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Home My WebLink About0035 OREO LANE - Health 3 ®reo Lane Centerville . P A = 247 140 M s i 5�� /I p J�aECrClEpco UPC 12543 No. 53.., LOR ��s1•CONS°a` HASTINGS, MN i TOWN OF BAMSTABLE a o3 J �- SEWAGE # L(?rATION O�GO � VULAGE �� ASSESSOR'S MAP & LOT9 INSTALLER'S NAME&PHONE NO. .SEPTIC TANK CAPACITY C/Ub LEACHING FACILITY: (type) 4�X G A (size) 60b 9 4 NO.OF BEDROOMS J /� BMILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachii g facility) ..-�- Feet Furnished by -Te%SIJ G J a.3 a a AVO aq 3 2-g 3 o y . y aq Iq v?;� TOWN OF BARNSTABLE LOCATION� 0«'-D I q A- SEWAGE # ;VILLAGE Ce, ery,Ik- ASSESSOR'S MAP & LOT aY?' BYO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY A50 LEACHING FACILITY: (type) -7' /A 1 o r4 1-1 (size) NO. OF BEDROOMS 3 BUILDER OR OWNER ( L PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Fumished by «- 11 on A Door6 O t O 3 `-1 g y0 �Lg No. Fee THE OMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS RpPfication for -Misposar *pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrad 4AbandonX ❑Complete System ❑Individual Components Location Address or L t No. s Name,Address,and Tel ,o. =Assee�Map/Par �gi Installer's Name,Address,and Tel.No. , AZI / esigner s Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Qc;4,,as p No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) r- Dat ast inspected: reement: 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health i ed Date 3 r Application Approved by $ Date Application Disapproved by Date for the following reasons Permit No. J A Date Issued r� �. No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,MASSACHUSETTS Yes Tipplication for disposal 6pstrin construction permit Application for a Permit to Construct( ) Repair( ) Upgrad Abandon Q ❑Complete System ❑Individual Components Location Address or Lot No. O " er's Name,Address,and Tel.�No. Asse5S'or�Map% arGel �(I Installer's Name,Address,and Tel.No. r / Designer's Name,Address,and Tel.No. Type of Building: �7 r Dwelling No.of Bedrooms c, Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Ce;4:71 e; w No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. A Description of Soil Nature of Repairs or Alterations(Answer when applicable) i / l Date,last inspected: t/ 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health ig ed p•` // /� Date lr 3 Application Approved by i © �/ �-- >. Date Application Disapproved by Date for the following reasons F. Permit No. j Date Issued ' J i / j - - - - - -------------- - -------------------------- \` �I- THE COMMONWEALTH OF MASSACHUSETTS d BARNSTABLE,MASSACHUSETTS ( U Certificate of Compliance THI S TO CERT that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Lat ed( by v has been cons. acc cte c with the provisions of Title 5 and the for Disposal System Construction Permit No a ed Installer / Designer #bedrooms �!— ' r� Approved design flow r\ ,'I gpd The issuance of this pe it shall not be construed as a guarantee that the system willni ' esigned.Date )O , j b Inspector A,J--------------- 7 ' CT - -� No. 'f ) Fee ��✓✓✓ i HE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal 6pstem Construction j3ermh( j Permission is hereby gran to�struct( ) Repair( Upgrad ) �ando s System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must Ve co leted within three years of the date of this permit. Date Approved by } Cx15 �r�a / 14rsr F/®d _ ao LO - 5 0 r-e o � V4 3 ozy— . 3v 1a /� N 1ecl . 1 r �-� �\ 30 i 1 1 c� 1 � 0 AL 3 30 V e� /V-e S � E-1-21 - 3 �GT7ice� df �ladr 2 I 3 ! 0 I � f 1L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC I, Owner Owner's Name information is ill enterve Ma 02632 2/29/2016 required for every C � page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in adk way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, . use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection ±-41 Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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 �--2/29/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 C Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owners Name information is required for every Centerville Ma 02632 2/29/2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 35 Oreo Lane Centerville(cottage system) is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 4 Infiltrators in a 11'x25'trench. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 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 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Oreo Lane (Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 page. Cityfrown 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 '/day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 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 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•3113 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 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owners Name information is required for every Centerville Ma 02632 2/29/2016 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): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° M 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 35 Oreo Lane (Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is Centerville Ma 02632 2/29/2016 required for every ii page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 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: system installed 8/23/1999 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5feet 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 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 3" Scum thickness Tv Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally 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 t5ins•3/13 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 35 Oreo Lane (Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 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 ,M 35 Oreo Lane S stem (Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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.): * 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owners Name information is required for every Centerville Ma 02632 2/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): s.a.s. consists of 4 Infiltrators in a 25'x11'trench with 4' stone. Vegetation was normal, soil and stone was dry with no signs of past saturation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Oreo Lane (Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately { -S° (� J, � � �;� �)3 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Oreo Lane (Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 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: 12+ feet i Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 35 Oreo Lane(Cottage System) Property Address Mass Building Systems LLC Owner Owner's Name information is required for every Centerville Ma 02632 2/29/2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � 1 CO'MMONNIE.ALTH OF I�LaSSACHt;SETTS a EXECUTIVE OFFICE OF E\�IRONAIENTAL AF F.aIR 1 DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE nZNTER STREET. BOSTON \LA 02106 (615) 292-:i:il TRUDY COX— Secretar. ARGEO PALL CELLL-CCI DA�'ID B STRi;I-IS Cornnuss:o:,e: Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: �S 6(Q�Q LIu, Name of Owner 101-As \1, W. #J IS dd�s of Owner: (Lr \Z q Date of Inspection: 7' 1 S 1 ,�+ // ,`� �t ,/U Cjp�� f �A Name of Inspector:(Please Print/ ( .