,----.--'' Diaozeter--_---' Depth below iolrc--.------- Total leaching area..................sq. {t. � Z Other Distribution box ( ) Dosing tank ) '- Percolation Test Ileoolto Performed by.......................................................................... Date........................................ Test P6 No. l................minutes per inch Depth of Test Pit---'-_..-- Depth coground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth toground water........................ - --_-_-_—.---'__._------------'-'-----'_--------_---_�-'-_-_-- 0 Description ofSoil._ -----------------------.----..---_--_---_-_------.----..-----'-_.. � _----'-'_--__-'''-__'--___-------'-----'----_-_-_--.------'-------.-----------------.-'----'----- ._-_-------.----_-._'__-_-_-.-_-__--_'--.--_---_-.._ U Nature of Repairs or Alterations—Answer when applicable lAt',ST 4 6 6�(2o....... .......... � -����/�-/.����»��-'~c�./'--'_-'.--'-_--_'____-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal the provisions of IZ��� �of the State Sanitary Code— The undersignedjurtlR�r a-r operation until a Certificate of Compliance haS1D_ en sued hy the b fl 1 11 0 V D. Date Application Disapproved for t 7o/ ing reasons:................................................................................................................ ------_------'---'---------v............................................................................................................................................... Date Permit '`� ' ' - r Date THE COMMONWEALTH OF,M;XSSACHUSETTS | _ BOAR / , " ---_. .......xSdA����1 THIS IS TO CERTIFY, That the Individual Sewage DiQosal S5-r'S'tem constructed or Repaired (X) has been installed in accordance with the provisions of TITLE 5 of The S ,;ate Sanitary Code as described in the ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU S A GUARANTEE THAT THE SYSTE���� `MULL ONOON SATISFACTORY. ' DATE..../�- k,2............................................ --_--_------------_--.-___________' ' - `- | THE COMMONWEALTH r ussrrs | BOARD OF . ---.���.���.�---'��F-'_ '-_-'-'-- ...............� Permission is hereby .................................................... � to Constructor Re Street as shown on the Construction -'- ----- FORM 1255 x600swWARREN. INC., pooLIs*cns \ � t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. Citylrown 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 Ion the computer, 'I• use only the tab 1. Inspector: key to move your p cursor-do not Jonathan L Stolnacke use the return Name of Inspector key. Nauset Septic Pumping Co. my Company Name P.O Box 114 or 15 Daniels Drive Company Address Wellfleet Ma 02667 Citylrown State Zip Code 508-349-7755 si13524 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluati by the Local Approving Authority 05-17-2012 I e or's tigMiure 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. I � t5ms•11/10 'IV.rm:Subsurface Sewage isposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. Citylrown 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: 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): Concrete t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. Cityrrown 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): r+¢ ❑ 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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. CitylTown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 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: 0. ❑ ® 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 , 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 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): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 A Commonwealth of Massachusetts o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 gallon tank, d-box, leach pit(6x6). All on file. 8x8 cesspool w/8x8 overflow conected Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 104,000.00 9 ( Y 9 (gP ))� Detail: Readings from Jul-Dec 2009,26000 gallons.Jan-Jun 2010 27000 Jul-Dec 2010,28000. Jan-Jun 2011,16000 gallons.Jul-Dec 2011,7000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: 01-15-2011 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 01-15-2011 Date Other(describe below): General Information Pumping Records: Source of information: B.O H. Pumped 9-30-2002 U-16-2007 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): cesspool w/over flow connected 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 