-act � / �EL I am a DEP approved system inspector pursuant to Section 15.340 of True 5(310 CMR 15.000) Company Name: 1q& r 2 �k t� _L�a bo J! A- Tck Marling Address:-_� &0 L �C, N i9<Nn I'1 ,2G4-c Telephone Number: K :7�QZ� —(-t7 sZ CERTIFICATION STATEMENT t I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's SignawrJ �I, &)" Date: r The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS N G� Al r 0 19 revised 9/2/98 Page IofII `i Primed on Recy<kd Piper 1 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'roperty Address: 35GLt� Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: ' A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 ; 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 completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y. N, or NO). Describe basis of determination in all instances. If 'not det. The septic tank is metal, unless the owner or operator has provided the system inspector v Compliance (attached) indicating that the tank was installed within twenty(20) years prior the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial i failure is imminent. The system will pass inspection if the existing septic tank is replaced v approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is du or due to a broken, settled or uneven distribution box. The system will pass inspection if 1 Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obsttvcted pips inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 'Ve r t� revised 9/2/98 P2ge2Of11 r ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: 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' the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 10 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: r _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a s It marsh. i i . f, 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 HEAPN AND SAFETY AND THE ENVIRONMENT: f _ The system has a septic tank and soil absorption systt'm(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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption�ystem and the SAS is within 50 feet of a private watertupply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for eoliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility eq6 the presence of ammonia nitrogen and nitrate nitrogen is equal to or less t pp than 5 m. Method used to determine dist6nce (approximation not valid). i 3) OTHER t 1 revised 9/2/98 / Page 3of11 Al SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: - Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or -No" to each of the following: I have determined that one or more of the following failure conditions exist as desc/dnCMR 15.303. The basis for this det ermination is identified below. The Board of Health should be contacted to detewill be necessary to correct the failure Yes NoBackup of sewage into facility or system component due to an overloadedSAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface w 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 cesspcol. Liquid depth in cesspool is less than 6" below invert or available volu'me is less than 112 day flow. _ Required pumping more than 4 times in the last year NOT due to;clogged or obstructed pipe(si. t Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy,is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for 'coliform bacteria, volatile organic compounds,�mmonia nitrogen and nitrate nitrogen. / E. LARGE SYSTEM FAILS: You must indicate either "Yes" or -No" to each of the follo ing: The following criteria apply to large systems in a ition to the criteria above: The system serves a facility with a design flo of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment becau a one or more of the following conditions exist: Yes No the system is within 400 feet f a surface drinking water supply _ the system is within 200 fe t of a tributary to a surface drinking water supply the system is located in nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such syste shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inf mation. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N;A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. f — All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance it unacceptable) [15.302(3)(b)) The facility owner (and occupants,if different from owner) were provided with information on the proper maintenaar&of Subsurface Disposal Systems. revised 9/2/98 Page 5oru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.. PART C Q SYSTEM INFORMATION 'roperty Address: 3SQ�d Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:ISO g.p.d.lbedroom. Number of bedrooms (design): Number of bedrooms (actual). CIS Total DESIGN flow 3 38 Number of current residents:.-0-1 Garbage grinder(yes or no):_f,> Laundry(separate system) ( es or fL; If yes, separate inspection required Laundry system inspected e! or no) Seasonal use (yes or no):A.) Water meter readings, if available (last two year's usage (gpd): UV Sump Pump (yes or no): 1� Last date of occupancy: eli COMM ERCIALANDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION r � PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_4L-4D If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) � revised 9/2/98 Page 6(of II r � v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 6 '� Owner: Date of Inspection: BUILDING SEWER: 6A43 (Locate on site plan) Depth below grade:_ Material of construction: _cast iron_40 PVC_ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: t{S (locate on site plan) Depth below grade: ht( Material of construction: concrete_metal_Fiberglass _Polyethylene_other explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) f Dimensions: �aC� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness:_ tl Distance from top of scum to top of outlet tee or baffle:�� Distance from bottom of scum to bottom of outlet tee or baffle:_ How dimensions were determined: i/1/L�1a�Mc� comments: al integrity, (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structur evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 r; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: JJ� Owner: Date of Inspection: � TIGHT OR HOLDING TANK: VAA'-y (Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: 1fT" (locate on site plan) Depth of liquid level above outlet invert: 1JiUc..Js 1"j Comments: (ngte if level and'distribution isual, evidence of solids carryover(�evid ce of leakage into or out of box, etc.) �U1C lx, AA1 PUMP CHAMBER: ' (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or Not Comments: (note condition of pump chamber,-condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'ropertyAddress: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible: excavation not required.location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers; number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology Comments: ( to c;edition of soil, sign��chydraulic�failure, level of p nd'in g, mp oil, condition of vegetation, etc.) 4 II CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: K inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Dimensions: Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofIt n 'l 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) "roperty Address: J�0"0 )caner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Z 10M- (� 35' '.a3 r revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C cc SYSTEM INFORMATION (continued) roperty Address: Owner: Date of Inspection: NRCS Report name - —"— Soil Type— — ------ - -- Typical depth to groundwater____._ _ --_ USGS Date website visited Q16 Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface waterq_-f-a Check Cellar J-4,14 Shallow wells hJ 1 Estimated Depth to Groundwater'��S Feet Please indicate all the methods used to determine High Groundwater Elevation: . t Obtained from Design Plans on record Observed Site (Abutting property, observation hole. basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _ r 'j Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 TOWN OF BARNSTABLE LOCATION 3 S' o 2.�0 bktf(5- SEWAGE# '2-0 1 0 s /54 VILLAGE C9k-rMd1LL,(!5 ASSESSOR'S MAP&PARCEL 2-47 liko INSTALLER'S NAME&PHONE NO. :"IVS SEPTIC TANK CAPACITY /OD O (aJ 57—/&(Q LEACHING FACILITY.(type) �C. / (size) JX: 5-00 NO. OF BEDROOMS 3 OWNER PERMIT DATE: -7 l D CO LIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 7 f 2 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) /6Feet Edge of Wetland and Leaching Facility(If any wetlands exist within .( 300 feet of leaching facility) N Feet FURNISHED BY 1'L" 0M ��C�p Al 3��0 Z 36 - r 2z_� 1, _ Z C> S- 7- a 4� + i i No. J��U _ l.Sy THE COMMONWEALTH OF MASSACHUSETTS FEE ) BOARD OF H ALTH �� W OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components Locatigp Map/ParccA�# YhAddress� Te�KphonP/'1' 11�� J� ) De �elatgll—LJI /t}"1 Telephone# Telephone# Type of Building: v�Z�l Lot Size) 9—? Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required)-33 ® gpd Calculated design flowZ�- -gpd Des i flowprovideA gpd Plan: Date '"-�� '" 16 N 11)m er of sheets Revision , T Title JJ Description of Soil(s)6 Soil Evaluator Form No. NawL� t r SWi Date of Evaluation)l 0'— DESCRIPTION OF RE(AIRS OR ALTERATION/S The undersigned agrees to install a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to pl ce' a system in operation until a Certificate of Compliance has been issued by the Board of Health. i Signed Date Inspec 'o P—S, FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 _ n No. _10 to — THE COMMONWEALTH OF MASSACHUSETTS FEEJim—' BOARD OF HEALTH.; //—_� OF APPLICATION FOR DISPOSAL,SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ( )' Abandon,,( )'IE]Complete System -❑Individual Components Map/Parcel# Address r` 3 �CJ�L� o �l� -> L Tel#phonlrt 1 � it nsta�eg3—Irr� Desi�gn(�el ,a'Y 1✓ ��i r f,/gs ddress,, Telephone# Telephone# Type.of Building: Lot Size f'?Sq.feet Dwelling—No.of Bedrooms - Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. fl required � gpd Calculated design flowM�gpd Desi n o vide prodS�gpd Plan: D to 4 3 O �6 .Nutt er of sheets .r Revision Date _- - Title Description of Soil(s)(3Lb F) `Jf 3, .Soil Evaluator Form No. Na ei�'roi�l I�v� �r f Date of Evaluation, 1 DESCRIPTION OF RE(A $OR ALTERATIONS •fry �2 qua LIN, ca The undersigned agrees to install t e above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place a system in operation until a Certificate of Compliance has been issued by the Board of Health. Y r Signed Date 5 . 2-/ . /0 i13, InspectiogDrp An1 FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. 0LQ �y �� / THE COMMONWEALTH OF MASSACHUSETTS FEE A)0 'I�OARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded Abandoned( ) by. Ii nA 4) 0(, >r at 3S oroco LAnP_ has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.a 0!0 dated E ` -7 /J Approved Design Flow U(gpd) Installer jam. lrK•L1� I(� l� 1 1 l C � Le 'Inspector I I 1/0 Designer: j � nv Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 L No. 'CIS THE COMMONWEALTH OF MASSACHUSETTS FEE Uv BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at •3 0� (� .L j��-- 1�,4, yz_ / as described in the application for Disposal System Construction Permit No. 0/0 / W,dated /?26,7 �. 7 . Provided: Construction shall be completed within three years of the date of t 's peJ,..All local c6nditions must be met. Date �!7 '.7 �A Board of Health ' �r.. FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARRENrM PUBLISHERS- BOSTON i �1 Jun 10 2010 4: 28PM Hood Suryets Group 508-833-8212 p. 1 i Town of Barnstable t Regulatory Services 5l, Thomas F. Geiler, Director Public Health Division AM t6�9'& Thomas Mclean,Director 200 Main Street, Hyannis,MA 02601 Ofice:l!508-862-4644 Fax: 508-794-6304 Date:G _l 0® Sewage Permit# 2.01 D — 1S�Assessor's Map/Parcel Installer &Designer Certification Form Designer: F: taller: A-✓vt ES �I Address: (Address: T D. i3ox 7o A 25�owls �� _ P � �De��e�� ` � was issued a permit to install a ate) (installer) `P septic system at off_x��N 1 0- y n a design drawn by (address) I ( esigner) U I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 1.0' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required) was inspected and the soils were founds tisfactory. N Of (Installer's Signatur • go kARRY �Gn f c EARL LANTERY,JR. � No;26575 p sign r' Signatur {A i} a. Here) SlaNAt E� PLEAS ® BA TABLE PUBLIC HEALTH N. CERTIFICA OF COMPLIANCE WILL 1VOT BE ISSUED UNTIL BOTH THIS (FORM AND A5- BUILT CARD ARE RECEIVED BY THE BARNSTAB E FILBLIC HEALTH IDIVISION. THANIC��. gSoffice formWesignereertification form.doc May i7 2010 9: 26AM Hood Survey Group 508-833-8212 p. 1 ADVANCED TLC CAL SOLUTIONS P.C. Box.99 Bast Sandwich,MA 02531-0099 Phone 508-888-4.029 ,`ax Message Cover Page 2 Recipient: -�� v lam► a `-'!�/ "s ^ Fax Number: d� Number of Pages to follow: Date of Transmission: From Comments:' Mad ,27 2010 9: 26AM Hood Surve,d Group 508-833-8212 p. 2 TRANS. NO.: CITYlTOWN: APPLICANT: ADDRESS: � 7 OF DESIGN FLOW: DATE: REVIEWED BY: � � EARLto tANTERY, JR. Z: NIA OK NO A5 '9 No.26575 j - s1. Legal boundaries denoted [310 CMR 15.220 4 Street,Lot,tax parcel number and lot number noted on plan [310 / CMR 15.220(4)(u)] V Locus Provided 310 CMR 15.2204 t) plan proper scale? (1"=40' for plot plans, 1`20' or fewer for components) [310 CMR 15.220(4 Easements shown f310 CMR 15.220(4 (b ]System located totally on lot served [310 CMR 15.405(1)(a) for u grades]- i. not, a variance is required [310 CMR 15.412(4)] areas etc. ' Location of impervious surfaces (driveways,parking ) Y 310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] j Location and dimensions of system components and reserve areas. [310 CMR 15.220(4 e) System Calculations [310 CMR 15.220(4) ] daily flow se tic tank capacity(required and rovided) soil abso tion system re uired and Provided) whether system designed for arbage finder North arrow f 310 CMR 15.220 4 (g) Existing and ro osed contours [310 CMR 15.220 4 ( ] Location and log of deep observation holes(existing grade el. on each test [310 CMR 15.220(4 h Names of soil evaluator and 13 representative [310 CMR 15.220(4 h) and (i)] 9 onned at proper Location and date of percolation tests (perf J elevation? 310 CMR 15.220(4)(i) 1 , j Percolation test results match loadin rate? 310 CMR 15.242 Certification statement by Soil Evaluator [310 CMR 15.220(4) Observed and Adjusted groundwater (method or CMRlnent given or indicated) [310 CMR 15.103(3) and 3 15.220(4)(n)] Sheet 1 of 7 Address May +27 2010 9: 26AM Hood Survey Group 508-833-8212 p. 3 N/A O. NO Location of every water supply,public and private, [310;CMR 15.220(4)(k)J within 400 feet of the proposedsysteni`'locat on iri the case of surface water supplies and gravel packed public water sy2ply . within 250 feet of the proposed system location in the case within 150 feet of the proposed system location the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 f1._ [31.0..CM12 15.220 4)(1) Water lines and othersubsurface utilities located [31.0 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.211 1)[1]) Profile of system.showing invert elevations of all system components arid.-the bottom of the SAS [310. CMR15.220(4 (o)] Stain of designer 310 CMR 15.220(1 and 310'CMR 15:220 2 ] Stamp of Registered.Land Surveyor (required if construction activities within 5 ft, of lot line 310 CMR,1.5.220(3 Test Holes adequate (two in each of the primary and reserve unless.trenches as. rmitted pe in..310 CMR 15..102(2) crag approved for an upgrade under LUA at 310 CMR 15.405(1)(k Test hole adequate to.'demonstrate.four feet of suitable material? [310 CMR 15.103(4)1 Test Holes adequate to confirm adequate groundwater separation? 310 CMR 15.103(3)] Benchmark within 50-75' of system 31.0 CMR 1.5.220(4 Materials specifications noted?.[various sections of 310 CMR 15.000] System components not.