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 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: Installed 11/21/83 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12 inchesfeet Material of construction: ❑ cast iron ®40 PVC ® other(explain): orangberg on cess/overflow system Distance from private water supply well or suction line. 100 plus feet Comments(on condition of joints, venting, evidence of leakage, etc.): All looks fine on T5 system. Orangeberg from house to 1"`pool &to overflow Septic Tank(locate on site plan): Depth below grade: 6 inchesfeet 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: 5 Sludge depth: t5ins•11/10 Title 5 Official Inspection Forth: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 < 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. City/Town 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 28 inches Scum thickness 0 inches-both ends Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle No scum How were dimensions determined? sight and tape measure 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 looks fine&very clean. Cesspool has tee going to overflow. Overflow has indications of only being 1/3 full in the past 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M r ' 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. Cityfrown 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.): All tees in place. Covers close to grade on T5 system.Both covers to grade on pools,tee in place leading to overflow. Overflow cesspool has only been full to 1/3 capacity in past based on staining on blocks 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.): v 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 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.): Box is level &working properly. Water level was at operating level prior to running water thru system. 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: Was located. t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: one ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: pool w/overflow on separate ❑ 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.): Vegitation over 36 inches presant in leach pit area. Vegetation in both cesspool areas over 36 inches Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2. cesspool connected to overflow cesspool. Both 8x8 Depth—top of liquid to inlet invert empty Depth of solids layer 0 Depth of scum layer 0 Dimensions of cesspool 8x8 Materials of construction cement block 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 M 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): House has two systems.Cesspool W/over flow pool for ground floor kitchen &bath as well as laundry hook up in basement.Title 5 for top floor&basement baths Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owners Name information is required for every Centerville Ma 02632 05-17-2012 page. CityrFown 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 O cas5 ��J1 t- 1, ry C3 � t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Assessing As-Built Cards Page 1 of 1 e-TZS LOCATION SEWAGE PERMIT NO. VILLAGE A'& B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, XA 02601 BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED I O ' I i i I i http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=248139&seq=1 3/11/2012 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 plus-on file 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: 05-07-2012 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Cert of occ& permit states tank&pit installed under T-5 requirements ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Cert of Occ on file 248/139 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 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l441 Old Town Road Property Address Tallman, Constance v C/O Stolnacke,Carol A- P.O.A Owner Owner's Name information is required for every Centerville Ma 02632 05-17-2012 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE BAR-W 3726 { ' Ordinance or Regulation •, I ! WARNING NOTICE A' Name of Offender/Manager (0 Address of Offender 41111 /)f MV/MB Reg.# . Village/State/Zipiar.� nwr` r.,. tl,24fi / Business Name };�!`i'� /CM/pm, on <'// i 209? Business Address A..,7 _A)��J 116 Si!"gnature of Enforcing Officer Village/State/Zip (� Location of Offense / / f POO.I/(- i)"r %4 /4, ' Enforcing/Ddpt/Division Offense- ,r rt�r «r,.nfr r" R)10 Facts "f l�fan rog rI", t d X� R�1 �. ,C ;fin fh'.+P1 014 A,/>1 e1r11''_1/'_ Jr •4-1 /Af1T tt ^J 4 .1.1 At, lJo.4 h0or• ,ddr This, will se rg e 6n1y a a warning/At this time' no legal action has- been taken. It is the goal of Town agencies to achieve voluntary compliance of Townes' Ordinances, Rules and Regulations. Education efforts and warning notices are ?p attempts to gain voluntary compliance. Subsequent violations will result in• appropriate legal action by the Town. 1SS',r WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. Jh /S . Health Complaints 26-Jun-03 Time: 1:05:00 PM Date: 5/29/2003 Complaint Number: 4061 Referred To: DAVID STANTON Taken By: KARYN DACE Complaint Type: CHAPTER II HOUSING Article X.Detail: ILLEGAL OPERATIONS Business Name: Number: 441 Street: Old Town Road Village: HYANNIS Assessors Map-Parcel: Health Complaints 26-Jun-03 SANITARY CODE. A WRITTEN WARNING WAS ISSUED TO THE LANDLORD IN PERSON AT THE END OF THE INSPECTION. THE LANDLORD ASKED HOW CAN SHE GET INTO UNIT IF HE CHANGED LOCKS. I TOLD HER TO MAKE AN EFFORT TO GET PERMISSION FROM THE TENANT TO MAKE THE APPROPRIATE REPAIRS. 6/2/03, CONSTANCE CALLED FROM (508) 775-5732 AND LEFT MESSAGE THAT MIKE PERRARA(508) 576-3433 TURNED OFF GAS DOING REPAIRS AND LEFT OFF BY ACCIDENT. DS CONFIRMED VIA PHONE CALL TO JOHN THAT THE GAS WAS BACK ON, AND HE SAID THAT IT WAS BACK ON. NO FURTHER ACTION REQUIRED AT THIS TIME. Investigation Date: 5/30/2003 Investigation Time: 10:30:00 AM 2 Assessor's ��:;ioe (1st floor); � Assess.�r,� m and lot number .. r� �` �l� ���� ��r���� ���� P�oFTNETo�♦. �.r. . Board of Health .(3rd floor); " `tAR � R + o� Sewage Permit. number ..............:� tU7 ,� Y���E® IN e'i®MPL'AN WITH TITLE S B99TABLE i 5 Bd Engineering. Department (3rd floor): /'� 9`o�P tA6�ME6NYAl. ®®F JA rb q House number :`:a...y..................... 'O 0 ✓c �;'f +��1f � ��� ��f`'� 0 Mai a� APPLICATIONS PROCESSED 8 30 9:30 A.M. •and, 1:00 .2:00 P.M..only; TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR';PERMIT TO TYPE OF CONSTRUCTION ... . !//.<.. EPL: . ................................................................................... . 19455.6. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location y� l41� T�`Lt �LD ..� Proposed Use .....ff .1.(,��?..�..........q,�v ................................................................................................. ZoningDistrict ........................................................................Fire District .................................................................... lR�'ylr�.3 / ate Name of Owner .. ... ..... .<1�....... f!.......................Address Name of Builder 01.... ° ...".............. BPI r� II ..........Address . .f........��........�.......t5�s..........t.�.........�ff�.:!'. l.,S.. Nameof Architect ..................................................................Address .................................................:.................................. Number of Rooms v.... ...l ec�...69K5.......��,�...�`�....Foundation ......................... . ..................................................... Exterior ... ...... :l. .�f. ..........................................Roofing .. �/ if Floors ...C-10c�� .... V.v........... 5!L_....Y..! ...................Interior - Heating .......i'7... !!2.........................................................Plumbing ... ����.........13o.vf `.......................................... Fireplace ::. ..........Approximate Cost ....... .. .. ... . ... .. Definitive Plan Approved by Planning Board ________________________________19________ . Area Q... F. �?....0 c Diagram of Lot and Building with Dimensions Feejj SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Construction Supervisor's License ...0 11.S.Wel.............. t _ , �. ! �� j �. '� ! I w. �� �_____ I_ --._iz_...:._:__---_--�--._ � S ' � E ►v �N � I � M ,% �L 0 t 4 i, � o �) � ri �� �\ ` � fV y� V � ��� � �� � � ! tS (� !� ,N � j ty �� /G o NO. DATE QC4 __�`O,1 9 c�CO yofTNETO� TOWN OF BARNSTABLE FEE - 6�P OFFICE OF DAflIlTABLL RECEIVED BY .�.� BOARD OF HEALTH '679• `e�° 367 MAIN STREET HYANNIS, MASS. 02601 VARIANCE REQUEST FORM 6 All variances must be submitted FIFTEEN (15) days prior to the scheduled Board of Health meeting. NAME OF ,APPLICANT TEL. N0. ADDRESS OF APPLICANT 2 NAME OF OWNER OF PROPERTY ,,z SUBDIVISION NAME DATE APPROVED �I ASSESSORS MAP AND PARCEL NUMBER f7 LOCATION OF REQUEST tf / _ � `T . SIZE OF LOT /) 40 —SQ. FT. WETLANDS WITHIN 200 FT. OF PROPERTY: Yes No� VARIANCE FROM REGULATION(List Regulation) ta► f1 OP N CIAI:�)P_1� :)I' �,c REASON FOR VARIANCE(May attach letter if more space is needed) - .n''C'�Fif°A cs-a..