>.3C." deep (unless Local.Upgrade Approval or LUA re4uested) 310 CMR 15.405(1(b Address as � � �� Sheet 2 of 7 , May ,27 2010 9: 27AM Hood ,Surve�j Group 508-833-8212 p. 4 „NhA� QK NO Size OK? [310 CMR 15.223 1 Inlet tee located ten inches b.el.,ow ow,line [.310..CMR 1.5.227(6)1 Outlet tee 14" or 14" + 5"per foot for increase ft depth [310 CMR 15.227(6) Outlet tee.with gas baffle or approved filter 310 CMR 15:227(4) Note regarding installation on stable compacted base [31Q CMR 15.228(1)] Y Separation between inlet and outlet tees (no less fan liquid depth) 310 CMR 15.227(2)] Inlet/Outlet elevations at.least 12" above high groundwater (except as described 310 CMR 15:227(5)) or permitted for upgrades under LUA 310 CMR 15.405 .l ] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3) Three access covers'(inlet and outlet must be 20" or greater) - / middle access at least 8 b. 7/07 310 CMR 15.228(2)] Access to within 6 ." of.grade one.part.forsystems<1000gpd, two fors stems >1000. d 310 0CM 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2) > 10 ft from building foundation [310 CMR 15.211 1 Buoyancy calculation Re uiredlpone 310 CMR 15.221(8) H-20 Where a ro riate? [310 CMR 15.226(3) Setbacks from:resources. 310'CMR 15..211_ Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15.223 1 First compartment 200% daily flow; Second compartment 10.6% daily flow 31 Q.CMR i 5.224 2 and. 3. "U" pipe through or over baffle,outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address ® � - '' Sheet 3 of 7 May -27 2010 9: 27AM Hood Survey Group 508-833-8212 p. 5 N/A OK NO Located at least ten feet from any water line? [310 CMR. 15.222(2)] Disposal piping at least 18" below water line (when water and sewer cross, see 310 CMR 15.211(l)[11) Cleanouts required/provided.? F310 CMR 1 5.222(8) Thrust blocks specified in force mains? 310 CMR 15.221 6)(c Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable , r [310 CMR 15.222(6 Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) 310 CMR 15.251(9) and 310 CMR 15.252 2)(c)] Si hon problem/ leachfield below um chamber Endca s or vent manifoldspecified? Size and orientation of discharge holes specified? (not smaller / than 3/8' not larger than 5/8 ) (310 CMR 15.251(8) and 310 ,ti/ CMR 15.252 2) h ] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base [310 CMR 15.221(2) and 310 CMR v 15.232(2 (a Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3) P side minimum dimension 12" [310 CMR 15.232inimum sum 6" 310 CMRI5.232 3 e)atertight cover if<2000gpd);waterproof manhole if>200Qgpd I0 CMR 15.232(3)(d)] Capacity(emergency storage above working=design flow)? [310 / CMR 231 2 ] �0 Proper setbacks f 310 CMR 15.211 (same as septic tanks Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231 5 ] Y Service components accessible(not too deep with piping, disconnects accessible Alarm floats - alarm on circuits arate from pumps ecified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and 8 Stable Com acted Base 310 CMR 15.221(2 Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)] l Sheet 4 of 7 Address May •27 2010 9: 28AM Hood ,Survpy Group 508-833-8212 p. 6 N/A OK NO Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1 Required separation to groundwater? 310 CMR 15.212) Ag e ate s ecifled as double washed [310 CMR 15.247(2) System Venting required/provided? (system under driveway or >36" de, [310 CMR 15.2411 Inspection ports specified and within 3"final grade? [310 CMR 15.240(13) net? (No v Breakout requirements iiolation of breakou ation within 15 ft of SAS unless barrier) [310 CMR 15.211(l)[41and Guidance Document Chambers and Gal. in trench configuration supplied with ii-let every 20 ft. [310 CMR 15.253(6 Each structure with one inspection manhole(if>2000 gpd must be to grade) 1310 CMR 15.253 2A Ag egate 1'minimum- 4'maximum. 310 CMR 2' sidewall credit inaximum [310 CMR 15.253(1 a)] h1 bed configuration, inlet eve 40 s , ft. 310 CMR 15.253(6) Width 2' minimum 3'maximum 310 CMR 15.251 1) 100 feet-maximum length 310 CMR 15.251 1 (a)] ` ver Minimum separation 2x effective depth or width which{ eater 3x if reserve between trenches) [310 CMR 251 1)(d) Situated along contours [310 CMR 15.251 2) Breakout OYU 310 CMR 15.211 1 Al and Guidance Document] ". .. minimum 2 distribution lines j310 CMR 15 (d Maximum se aration between lines 6' 310 CM R15 252 2 Maximum separation between lines and outside of bed 4' [310 \�' CMR 15.252 2 e `( Aggregate depth below discharge pipes 6"minimum, 12" maximum• 310 CMR 15.252(2 ) Se aration between beds 10' minimum• 310 CMR 15.252(2 5 2 21 ] Bottom area used in calculations only 310 CMR 15 ( )� Sheet 5 of 7 Address Ma,y •27 2010 9: 28AM Hood .Survey Group 508-833-8212 p. 7 N/A OK NO Pressure Dosed System P `Pro-viaed pump and piping calculations as required 310 CMR 15.2200 r Pressure dosing required on all systems >2000gpd or alternative systems under remedi4l,approval[MO CMR 15.254(2) and I/A. Remedial Use Approvals] If used in gravelless system - make sure jet is.directed as:not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd)or quarterly (>2000 d) good to note on lair 310 CMR 15.254(2)( Construction in fill - Did4he plan specify that.the fill shall meet / the specification of 310 CMR 15-:255(3)? Impervious barrier and/or retainin wall ? Guidance Document] Impervious barrier installatiori rust be supervised by .. designer [310 CNM 15.255(2) Retaining wall must be designed by Registered Professional Engineer 310 CMR 15.255(2)(4) Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15:252(2) and Guida nce ante Document At least 5 ft. from,impervicus barrier,to edge of,$AS (10 ft. recornrriended 314 CMR 15 255:. 2 .e Check DEP Approval letters.Iror credits and.design conditions: If used with pressure dosing do not allow pressure discharge to scour soil interface Was DEP Approval Letter provided;and/or have you reviewed! cgnd:itipris� Is the technology being properly applied and does it meet all f DEP Approval Conditions? u Is there a.note on the plan regarding the requirement for K f perpetual maintenance agreement? 1/ Any alarms involved on%separate circuits Did the applicant submit an operation and maintenance manual? Hasa licant subnutte& COPY of a maintenalice Are the variances listed on the plan? [310 CMR 15.220 4 RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] V New construction or increased flow proposed- [Refer to 310 CMR 15.414 Address�, Q -�y` Y Sheet 6 of 7 . 0ai - 27 2010 9: 29AM Hood .Survipy Group 508-833-8212 p. 8 NIA OK NO ,� @•i': .,:•!;. m+a .. ;. :.f- -F 511u. Is the system in a Designated Nitrogen Sensitive Area (Zone II for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 -also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? 310 CMR 15.214(2 Are the nitrogen loads proposed in compliance? [310 CMR 15.216 1)] ., •.:....r . .... ..r _'4be . 1, t�4t Jfi qa ., ad IF Pumping to septic tank ? [ 310 CMR 15.2291 Shared System [310 CMR 15.290 1 L�L Address ��" Q� Sheet 7 of 7 Town of Barnstable P# 17 7 oF�t�rqt, Department of Regulatory Services BABMSPABM : Public Health Division Date y MAM 200 Main Street,Hyannis MA 02601 ED►�s b tjv_ Date Scheduled 3 U Time Fee.Pd. Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: L71 V i LOCATION& GENERAL INFORMATION Location Address 315 0 R t�0 Owner's Name R,C 0W:-,M14 0-1v q 0WM- v 1 ♦rL Address C dX�p e f+ .,. Assessor's Map/Parcel: 2�� / �'© Engineer's Name F A.RL L 1V4 Tk`;t V NEW CONSTRUCTION REPAIR ' Telephone# ;7+ -3 j I.- (� 1 � Land Use q))d ��l-" I W v Slopes(%) Surface Stones -V O iy Distances from: Open Water Bod} �©�S! ft Possible Wet Are a0_ ,ft Drinking Water WeI;>1S© /ft J J Drainage Way >-Z p© It Property Line O 6 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) P_�M, Q I Parent material(geologic) v Z� Depth to Bedrock Depth to Groundwater: Standing Water in Hole: r Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping f o:n side cf'abs.he!e: .. ground vant;:r Adjustmoat ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date Time Observation Hole# Time at 9" Depth of Perc 7 Time at 6" Start Pre-soak Time@ Time(9"-6") End Pre-soak y�{� Rate Min.Anch )vw 4� '0� Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate Man: !