�.].� �� lil"I��tt�a-�' J�1i��3 D.t. - t_:..---r'r L•v� L " .ram-��; e 4 y ` • ✓^ PLAN — TWO COPIES OF PLAN MUST BE SUBMITTED CLEARLY OUTLINING VARIANCE REQUEST. / pn wcrlLma.ss cant• VARIANCE APPROVED _ NOT APPROVED REASON FOR DISAPROVAL Robert L. ,Childs, Chairman Ann Jane Eshbaugh Grover C.M. Farrish, M.D. BOARD OF HEALTH TOWN OF BARNSTABLE, A ,y On l �c,r, �/ � + 4-0 _{ f'o;a : 1 �1 10 pa /►��� C �2 n��ti t��--- a`s'a.� '�( �C�Tc7b�'Y.S � � �Cfc�.0 O� November 5, 1966 Gregory and Constance Tallman 441 Old Town Road Hyannis, Ma 02601 Dear cir. G mars. Tallman: You are granted a variance from the Interim Ground Water Protection Regulation, limiting sevjage flows to 330 gallons per acre in certain zones of contribution. Vie will approve your bulle..in permit �o add a second floor bedroom at 441 Old Town Road, Ifyannis, with, the following conditions: (1) the existing septic systems must be pumped every two years and written certification to the Board by a license& selptage haulea. (2) The dwelling is authorized a maximum occupancy-of.six persons. This variance is approved because of the many Medical problems existing within the -family and the fact that the occupancy is limited to six persons. Six persons would occupy the dwelling regardless, even if the addition was not approved. Town sewer is planned for this area within the next 6 yearn. Very truly yours, Ann Jane9EsBaugh, Acting Chairman_, BOARD 01 HEALTH TOWN OF 3AR S i ABLE JMK/bs U � .iu ` r A Oppq'� P W •'Ir © r � N ta _ � `• �_o ,e+b ® y -gip �N S a so 8o 41,` p 4116 ® qr • ® g 9 N� �N to o PNp �.V on ® ®j i d ^ N a _ A i .. {� tj N N it �` V WN ' P d i �� .. a Nn •t N y it „N ®12 •0 O d� �+ p ' RV 91 O pi W t S� to „- N op 0 LO i so N ` ` M R 1 V� N O p a CA 0 ® W ® N O ro d p V W P C� i o p'6y b kA " R a q. ►sA16co r to :ir 4 �p� .. O � tee+ T'F ap@ Q O .'9 o a p •' = M 94 t 94 r � ® bo on a VA t' view r •ooj aIr Of VIP p • � ��N � $ �P ® 8 A '�p ? • r a v Q r e 7a �,� O •�� ~d � s. ® •�, . . `Ptv add a 1 * �39� Id a , r� o' f � - 4 - �� - Jam. . r V u,,-c���._ �.�r..�.C�-c.('-�"`� - - cam""--e---• ---- _. �I��j -!'�-.�Gam'—a--C�,._____ _,uY—./_tea_._ ce-r� :�,.� ._ ` Cy(1�-P , 64-� _.- �-„�- `' fo=sld—. - • � - __ _ __ __ � -. __ -�-- I -- I i , E f ._ ____ t . .. �. _ - . , . . �� �- ._ _ _ _ �.__ __ -_. _. --•--t .ter ._ -� _ 1 i • T - � i __ � � - _ - • -- __ I � I � .................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HEA T Appliratinn -for 43i!i oiial Dark.. Tonstrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - =------------------------------------------------------------------------------------------- e" .. ----------------- Location•Address - o Lot No. ° fob / ---- �c..� E.......... �Dfl--" '----------------------------------------------------- -------- caner Address Installer Address Q Type of Building Size Lot_._-__---___•---------------Sq. feet U Dwelling—No. of Bedrooms________________________________ _____Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons..____--.--___.--_-.------__ Showers ( ) — Cafeteria ( ) a'' Other fixtures ------------------------------------------------------------------------------.----------•-------------_--_------------------------------------------ d W Design Flow............................................gallons per person per day. Total daily x flow-__-._--------:-_--.__----__-____.----------------------------------------gallons. WSeic Tank—Liquid capacity-----.-.--_.gallons Length---------------- Width................ Diameter................ Depth_._.--_-...... Disposal Trench—No. .................. Width-__--___-_-__--. _- Total Length Total leachinarea-------------.------s 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......------------•------------------ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water--------------------- ----------------------- ----------•-------------------------------------------------------------•---......................................................... 0 xDescription of Soil...............................................................-•------------------------------------------------------------------------- --------------------------- w x U Nature of Repairs_or Alterations—Answer when applicable------f/1` W....__..® ✓./ ._._...__� _--_....._ -----.......e`...