� Above 500 year flood boundary No Within 500 year boundary No Yes i/ i_J Within 100 year flood boundary No V Yes Depth of Naturally Occurrins Pervious Material Does at least four feet of naturally occurring pe,v - erial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify tha on M have passed the soil evaluator examination approved by the Departm'ent of en l rote at the above analysis was performed by me consistent with the req - in' an e n e scribed in 310 CMR 15.017. , � � '�'�� Signature R Date`S7 �C/STEM FSSrONAL EN6 Q:\SEPTIC\PERCFORM.DOC The Law Office of Peter M. Daigle,P.C. Peter M. Daigle, Esquire 1550 Falmouth Road,Suite15 Centerville,MA 02632 Telephone 508+771+7444 Facsimile 508*771*8286 September 5, 2006 Thomas A. McKean, R.S. Director Public Health Town of Barnstable 200 Main Street Hyannis, MA 02601 Re: 35 Oreo Lane, Centerville—Richard and Diane Mahoney Dear Mr. McKean: This office represents Richard and Diane Mahoney in connection with the above- referenced property. In response to your letter of August 24, 2006, we are in the process of evicting the current tenant from the property and are due in the Barnstable District Court on September 2, 2006 on the summary process matter. Considering rights tenants in general have available, it may take until at least October 15, 2006 until she can be removed. Until the tenant has vacated the property, it is unrealistic to repair/replace the ceiling and repair the flooring in the bathroom as specified in your letter. Most of the other items will be completed during early September. I am asking you to extend the time to complete the work until November 15, 2006 in order that we can compiete the eviction and perform the balance of the corrective, work. , May I hear from you? c, Sincerely, Y . f E Peter M. Daigle c PMD/sjr cc: Richard and Diane Mahoney HAMahoney,Richard and Diane\ltr to Board of Health.doc Date: August 25, 2006 To: Building File From: R. Giangregorio Re: 35 Oreo Lane, Centerville M&P: 247-140 Zoning: RB Overlay: AP David(BOH) identified an addressing problem with this lot when he responded to a complaint. It appears that there are 2 DUs on this parcel. Frank in Eng would not assign a new number until the legality of the second unit was confirmed. A review of the building file shows the following: • There are 2 structures on MP 247-140.. • Both are identified as sf by Assessing. • The 2-story primary dwelling)was constructed in 1934 and effectively rebuilt in 1975. • The 1 3/4 story dwelling was constructed in 1935 and effectively rebuilt in 1969. . • BOH informs me that there are 2 separate septic systems. From the age and outside appearance of the secondary unit it is likely this unit was originally constructed as a garage circa 1930's and converted for residential use in 1969. Concrete still butts up against the structure as was common in the 1940's & 50's. (See BOH pictures taken by David Stanton). The interior pictures of the unit in question appear be typical 1970's style. All building permit applications will be referred to the ZBA. I reviewed the file with the BC. He agrees that the burden of proof is on the applicant because there is not sufficient evidence supporting the theory that the secondary unit was originally constructed as a sf. Certified Mail#7003 1680 0004 5458 3909 Town of Barnstable Regulatory Services sist Thomas F. Geiler,Director MASS Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Mr. Richard H. Mahoney August 24, 2006 6835 Morley Road Concord, OH 44077 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION, AND THE TOWN OF BARNSTABLE CODE. The property owned by you located at 35 Oreo Lane, Centerville, MA (Assessors Map-Parcel 247-140, rear dwelling which is improperly posted with the number"33" on it)was inspected on August 21, 2006 by David W. Stanton R.S., Health Inspector for the Town of Barnstable because of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: Two large water stain marks were observed on the ceiling upstairs, a water stain mark was observed on the ceiling of the mechanical room and a water stain\crack was observed on the ceiling of the first floor near the entrance door on the Northern side of the building. The drop ceiling upstairs appears as though it will collapse soon. There is an opening in the mechanical room to the outdoors located near the chimney. The floor in the bathroom was not level and had several cracks in it. The kitchen wall at the corner to the bathroom hall was observed damaged. The wall at the head of the bathtub was observed damaged. The concrete blocks used as stairs to the mechanical room constitute and accident hazard. A large amount of mold was observed on the bathroom ceiling. The entrance door on the South side of the building was observed with duct tape on it covering up the cracks. The storm doors on the North and South side of the building were observed damaged. The staircase railing leading to the second floor was observed loose. 105 CMR 410.482: Smoke Detectors: No operable smoke or carbon monoxide detectors observed. 105 CMR 410.401: Ceiling Height: The second story of the building is considered uninhabitable as it has a floor-to-ceiling height of less than seven feet. 105 CMR 410.351: Owner's Installation and Maintenance Responsibilities: The plumbing underneath the kitchen sink was observed leaking. The toilet was inoperable and set on an uneven floor with wood shims supporting it. The bathtub surround wall had crud coming QA Order letters\Housing violations\35 Oreo Lane.doc through the seam. The bathtub was observed draining very slowly and would bubble up when the bathroom sink was turned on. The bathroom and kitchen light switches were observed loose. 105 CMR 410.551: Screens for Windows: Several windows were observed without screens. You are directed to correct all the violations listed above within thirty (30) days of your receipt of this notice by stopping the source(s) of water damage throughout the building,by replacing the water damaged drop ceiling,by repairing the cracked ceiling near the North side entrance, by sealing the hole in the wall of the mechanical room, by repairing the bathroom floor so it is level, by replacing the damaged and cracked linoleum on the bathroom floor,by repairing the damaged kitchen and bathtub walls,by installing proper stairs into the mechanical room, by removing the mold in the bathroom, by repairing the cracks in the entrance door on the South side with an appropriate wood filler\sealant,by repairing or replacing the damaged storm doors, by securing the staircase handrail,by ensuring the appropriate smoke and carbon monoxide detectors are installed according to the Fire Department, by making the minimum floor-to-ceiling height of the upstairs at least seven feet,by repairing the leaking kitchen sink plumbing, by repairing the toilet so it operates properly and is properly secured to a level floor base,by repairing the bathtub surround to prevent the crud from coming in through the seam,by cleaning or repairing the drainage pipes so that the bathtub drains properly, by repairing or replacing the loose electrical light switches in the bathroom and kitchen so they operate properly and safely, and by installing screens in all of the windows. "Note: Any work that requires a building permit must have a valid building permit. It is noted that the Town of Barnstable Engineering Department has been notified about the improper posting of the 1133" on the dwelling. Engineering is awaiting the results of the Zoning Departments investigation to see if the building is legally considered a dwelling before they will issue an order or a change of address for the building. It is noted that COMM Fire Department has been contacted regarding the lack of operational smoke and carbon monoxide detectors. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. Mc ean, R.S. Director of Public Health Town of Barnstable Cc: Felicia Barreto, Tenant QA Order letterAHousing violations\35 Oreo Lane.doc TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION l Date UL, C31ureo Owner ►"i M omeu Tenant - f-C r G i' e Address Address 3 C�.�tPr�•��-e ✓��3 Compliance Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities X OW Sir lS [ecaPA1q 3. Bathroom Facilities V b s�w d ^ vy bu kR , 4on 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 4 W' ° s 7. Lighting and Electrical Facilities 8. Ventilation p.Iv SCreer Wt,r ws,i M"4wl r dewlr. 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use yr S ' � eJJ Wo 7 12. Exits V 00 �nq 13. Installation and Maintenance of Structural �P jfJ i/`74 f -1 ce/%.,, Elements f 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing PART II _ �� w►'��q r � ft -j�e sadI ss A)o C,e de ears. 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition c Person(s) Interviewed ` �� L' Inspector ),PyWt9S. If Public Building such as Store or Hotel/Motel specify here �A' t 114 Z7 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTF-ar RECEIVED JUL 3 1 2GU3 TOWN OF BARNS IABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICAT Property Address: 35 Oreo Lane Centerville MA 02632 (A l Owner's Name: Dick Mahoney Owner's Address: 6835 Morley Road v Concord,OH 44077 Date of Inspection: July 22 2003 Name of Inspector:(Please Pratt) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Map:247 Osterville.MA 02655-0049 Parcel: 140 Telephone Number: (508)862-9400 Lot:4 CERTIFICATION STATEMENT 1 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 N Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: July 23, 2003 The system inspector shall subm 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: • ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"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 'h 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. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 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: Yes No ✓ 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 CNM 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 FLOW CONDITIONS RESIDENTIAL 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: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) hmovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Oct. 31194-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs ofleakage. Recommend pumping every three years for maintenance. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -4'x 6'-600 gal. (H-20) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit had Yof water on the bottom. There were no signs of failure. The bottom to grade was 7'6" The cover was 2'below grade. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 Map:247 Parcel: 140 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot:4 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. A A 4 iq 43 a a3JO aq 3 3 ag 3 o y y aq yy 10 r s Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection andlor this report. 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL A5-FAl'-RSCE1VED DEPARTMENT OF ENVIRONMENTAL PROT CT5T 3 12003 TOWN OF BARNST,ABE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERT FICAT Property Address: loreo Lane Centerville MA 02632 Owner's Name: Dick Mahon , Owner's Address: / 6835 Morley Road Concord OH 44077 ( D Date of Inspection: July 22, 2003 Name of Inspector: (Please Print) James M, Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map:247 Osterville,MA 02655-0049 Parcel: 140 Telephone Number: (508) 862-9400 Lot:4 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 Need urther Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: July 23, 2003 The system inspector shall submit 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/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. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 11 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 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? P g ✓ 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: Yes No ✓ 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(3)(b)]. 5 I - - Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection (yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Aug. 23199-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs ofleakage. Recommend pumping every three years for maintenance. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was level. No solids were present. There were no signs of backup or failure from the leach field PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers,number: ✓ leaching galleries,number: 4 infiltrators with 4'stone(11'x 25)-per as built card 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.): There were no signs of failure from the leach field. The bottom to grade was approximately 5. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 Map: 247 Parcel: 140 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 4 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. Aoor 0 0 A Q i3oaa a 03 a 3 c0 a9 3 y v OL y y G3 s3 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 33 Oreo Lane Centerville, MA Owner: Dick Mahoney Date of Inspection: July 22, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record -If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximate 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 3 TOWN OF BARN TABLE LOCATION .% / A SEWAGE # ~' VII LAGE E1�j �� ASSESSOR'S MAP-&LOT =,� 1 INSTALLER'S NAME&PHONE NO. /214 0 C401` 4 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) y /'� �f NO.OF BEDROOMS BUILDER OR OWNS PERMITDATE: COMPLIANCE DATE: l / Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by CE7 Q b� TOWN OF BARN TABLE_ � qq:77.. LOCATION .yn /s 6,� SEWAGE # VULAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. _ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNS PERMI TDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist _ within 300 feet of leaching facility) Feet e Furnished by < ,c 0 A3 No. J i, -` J 4 Fee C THE COMMONWEALT OF MAS CHUS TTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN O ARNSTABLES MASSACHUSETTS 01pprication for Migogar *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No.ZS 012eO U10 C Owner's Na�mte,Addrr s and Tel.No. Assessor's Map/Parcel , o �� \_�V4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _C?11 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank \SQQ Sep\�iL Typ^e of S.A.S. 1�,�CscQccCb`i Description of Soil d Nature of Repairs or Alterations(Answer when ap licable) e1..S1� W V � u(EZIL- di 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 EnvironMgntal ode and not to place the system in operation until a Certifi- cate of Compliance y is of Signed Date Application Approved by Date Application Disapproved for the fo owing reasons Permit No. Date Issued s No. ' r_«..ice tit. D I 1V F¢¢ i - TIME COMMONWEALT OF MAS CHUS TTS Entered in computer: Yes ri PUBLIC HEALTH DIVISION -'TOWN O ARNSTABLE., MASSACHUSETTS- `. Application for �Bigogal *p aem (Congtructton Permit Application for a Pemut to Construct( )Repair( )Upgrade( )Abandon( ) omplete System ❑Individual Components Location Address or Lot No3'� Q e 0 Owner's Name,Add sand Tel.No. Assessor's Map/Parcel aC4 N�-_ � "l0 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of-Building: J Z Dwelling No.of Bedrooms -C?> Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons t. Showers( ) Cafeteria( ) Other Fixtures W Design Flow �--� gallons per day. Calcula ed daily flow( gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 00 S� `AC_ Type of S.A.S. C'cl Description of Soil �. Nature of Repairs or Alterations Answer when a licable :r ;'A< ( -- {. G C_ ./ t a4N0 - ( / flu Date last inspected: - r '- 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 Enviroa=jUqljQode and not to place the system in operation until,a Certifi- `t cate of Compliance, en-msue—Tl5y fhi"s" of Signed Date - ` Application Approved by Date Application Disapproved for the fo lowing reasons Permit No. ' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (tertificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(� Abandoned( )by l�-' — 1 at L F2 has been constructed in acc$rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit sha not be c tstrued as a guarantee that the 6 stem will functions desi edl {1 Date /t Inspectors q —=— No.--/�—� ----------------------- Fee THE COMMONWEALTH O.F.MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Otgpogal *pgtem (Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( Ab�anndon( ) System located at �� oX2 ac-) L-.o%, c-tpy,- t 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-perinit. Date: y / Approved by C Cle- SQ/ L``— -4 r,-e C- ifs QS"ll- �G�s, ' 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, hereby certify that the application for disposal works construction permit signed by me dated O —1507,R ( concerning the property located at C<;KK meets all of the following criteria: t,�- The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. (There are no wetlands within 100 feet of the proposed septic system C, There are no private wells within 150 feet of the proposed septic system v There is no increase in flow and/or change in use proposed v There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the ro osed P P leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) �1 B) G.W.Elevation �i a+the MAX.High G.W. Adjustment. DIFFERENCE BETWEEN A and B I�l SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder.cert ��`�r �._. �� w ', TOWN OF BARNSTABLE LOCATION ,f L'S SEWAGE VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 16 6 � LEACHING FACILITY:(type) (size) NO.,,-.OF BEDROOMS '' PRIVATE WELL OR PUBLIC WATER �e BUILDER OR OWNERS DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 9 \q })VIA' No.. ..:.: ............ Fss..... ... .... a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ...................OF....................:.........-.............,............................................. Appliratiun for Uhipasal Works Tome rur#iun ami# Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: Lot #4 — Black Oak Rd. ,, Ylarstons Mills g MIA ........................................................................................•--•-----. .............. •••- ••----•-••-------------......-•----.......------------•-----------.---•------- Capricorn Retojat st 765 Falmouth Rollo°; Hyannis ........---•-----...--.................•----•-•---..........--•--------............._............ ................•----•-•---•----•......----...._.........----------.........--•-----......---••--- W Steve Lebel Owner Address .........---•.................••-•---.....---...............------..---•-------------....--- -----.....-----•--•-....._......_..........------...........--•-•-•--......_,......---------...... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms 3.........................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of BuildingrariCh- ------------- No. of persons............................ Showers Cafeteria ( ) Pa Other fixtures -------------------------------•--••-•-••..................••-- W Design Flow......55...............................gallons per perso� er day. To al daily fl .Diameter________________ DeptkS_. ......... x Disposal Trenc�—No..................... Width._._._-----_._------ Total Length---_V........... Total leaching area.._-66--------- sq. ft. Seepage Pit N ..:.................. Diameter...b6_....._..__..... Depth below inlet................... Total leaching area....._______...._sq. ft. z Other Distribution box ( ) Dosi nk (� etl ) TltPrge Engineering 11-25-81 Percolation Test Results Performed bY-•-•--------••----•-•....-..---•--•---••--••-........................... Date........................................ 2.0 a Test Pit No. 1...........minutes per inch Depth of Test Pit-i2.�_____ Depth to ground watpone encounter— i / d Test Pit No. .............minutes per inch Depth of Test PWIA............. Depth to ground waterw ............... e 0. ....__...2............................................................. il. -... 1 Description of Soil.._.__._ Y ______________ x 2 n .....•Nf&dium yellow sand--------------------- -------------- 1�' - i2Y fined......Yii e sand•��race9 of`-----ravel no wafer at 12' --- g J--- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------=-------•----------•----•--••------•-------•-----------------...........------------....---------------------------....------------....._......---------------------------:.•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System ' acco ante ith the provisions of TITLi; 5 of the State Sanitary Code— The undersig d further agrees plat lie s em in operation until a Certificate of Compli ce �enh of health. Sign . -•••-.. . ---------------•-• 5....__ 7.118/8 Date Application Approved B _A _iy_ .e PP PP Y......... ......•-•----............................----........................................-- .......................... .1...... Date Application Disapproved for the following reasons:---•--...------•...............•------••-•.-•-•------...------•--•------•-------........._............••------•- I ...............................•-•----•-•---..............••••----•...--•--••-••-------- ...... ............•..............................................................Date PermitNo........ --•-..... Issued......................................................... Date ------------- Nc�. i Y T liw a� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable -- . ...............OF...........................--..._..........----------....--•---------.._....._........... Applirtttion fnr' DWVviittl Works Tomitrurtion rrmff Application >s hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage""Disposal System at: 4 Black Oak 1,d. , _U # jVia"rstons Mills 1, MA ........................................•---........._._..-•--------•--•-----•--•--••--•----_..._. _...._._.._..----•-....-•-•-•------•--------------._........._._......-----._.................__.. Capricorn Rea ` n A 'rust 765 Falmouth Roa ;N�iyannis .............................................. y..........._....._.......-•-------_----- ----••---••••---•-----•........--••--_..... --•-••--------.....•-•-----.................... W Steve Lebel Owner Address -----------------•----•----••---••-------.........-----••-••--•---------...--•----•-•--••••------- •------------•-•--....------...........-----------•-•-•---.........__....... .----...._......•••- Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms-3...........................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ranch............... No. of ersons_._._....__..._......__.__.. Showers — p., yp g -. - - p ) Cafeteria ( ) Q' Other fixtures ............................... ... W Design Flow.......5.5...:........................_.__gallons per person; per day. Total daily�flow_.......33_0____....._.........._........gallons. ll WSeptic Tank—Liquid capacit;�00Q..gallons Lengt§___ __________ Widtl __.1�..__.. Diameter..._..____.._.__ Depth.__$..___._.. x Disposal Trench—No..................... Wid�l;....................Total Length..... ........__ Total leaching area.._26b__......Sq. ft. Seepage Pit Nc�____________________ Diameter.... Depth below inlet_._.............._.. Total leaching area..___......___..._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..r'ldred e Eri lrieerin 11-2 81 g g.....................................g Date �r a 2.0 12' one encounte - Test Pit No. 1--j-------------minutes per inch Depth of Test Pit_..j.___.._..._____ Depth to ground water..._//..------_-_---__. 4A NZ............ per inch Depth of Test PiWA............. Depth to ground water.!l.__A..._._.__..___. e (s, -Test Pit No. ......................................................-...................................................................................................... O Description of Soil........ 2, loam._&..tOPS011•.-- • -••-••--------•.................. x 2 10 IY:edium yellow sand ------------------- -- ------ - - - 10' - 12' med. white sand traces of ravel no water at 12 ' W ----••-------- -------------••-----••---••--•-••-•----------------- g ••---•---•-•-•-••-•-•-•-•--....._......... VNature of Repairs or Alterations—Answer when applicable................................................................................................ --------------------------------------------•••-•-•••-•-•--••-•----•---•----•----•---•--•---........•-------...•--•-----••-•-•---•--•-•--••--•••--•-•----••-••-•--•--•-••--•-•••-•--•-•.....--•---..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL is 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Pres. Signed...................................................................................... ...... ._._ .... �D to Application Approved By.......... _'��...._.' ov— ••- ---- _-_---••----------•-•----------•----•-- -----•-_•---__- ---Date ___-_•--•--- Application Disapproved for the following reasons-------------------------•--.....----•--•----------------------•-----------.......---------...-------•-••••--_... -•-------------------------------•--•-------------•-------------------------------.........---•-••-------•---••..._.....-•--••-•...-•-----••-•-----•--•----••-•---•--••••----•-••---••---.........---- Date Permit No...........-I !Lt---- -y" ----------------- Issued_-------•-------- Date j THI="COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .: Town tim_:. .,............O F......A.krns t abl e ...... ..................................................... ��er#ifirtt��e of f�aaut�littnr>e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( . ) by-------------------- ---•----•---- S t e ve L e bel----------------•-------.._...---------•--._....-----.....-•-•-----..._...---------.......---•----------•••---....._ — Black Oak Road, Install at........Lot =�_-_._ __ ___________ �Vlarstons_•.Mi11s , r.;A has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the . ...........-•-•--•. dated................................................ application for Disposal Works Construction Permit No.___._.. .. .4/ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............. ..................................... Inspector. --.::..�-•---•---••-------•-•----•--•---------•--•----......--•-•----- THE COMMONWEALTH'OF MASSACHUSETTS BOARD OF !HEALTH Town Barnstable' y OF...... ... ... .................. ................................................. No.......A................ FEE..............---X..... Mipaasat Works Ounotration rruti# Permission is hereby granted.. Steve_..Lebel•-•-•---•••••--•-•••.••••--•---••---•-•-•-•--•••-•••...................................... to Construct .. ) tar Bak( Oj•kn 1� jual Sewa a Disposal System T ...._..---•--•-•---••ar s to n s__Mi l l '"A at No...__�ot Street as shown,.on the pplicat n for Disposal Works Construction Permit No Dated_________________p�°`�s......_._.... .................. Board DATE--------------------------------...................................-........... . of H th FORM 1255 A. M. SULKIN, INC., BOSTON oi , a z r 66 Qq h3✓_ -_.... -...... - �6 �1_.'•T• ice, '• �f`o i b� - ' �.- . N 3z r T 5� , Ae 71� /. �. AC7 \ fill 7 IX v ti \b tv c A c is 1 F �h / S '� '� N�! �S 5✓n,Na C,c?T f'!,�oT't'._c?'7 c/� 7'UWN T�L( C.4W5 OF ( ,� CERTIFIED PLOT PLAN. LOT13L 4 C K ,D�' r 1 ti o ORSE q ROBERT . r v �. / BRUC.E �•� �jl �7T0 /�/ LLS t . No.10951 ,o9'P�� ELDRED • IN x r i fs MNA< r 1 ; , SCALE /"=30 DATE 1 LDRE`DGE' E"NVANEEMINe r��,✓� CLIENT_ i CERTIFY THAT THE PROPOSED hr0lSTER REGLST�1�E , riF, 00� NO. 83'25 6 BUILDING SHOWN ON THIS PLAN IVI.L. CONFORMS; TO THE ZONING LAWS N IP1EER D8Y? OF BARNSTAB L E MA S ?12. MAIN .STREQE� T'°� z��i' HY� B ,. L 'H Y A N N I-$ M A �: ?� �`,: d DATE REG. LAND SURVEYOR 4 Yd1a T. NR -. _. . .. �. .. ink .. n, ._ - • u, I. 2- G PITuA ite MORE 7 M.,V AZ BM-0 Pli/ -24"VIAAIIA=T.ER 4&-F oY7' 710 4,TA Co&CR&r'= -4 Vy 1�:A 5 7 /lVo COV,- R'AllAol. A?TC j E.o COPERS Y8 AWR =7. 4WI VA- JVA Y AMV. co PIZ=lql C 4 =A Al -TA N AS) 46A C-+e L 4"CAST *LAYER GAL. 0 ,alp MIN.PfrCN • • P& . D15 , WAS H--D 570ye AK ajoy t 1 0 STONE A & .76 *pp 4�. • PRECAS r EIA6f lAtVeAr y- P1 7 OR,AW411 V. 8;Z, 453 INVERT.A7- 01114.011V6 6 0;J Fr % /0 F7 471AIW. IV4,E7' JWPTIC .71.4NK i C(54-5 7;WVI-4 7-1 0,V )VH -7 04,174467"SZP771C 7A lAoL.=. r-0-157R.14011710H 80)e S'Xs 4c'7 GROUND W,4 TeT TABLEBOX ooc- hV4R7 ,L--ACY1lVa 00-17- A014So0P4%SAJ- S)"..S716M . LEACH/ 0411-ATIDA" , lVoCP PIT 7A DRSISAI CRITERIA SCALE cullFIV51 0 At A P"T. 'VZ1Af&ZR OF BEDRoOlyS Y 4 F r /,I, SDI Z-O& rO7-44 &--4rT1t4A-r,=,o =I_O*V 330 0,41 TEST T $0/4 7L4 M-S 7-02 S,011- TEST A Y SO It L. NUMBER 0,oc' 4,eACMhVa PMS ,[DATE 7' SIDE 4MACHIlVer PER R17- /9-S- a 0 rroAf LAS4 C/Y/,Vc- 7 o - 2- ,' 7- RESUArs AvirIv&ss�--p By /3,13,'-c -1A so. Ar Z- j.,Al1lVCH TOTAL 1-Z4CH1WCr AREA Z& FW1tC0l-11'r1ooV RA7-,4=A Z ✓MJIV.///VCJY W. FT Zip tk OF O�F -k- R ERT ALB 7`62AI-Z' /V7 L-&S^ U E ELDRED E Na 1095t CIIIIL-%x AE I-DREDGE ENCH CISTS LJ ei- AJAJAI -577kD , 0 M.Ea6 HYA AA I MASS. 0 �-- ' ,A- 0,4 7"��- 7/11 lo G)TO UVZ�, kVA 7 A r -,EV R3 -,--s6 -z- Jola 1� TEST PIT -* PERC. TEST LOCUS VGRADEY ISTIN PB # � # 2 99.2 _ _99.3 97.8_ LOAM 97.9 ' LOAMY SAND 100.00, 9G.2 PERC RATE < 2 MIN/IN. 9G.3 APN 247 - 140 @95.0 ti 14,477-t 5F (CALC) LOCUS N.T.S. DESIGN / GARAGE 13' 0.0' MEDCOARSE AND SINGLE FAMILY DWELLING W/3 BEDROOMS EXISTING PIT � r--- ---2 / BENCHMARK: ELEV. = 100.00 5% GRAVEL NO GARBAGE DISPOSAL (TO BE PUMPED I (ASSUMED DATUM) DAILY FLOW= I 10 x 3 = 330 G.P.D. FILLED W/SAND). Tp I r� SEPTIC TANK(VOL. REQ'D) EXISTING TANK �-7 330 G.P.D. x 2 = GGO GALS (TO REMAIN) / I W 1000 GAL.TANK-O.K. (EXISTING) It O 89.2 NO WATER NO WATER _89.3 LEACHING AREA(S.A.S.) W O / O W O USE 2@ 5'x 8'x 2' P.C. CONC. L.C. 4' STONE if) a-- a / EFFECTIVE DEPTH = 2.0 ro ` j x 2 X [48+ 2G] x 0.74 = 1 10 ' x 13 x CITY = 231 TE5TED 1 1/30/09 TOTAL CAPACITY = 341 GALS. i IWITNE5: DAVID 5TANTON, R5, I I / k I DIRT DRIVE I /No. 35 / I 1/2 STY. TOF = 100.59 NOTES: I . DISPOSAL SYSTEM TO BE CONSTRUCTED IN STRICT ACCORDANCE WITH COMMONWEALTH OF MASSACHUSETTS ENVIRONMENTAL CODE TITLE V. 2. LOCUS IS SHOWN AS APN 247-140 ON THE TOWN OF BARNSTABLE ASSESSORS' MAPS. x 3. CONTRACTOR TO CALL DIG-SAFE 72 HOURS PRIOR TO BEGINNING CONSTRUCTION AND/OR EXCAVATION. 4. CONTRACTOR TO CHECK INVERF OF EXISTING TANK. 5. PUMP SEPTIC TANK, CHECK 75 AND INSTALL GAS BAFFLE. CB/DH FND HELD ` DIRT DRIVE 100.00, _[ G. THIS PLAN IS NOT RECORDABLE, NOR DOES IT DEPICT AN ACCURATE PROPERTY SURVEY, AND 15 THEREFORE NOT TO BE USED FOR CONSTRUCTION OF ANY KIND, OTHEK HAN THE ELEMENTS OF THE SEPTIC SYSTEM, AS SHOWN. -- `Q' 7. THE SITE BENCHMARK IS BASED ON AN ASSUMED ELEVATION AS SHOWN. LEGEND 8. LOCUS IS SERVED BY TOWN WATER. 9. USE 2 @ 8' x 5' x 2' P.C. CONC. LEACH CHAMBERS, WITH 4' OF 4" TO 12" DOUBLE WASHED O REO LOAD STONE ALL AROUND WITH 2" LAYER OF WASHED PEA5TONE ON TOP. 24 �_ 1 0. PLACE ZAB T"EL FILTER IN OUTLET ' OF SEPTIC TANK. PROPOSED CONTOUR I I . PUMP * FILL EXISTING PIT. 12. LOCUS IS SERVED BY TOWN WATER. 20 0 10 20 40 /��/ 10 EXISTING CONTOUR 13. LOT LINE DIRECTIONS ARE ASSUMED. (RECORD PLAN HAS NO BEARINGS SHOWN). DRIVEWAY ( IN FEET ) C FIRM ZONE III = 20' FIRST FLOOR 51TE PLAN EL. IOI.G TOP OF WALL EL. I OO.OG EXISTING GR. EL. 98.8 G"MIN./3'MAX. COVER ACCESS P)RTS It FIN. GR. EL. 99.2 2%SLOPE LW /IN 3"OFGRADE MIN. C V ER\\/ MIN:COVER G"OF GR. 2"PEASTONE EXIST. 1500 I [fOP O TESTHEALTH AGENT APPROVAL DATE GAL. TANKwive"97.3 (H-20) LEVEL 2'LEVEL - ° - \� EL. 97.0 D-BOX o 000�000 EL. 96.2 / FIELD P.C. CONC. �� Q�gq°bbpb bbo CHECK ��pp 6"MIN. EL 96.4 ��o�$°Opo EL 94.2 °°,$„o�go°o°%o° g9 ° OAAuB °�!�° 11PI Po° og EL. 9G.6 o6os .o�8o8dg9 �_ DEPTH OF LIQUID -4' \ G"CRUSHED STONE OR COMPACTED I O'MIN R74sn. 5'MIN- ° HARRY ti PROPOSED 5EPTIC 5Y5YTEM DE51GN INLET TEE DEPTH - 10"MIN. 2"MIN. 2`a C1'14 yc OUTLET TEE DEPTH 14"MIN. _ I 20'MIN. 35 OREO ROAD LANTERY, J . HI 13ARN5TA13LE *CENTERVILLE) MA 0 BELOW p No.2 EL. 89.2 0,�FG�s Ei �`�� RICHARD MAHONEY �sS/ONA! " DESIGN BY: sURV-Y BY: DATE: SCALE: JOB No. PROFILE OF D15P05AL 5Y5TEM �-¢-- ADVANCED TECHNICALSOLUTIONS j r.J. hood son, Inc. 30APRIO AS SHOWN 09210 �� (O JI P.O.BOX 99 18 ROUTE GA ( DRAWING NOT TO SCALE ) EA5TSANDWICH,MA02537 SANDWICH,MA025G3 DRAWN: CHECKED CHECKED 774.313.9547 506.533.7100 rrJh HEL fJh(Survey) i