+'t.... A<K------------ ----------------------------------------------------------------------------------------------------- Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has(Veen issued by the and of talth. _ Signej Date ApplicationApproved BY-------------------------------------------------------------------------------------------------- ................. -------------- Date Application Disapproved for the following reasons------------------------------------------ ----------------------•----------------------------------------------- ----------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------- y Date Permit No......................................................... = Issued..s3 -- ---...7- �------------ Date • f No. �" e - Fmc 'a. ................ l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... OF....:.... .... ... ... .. ....................... 440 Appiiratinn -for Uiiivuitti lVarku Tomitrurtinn Pumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: era Location-Addre s or Lot No. Address W � Installer '-•--......--•---•----••----•------------- U Type of Building Address Size Lot............................Sq. feet. Dwelling—No. of Bedrooms--------------------------------------------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 Leng h............... Width-------......... Diameter_-___...:_.____ Depth--------------- Disposal Trench— Seepage Pit No _No:._______ Diameter Width..... =-':_;--__- Total Length.................... Total leaching area-----------------:_.sq. ft. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) i Percolation Test Results Performed by--------------------------------------------------------------------------- Date................_-------.-.------------- ,� Test Pit No. 1................minutes per inch Depth of Test Pit".._-"______-...___ Depth to ground water........................ G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__--.."-_"_-___-.___.--. P4 ----------------------------------------- --- 0 Description of Soil-----------------------------------------------------------------------------------------..:-------------------------------------------------------------------------- x U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•••------•...-------- ------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- .................. U Nature of Repairs or Alterations—Answer when applicable.-.---- ,e�/��`j ��(..........a-d(_/r---_-_ 4,0t---- /,Q14--------- - t�ru%V...R�-1�----------..av*u. 0vj--------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed .Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ee issued l Y the and of alth. Sign Date ApplicationApproved.By---------------------=':_.-- -----•------.--••••......--•---...................................... -•----..._............................... Application Disapproved for the following reasons:----•--.------,•------------------------------------------------------ _Date .......................................... _._'-f....___.........__..........._....................._______----------------------_.---___".___.__.___.•-___--____-. "____--__----"__-_-_"__-___•-_-- Date' Permit No.--- ••-•----••-•......•----•--•••-. ~ Issued ......--•-•-•- Date THE COMMONWEALTH OF MASSACHUSETTS ,,.. . BOARD OF HEALTH \J..... OF............4. : ........<..... r ort f iralr vnff 'Ti utV iatnrr THIS IS TO C RTIF , That the Individ ,ewage Disposal System constructed ( ) or Repaired ( ^ b ........ A---------- ------------------- .... --- tAftic taller -----at-- - has beet'insta led m accordanc tt�r the�provtstorisXP of The tat Sanitary ode as described in the application for Disposal Works onstruction Permit No. ._. ...- dated......THE ISSUANCE OF THIS CERTIFICATE SHA OT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY:. u{y v DATE-----• '----------••-"-•--•-----------•----"----•------------••............... Inspector..........--------•--•--•---------------•"-------------•••---•-•••----............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH �..�^ . .....OF................. ..... ... -� G• .. . 4"�/ FEE..... -----..--. h BisVntitt1 Works Qlanfitrurtijan rrr it Permission is hereby granted � '----------------------------------------------•------ to Construct ( ) or Rep •r ( an In`divi�ual Sew ge isposal stem atNo.--*--- - ---- (l ........ .......;. ..... X ......................- F as shown on the application for posal Works Construction Per No'__ Dated----- V .. •-•--•------------ DATE...:.. ........................... -.-•-- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS