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0073 OVERLOOK DRIVE - Health
73 Overlook Drive Centerville A= 188 — 121 5 M E A D No. 53LOR UPC 12543 smead.com • Made In USA TOWN OF BARNSTABLE LOCATION 7 j Bel '-pa _ l ' k _"Oi/'t 1//_-- SEWAGE#_�015 VILLAGE ASSESSOR'S MAP&PARCEL/$B' INSTALLER'S NAME&PHONE NO. �'Od-`r�U —�JT3��os��✓� 0�,(j,4rraS SEPTIC TANK CAPACITY 4r60 LEACHING FACILITY.(type) 2-5'0 9 �ll/wo4A'�5 (size) NO.OF BEDROOMS 3 OWNER PERMIT DATE: Z/- /,- 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 FURNISHED BY p � � kl- 2 = So• � � �� S7•3„ -73 Overlook �9 t 3 3 4 14 TOWN OF BARNSTABLE LOCATION 7':�k CA)e-&ck DR SEWAGE# I VILLAGE('ew4i a'P ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. l SEPTIC TANK CAPACITY C_e ez'wod.S LEACHING FACILITY:(type) -00e( a I &+ size) NO.OF BEDROOMS OWNER CyY lC� PERMIT DATE: 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 o eaching fac' ' ) z Feet FURNISHED BY D to GU n I - r � e �` 36 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plication for Disposal *pstrm Coustfuction grrmit Application for a Permit to Construct(/if Repair(CKUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 75 Q w r L ook Or, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Qg- 2 I taller's ame,Address,and Tel.No.,5109 4/20-'?75 S' Designer's N e,Address d Tel.No.,g0s_ �oszo�i f� 1. rQv'v o 5 N1/ �:r �'oh Sc Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures J Design Flow(min.required) gpd Design flow provided �j"( 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) :,,Tj4.5r*I1 64/°b4G!!ti� TO Pll4li/ 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health, Signed r Date Application Approved by j2AIL 72 Date Application Disapproved by U Date for the following reasons a 1 Permit No. P Date Issued .- No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s Yes PUBLIC HEALTH DIVISION - TOWN O N OF BARNSTABLE, MASSACHUSETTS 01pplication for IBisposaf 6pstem Construction Permit Application for a Permit to Construct(4-f Repair(G)oUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.-f,3 D V&-'r L ocl1C'Or, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel g$-121 lyT��V'�/'" V�Z Installer's Name,Address,and Tel.No.f D$-z/20_ q,7 3 $ SD Designer's Name,Address and Tel.No. " 9 ✓os�ph 0. iod'e^o 5 Gl9ly7�Y7.c � �v tvtiS /=• S'�v� �vic�i �� U2,f�3 Type of Building: ; i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures t J Design Flow(min.required) gpd Design flow provided �j"1 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil w. f Nature of Repairs or Alterations(Answer when applicable) TR.5 r4Il 14/_'o rjl..,7 r0 OAZI-7�5 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health, \ C / Signed Date Application Approved by\. - Date �j "/��^ /5 Application Disapproved by Date for the following reasons f` Permit No. !'V l 5 Date Issued - ----------------------------------------=----------------------'------------------------------------------------ ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(44 Repaired(4-1 Upgraded(v) Abandoned( )by OSGb Ot Lg4,K, 0 at 7?, OI/!:y Lank Drey7s` ("150t4511y1111:E has been constructed in accordance _ \ with the provisions of Title 5 and the for Disposal System Construction Permit No.(9615 �/ dated �C� Installer A5404 Q-C 614!^N�S Designer y/J/-,y/ r ¢ sol1 S L/1 G. #bedrooms �3 Approved design flow -3 3D gpd The issuance of 's pe it shall not be construed as a guarantee that the system wil funs in io In desig ,. Date �� ❑ Inspector (/ --------------------------------------------------------------------------------------------------------------------------------------- No.p2OI S 3 (Tv Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair Upgrade Abandon( ) System located at '73 /,t//:l-L ook- !�✓i i//: y/%/1= 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. t --- Provided:Construction must be completed within three years of the date of this permit. L � 5 Date 5 — �-1 Approved by f ' 05/18/2015 07:38AM 17744139468 MEYER AND SONS PAGE 01/01 Town of Barnstable Regulatory Services $ Richard V.Scali,Interim Director 1 Public Health Division i Tbom►as McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form , Date: Sewage Permit# Assessor's Map1Parccl Designer: P �.� Sal., Installer: Address: T_�j�[ j �`� Address: g e a MM e Af )-AIV,= AA4 IVY t,rS 7�'ris In on a 6 - was issued a permit to install a (date) (inist�aller) septic system at 73 0 V� (00 " — r[_ based on a design drawn by {address) e dated' (designer) DC\,(ye,\ Mel � I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved cb=ges such as lateral relocation of the distribution box and/or septic tank. Strip out (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 10' 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. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA approv letters(if applicable) DR t er's ignature) M 140 (k/, (Designer's Signature) 40ii'� r lr6 -I PLEASE RETURN TO BARIYSTABI,E LIC UALTH DMSION CE,RTIFIC,A,,TjE OF COMPLIANCE WILL NOT BE ISSUER UNTIL BOTH TMS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION T {YOU. Q:\SqMiC\D03i9fterCezfification Form Rev 8-14--f3_doc stable Town of Barnstable Barn Regulatory Services Department •�- �"a�j BARNSrABM i ,0� Public Health Division �fD 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7014 1200 0001 0358 3315 5/14/2015 Sherri Vazales 12 Belle Avenue Petrosky, MN 49770 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 73 Overlook Drive, Centerville, MA was last inspected on • 4/17/2015,by Mark Polselli, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Cesspool structural) unsound. P Y You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace,the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH cKean, R.S., CHO Agent of the Board of Health i Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\73 Overlook Dr,Cent May 2015.doc Town of Barnstable i STAABL& ,A 059. ,�� Regulatory Services Department tfp may# Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/28/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §3607-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <1.2" below pit (per Town Code §360-9.1) OTHER Y�o S-�f"c VfI"Ik VA �o-UllU Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 e OL9 r Prop"Address e /'/ �a n is ner owners r�,�Gem-� /1/ �i4 required for every page. CRY/Town State Zip Code Date of tnspecC n Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checidist at the end of the form. a'P* "'�" A. General Informationffnq Out Q orms W ft computer, use b l �theta 1. Inspector your key to move / cursor-do riot use the alum Name of Inspectcrkey- r--- CbmQarry Address I O� C41Town 10q o)-O 0."._ /M state VO-e Zip ODde Tephone rower Um"Number B. Cerdfication I certify that I have personally inspected the sewage disposal system at this address and that the information repoded below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site ` sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The system: ❑ Passes ❑ Conditionally Passes Fails ❑ NeeN Further Evaluation by the Local Approving Authority 7//s 6u s signat<re Date The s stem inspector shall submit a copy of this inspection report to the Approving Authority(Board of H or DEP)within 30 days of completing this inspection. If the system is a shared system or has ign flow of 10,000.clod 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. t5m•3N3 rA850f4 d tMF-5, Fam Sutwfaee SexegeDisposal Snlem-Page 1 ofV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dlspt I System Form-Not for Voluntary Assessments 2's OmeylO0� S ✓y� iRoperty Address V,4 Z e,; le s oN ner Owner's Name inforrnatiay is ��✓V< •� rewftedforevery page. Oy/rown State Zip Code Date of pe ion B. Certification (cons) 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.orrepaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for'yW-'.`no'or'not determined"(Y,N, ND) for the following statements. 9"not determined,"please"ain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is stmdurally unsound, exhibits subs an'd infiltration or efittration 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 wdl 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): 19m•3h3 TMe50f PcW 1 sps0cnfart[Subsuf=Sewage Disposal System-Page 2of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments �3 0 Ile Y-loo� ,�✓a nv a rtyAddfess V14 Z le reqtdred for every State Zip Code Owe hsp tion POP. (2y/Town B. Certification (corlt.) ❑ 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 CNIR 1&303(1)(b)that the system is not functioning in a mannerwhich 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 t •3h3 TaleSof ad ImpeOMForm SuOsorfaeeSevperxspo1 SY"m-Page 3017 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11.3 oyek-adodr d✓ Property Address zte ON ner Owner's Name infonnation is regWredforevery r__eo ✓I/6 �lQ O�(� �� /> page. Ckylrown State Zip code Date of Ins B. Certification (cons) 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 colifonn 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' irate "Yes" or"No"to each of the following for all inspections: Yes No Cess�o l S4,1-U c r !-1 Kf o k k j Backup of sewage into facility or system 2ponent 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 ❑ tatic 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 1Sns•3M3 Title50ffd91mpwficnFam[Sub%deoe Sexagebispmd Sysbm•Page 40117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address requiredforevery aty/rown State Tap Code Date of hsp won pa B. Certification (conL) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ potion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 ket of a surface water supply or tributary to a surface water supply. ❑ Any potion 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. ❑ L�' 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 N 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, Zapnd Wed that no other failure criteria are triggered.A copy of the analysis chain of custody must be attached to this form.] ystem is a cesspool serving a facility with a design flow of 2000gpd0gpd. 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 fail ure. 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 drinidng 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—lWPA)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. t5ms•3tt3 rme50ffidd bup=6M Fart Subw1a=S6vQQeMV05d SAM-Page 50 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /�o lr /�✓ Property Address owner ow r�s Nave r/G /� �a �o� 7 pro � � req�,edforevery e page. Cdy/rawn State Zip Code Date of n C. Checklist Check if the following have been done.You must indicate'yes"or*no"as to each of the following: Yes NO ❑ ping information was provided by the owner, occupant, or Board of Health ❑ any of the system components pumped out in the previous two weeks? ❑ 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 thus inspection? Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? ❑ ere 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 scrum? ❑ Was the facility owner(and occupants if different from owner)provided with infor mation on the proper maintenance of subsurface sewage disposal systems? size and location of the Soil Absorption System(SAS)on the site has n 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: 3 Number of bedrooms (design): Number of bedrooms(actin): J DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5w-W3 T4e50ffiW kzpw5mFomt SubsWaw SewapDhposd Syom•Page W 17 Commonweahh of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 011ev-Iaok- 4e Roperty Address ON ner ON pees Name rW011n3ft is fe9lefy 660 t11161� pW, Cdyrrawn State zipCode Date ins D. System Information Description: (f) Q J - eSS [ Number of current residents: Does residence have a garbage grinder? ❑ Yes [9- No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes [A- No information in this report.) Laundry system inspected? ❑ Yes QLI46" Seasonal use? ❑ Yes MA46' Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commerciabindusbial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gal=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: true•3M3 rmesoffidd bspwSmFamt Subsuface Swaget)tgm al Sydo •Page 7of17 Commonwealth of Massachusetts Titre 5 Official Inspection Form Subsurface Sewage Disposal System Form Not fur Voluntary Assessments 9,3-- 0 Property Address / (le ON ner - ON nees Name U�6�� some Cep► r!e✓�i �e /�l 4L- reqtdredforevery tkyfrown state Zp Mode Date of tns n Pam- D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General information Pumping Records: /v Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gatbns How was quantity pumped determined? Reason for pumping: Type of System: ❑ 7ing. c tan (distribution box, soil absorption system ❑ 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval- ❑ Other(descri be): i lieesotfiaalsmp=&nFamcsubudacesawma posaiSystem•Page$of1 ' i5us•3n3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 0 IAe,-l(qC2�- Z�✓ R'opertyAddress z Owner Owner's Narne mWjftd for every Cep r�� AX, �oa 13 page. City/Town State Zip Code Oahe of#peaWn D. System Information (coat.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes Cr No Building Sewer(locate on site plan): Depth below gra feet Material :ons tn�ction: cast iro ❑ 40 PVC other(explain). Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank'(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tarn is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: •3h3 Tine5Of OO hspee5MForm Subsufaoa Savage Disposal System-Page 9of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments Property Address Ow nor Ommes Name CG ."I OD-6 3� information is ,,,, reqWredforevery CRy/rown Zip ODde Date of hispegfion D. System Information (conL) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, 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 Sm•SM3 Tine SO Sdd UspeCIM Farm 9AMdaee sew3et l SyOm•PVG 10 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2 �eY ©O �✓ t� I ! "Address 1/' le Ow nor Ow ne's Name DateQ f/90irtfOrMaWn is repired for every PW- aty/rown SM zip Code NW, In action D. System information (cono Comments(on pumping recornmendations, 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: gapers Design Flow. gal=per dej Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working osier. ❑ 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 ryas•Y13 ride50r5dra11mpec5mFina Submrfaee$w*geDiwasd system•Page 11 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Form-Not far Vol unta Subsurface Sewage Disposal SystemrY Assessments iir 1� � 1 Q 1/ev oo V a/- ftWty Address 11,4 2 cr �eS Owner Owner's Name /2� r/6l yaC�J Pap- oy information is (� dforevery drown State Z•iP Oode gate of lion Pam- D. System Information (corn.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. Yes ❑ No' Alarms in working order. Yes 0 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: S 12 u 17 trus•3It3 TitleSOfSaattrspeC6mFart[SubsulaceS�e ysffim•Page Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form /-Not for Voluntary Assessments Roperty Address 'redo e'on is Owners►Jame /�e N e ,.� O,2�T,- / (� /q regfm�edforevery State 2�Code Date of h n per- Ci rr wn D. System Informafl®n (corto Type: ❑ leaching pits number ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: - overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert / 11 Depth of solids layer Depth of scum layer Dimensions of cesspool 11/ 11QaC11447x � Materials of construction Indication of groundwater inflow ❑ Yea tsm 3"s Tile 5Offidd k spectm Fam[suheut=sewvae Sp%m•P 13 d 17 is Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments Di /2 O ye°t-�oo ly, a✓ Property Address ✓/�Z G C'-es' Om nor Ow ne's tine I information is ` e requaedforevery page. Cly/rown State Zip Code Dte of spe m D. System Information (cons) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ��S �o � /lit G (�t✓ �.t H St7�� f i i Privy(locate on site plan): Materials of constriction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ISM-313 Title 5OMW trspectl, Fam Subsurface Sexrage oisposd System-Page 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Z � le inf An►ner's Name CeV+ ✓f/ Q 4q �O`��� a�famtadion is requiredforevery ..12LI 5 Pap- Ci frown State Zip Code Dme of Mpea m D. System Information (cons) Sketch Of S Disposal System: Provide a view of the sewage disposal system, including ties to at least two anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where is water supply enters the building. Check one of the bones below hand-sketch in the area below ❑ drawing attached separately F12°r� Q a 14 Ae7 14J-1- Jo 30. 15m•3M3 Trde 50(k ial kspeckm Form Subsurface sere Dispwo System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form IV Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9,3 Property Address owner owners Nwre /'2 y�7�r/ �a�6 irdomia6on isreqtdred (� forevery Cily/rown State Zip Code 9!!OfAsped D. System Information (conL) Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells '�— Estimated depth to high ground water. feet �L 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: late ❑ 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 des how you tablished the high groundwater elevation: AA Id /lib 1,14 jt"-� Before filing this inspection Report, please see Report Completeness Checklist on next page. O s•3H3 rMe 5Offidd trspeegmForm SubsWace SewW Disposal System-Ree 16 of 17 • Commonwealth of Massachuwft Title 5 Official Inspection Form Subsurface Sewage Mq osai System Form/ •Not for Voluntary Assessments RoperryAd&M Owner Owner's Plane Wamoftis ce", � 1 011, l Qyffmn ftw rO Code Dab of E. Report Completeness Checklist U-�kspection Summary.A, B, C, D,or E checked M--- speCtion Summary D(System Failure Criteria Applicable to All Systems)completed �o111w n—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate fie WW-9N3 rM950f hl bspecI Form Subartw Some* SYtlm•Pt"17 of 17 t� ��o CIP Town of Barnstable Office: 508-862-4644 Fax: 508-790-6304 Regulatory Services Department M Public Health Division BARAULK Mom, . Thomas A.McKean,CHO 200 Main Street, Hyannis, MA 02601 F6 MA'S Payment Receipt Septic Inspection Payment received: $25.00 (Check) on 5/5/2015 Permit number: 10824 .Check number: 7901 Check amount: 2$ 5.00 Name on check: Brad &Sherri Vazales i Business: Envio Tech (Polselli) Owner: SHERRI VAZALES Address: 73 OVERLOOK DRIVE,Centerville i i Town of BA nstable P# Department of Regulatory Services L� 1� • Public Health Division Date ". 16J9- .b 6 200 Main Street,Hyannis MA 02601 .1 Date Scheduled r 'Time� Fee Pd. vJ ' � f oii Suitability Assessment fog- Se cajeisposaPerformed BY: Y Witnessed By: r i LOCATION & GENERAL INFORMATION Location Address �, dV t b � Owner's Name NT l/LV itA,� I Address IZ_..(3aa,l_C -t'tvE ,PET0 s I_ty 041 qq��o Assessor's Map/P4rcel: 1�jC, r 1 21 I Engineer's Name O a / ( I rr Y A F NEW CONS1'RUtON REPAIR Telephone# J'$,.-340 +` Land Use � Slopes(% "' �6 ��: Surface Stones Distances from: Open Water Body 20o f[ Possible WecArea->-2-0�ft Drinking Water Well_-L'I__11ft ))reinage Way ®o l) f[ Property Linc �/6 ft Other ft i SKETCH:($tree[name,dimension$of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) i 1 I f I i i 1 • 1 - - i 4 Parent material(geglogi Depth to Bedrock Depth to Groundwater. Standing Water in Hole:' Weeping from Pit Face Estimated Seasonal Tiigh Groundwater DIt ATION FOR SEASONAL HIGH WATER T"LE Method Used: In. Depth Co! standing in obs.hole: in. Depth to still mottles: ! in. j.Aftwater Ad)uet d. ft Depth toiweeping from side of obs.hole: ! _ A :►�tor.,.,._..9-- Aj fJraundwaterlevel,,,,s, Index Well# _ Reading Date:1 Index Well lev6l -- PERCOLATION TESTDate 'xlnse' Observation I Time at 9" -_.— Hole# . I Time at G" Depth of Pere Time(9"-G") Start Pre-soak Time.@ • i End Pre-soak I ; - I Rate MinJIneh Site Suitability Assessment: Site Passed Site Failed; Additional Testing Needed(YIN) Original:.Public Rjalth Division Observation Hole Data To Be Completed on Back--- U***If percola#bn test is to be conducted within 100' of wetland,you must first notify the G._,�„ eek prior to beginning. Barnstable C411servatien Division at least one(1) w DEEP OBSERVATION HOLE LOG Hole# Soil Other Depth from Soil Horizon Soil Texture Soil Color Moulin (Structure,Stones,Boulders. Surface(in.) (USDA) (Munsell) g Consistent %Gravel Al � �Q'M AytN Io��3ty o rrl 7 DEEP OBSERVATION HOLE LOG Hole# Soil Other Depth from Soil Horizon Soil Texture Soil Color M ttlin (Structure,Stones.Boulders. Surface(in.) (USDA) (Munsell) g Consistent %Gra el 3 Lo p-q-1' �b lNq" �• r � �@ �l DEEP OBSERVATION HOLE LOG Hole# A Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel MIA DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistency, ra I Flood Insurance Rate May: Above 500 year flood boundary No Yes -Z Within 500 year boundary No Yes, Within 100 year flood boundary No Yes " Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist,in all areas observed throughout the area proposed for the soil absorption system? \ 1.'P If not,what is the depth of naturally occurring pervious material? Certification I certify that on Q (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the requir ni R9,experti a and experience described in 3"10 CMR 15.0 p 17. Signature gX\ Date Q:ISEPTICIPERCFORM.DOC Commonwealth f o Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 OVERLOOK DR Property Address Owner COHEN Owner's Name information is CENTERVILLE required for MA 02632 3/3/08 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. '"'p°fta"t When filling out A. General Information forms on the .computer,use 1. Inspector: only the tab key to move your DOUGLAS A. BROWN cursor-do not Name of Ins ector use the return p key. DOUGLAS A. BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 " City/Town State Zip Code 508-420-4534 S 14297 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. T;h� inspection was performed based on my training and experience in the proper function and mai f tenance,:bf one site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15:340'of Title 5(310 CMR 16.000).The system: i N) ® Passes ❑ Conditionally Passes ❑ Fail `n Fl• ❑ Needs Further Evaluation by the Local Approving Authority co 3/3/08 I pector' i nature Date The s stem 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. Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is require for CENTERVILLE MA 02632 3/3/08 d every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MEETS MINIMUM PASSING REQUIREMENTS AT THIS TIME, CANNOT PREDICT FUTURE PERFORMANCE OF SYSTEM DUE TO AGE AND SEASONAL PAST USE. 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 Title V Inspection Form.doc•08/06 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 4 t Commonwealth of Massachusetts GAsm- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for MA 02632 3/3/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: j ❑ 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. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for MA 02632 3/3/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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. Title V Inspection FormAoc•08/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 S [ Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for MA 02632 3/3/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No _ ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '^ 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for � MA 02632 3/3/08 every page. Cityfrown 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)] TMe-V InenurNnr Farm„=.mina Ti�!e s Official ire � -on Form:Subsurface Sow age^isposa!System•Page 6 of 15 .. .. _ p oL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments rt 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for MA 02632 3/3/08 every page. Cityrrown State Zip Code Date of Inspection 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? '® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 06-30.1/07-30.1 Sump pump? ❑ Yes ® No Last date of occupancy: SEASONAL 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: Last date of oceupancy/use: Date Other(describe): Ta!e y!nspectior;F_rmA=-nail Title 5 Official irspio^Form:Subsurface S-.mp rn sa!SIVELarr.-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y` 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for MA 02632 3/3/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ 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: APPEARS TO BE ORIGINAL SYSTEM Were sewage odors detected when arriving at the site? ❑ Yes ® No Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. ' 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is required for CENTERVILLE MA 02632 3/3/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate an site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Tie v inspection Fo m Am•011106 Tills 5 Official Inspection Form:Subsurface Sai-vage Disposal S�stwm•pap 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for MA 02632 3/3/08 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): MAIN CESSPOOL AND OVERFLOW WERE DRY,STAIN LINE IN OVERFLOW AT ONE FT FROM BOTTOM, ORENGEBERG PIPE LOOKED TYPICAL OF AGE,BLOCKS LOOK OK FOR AGE. Grease Trap (locate on site plan): Depth below grade: - feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain): Tito V inspection€orm.doc•06/66 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '( 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for MA 02632 . 3/3/08 every page. 6ty mown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title V Inspection Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is required re wired for MA 02632 3/3/08 every page. City mown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ 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.): OVER FLOW CESSPOOL STAIN LINE AT ABOUT 1 FT FROM BOTTOM Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is required for CENTERVILLE MA 02632 3/3/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 IN LINE Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): BOTH POOLS DRY AT TIME OF INSPECTION, MAIN POOL HAS BEEN FULL IN THE PAST OVER FLOW, STAIN LINE AT ABOUT 1 FT FROM BOTTOM 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.): Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for MA 02632 3/3/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 2 i IRONT T �= 9- - 30 Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 OVERLOOK DR Property Address COHEN Owner Owner's Name information is CENTERVILLE required for MA 02632 3/3/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 15++ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: SITE IS ON TOP OF A HILL Tide V Inspection Form.doc•08/06 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 l Town of Barnstable Op THE Tpk yam` ti� Regulatory Services snxNsreate MAS& Thomas F. Geiler,Director 9$ 1639. Public Health .Division ArEo�y A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. h LOCUS MAP N.T.S. o 28 0 , R v LEGEND D PROPOSED CONTOUR o m BENCH MARK � � � � o TOP OF FOUNDATION o` � PROPOSED SPOT GRADE W v 4 6.5 3 43 —— 98 —— EXISTING CONTOUR �y ` BARNSTABLE GIS DATUM 44 ; F + 96.52 EXISTING SPOT GRADE �NgOW OR• 1 1 \ W— EXISTING WATER SERVICE 46 A 36 45h it 1 ;� TEST PIT BUMPS R R SITE Q �►�ER Oq0 I L_O T 9 1 1 $ AREA = 22000 sf+— \ 1 lam' SITE J/ o I PLAN BOOK 16 S PAGE 7 3 � 1 _ ASSR MAP188 PCL 121 LOCUS INFORMATION TITLE REF: BK 22761 PG 139 i 1 II 1 PARCEL ID: MAP 188 PAR. 121 o \\ SEPTIC SYSTEM wgTF o \ REPAIR PLAN �0 R 11 Cn lh `\ cg7F, 42 \\ O LOCATED AT: 11 \mo0 ,W,. —r �, \\ O 73 OVERLOOK DRIVE Z \a CEN TER VI LLE, MA 11 0,O PREPARED FOR It ,00, 41 \ VAZALES i \� 11 No � N i \c'n O MAY 12, 2015 0 0 OF MAss 40 \\ A N 9 s �} vent /' \\ o. 114 01�� ST \ SANI TAR\p PROP. 1 ,500 GAL �\ SEPTIC TANK MEYER & SONS INC. P. O. Box 981 E. SANDWICH, MA 02537 I I , PH. (508)360-3311 41 40 1 EXIST. CE55POOL I I 32 P fax (774)413-9468 i 42 (see Note I O)44 43 meyerandsonstitle5@gmail.com 9 mail.com 46 � PAL_ AN .. www.meyerandsons.com _ 45 + SCALE: 1 in = 20 ft SHEET 1 OF 2 J#1491 ELEV. TOP FOUNDATION NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE;- - FINISHED GRADE (41.50) = 46.53 �.,�F.G.EL: 44.50 F.G.EL: 41.10 F.G. EL: 41.10 VENT a MAINTAIN 2% MIN SLOPE OVER LEACHING AREA 1 A D F.G EL: 38.10 ��> 2" OF 3/8" DOUBLE WASHEDTOM 3/4" - 1-1/2" STONE OR FILTER FABRIC DOUBLE WASHED STONE a 6" " 4 4" SCH 40 PVC 10 I 14, 6 © S= 1% (MIN. ®®®®®®®®®®® A' TEE'S ARE TO BE INV.36.60 ®®®®®1®®13®®13 .a 4" SCH 4o PVC 2 E F. DEPTH:1 ®®®®®®®®®13a `..A: INV.36.78 INV.36.40 4' 2 X 8.5' 4' GAS PROPOSED OB-3 Exl BAFFLE EFFECTIVE LENGTH = 25' snNc ouTLEr � � INV. 38.03 INV. 37.03 °' DISTRIBUTION BOX (1-120) INV. ELEV.= 36.30 PROPOSED 1,500 GALLON SEPTIC TANK - GAS BAFFLE TO BE INSTALLED ON OF M9ssq BREAKOUT OUTLET TEE AS MANUFACTURED BY �`� �y TUF-TITE, ZABEL, OR EQUAL DARR M. TOP CONC. ELEV.= 37.30 ELEV.=, 37.30 No 1 0 INV. ELEV.= 36.30 110 ®® 00 E-3 0® . NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING ®®®®®®® PIPE INVERTS PRIOR TO CONSTRUCTION 'PfGI E ®®®®®®® 2) TANK AND D-BOX SHALL BE SET LEVEL AND MNITA0* BOTTOM EL.= 34.30 ®®®®®®® TRUE TO GRADE ON A MECHANICALLY COMPACTED 1 3.75' S FT. 3.75' SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN o(2" 310 CMR 15.221(2) SEPARATION 3.80 FT. EFFECTIVE WIDTH = 12.5' 3) INSTALL INLET & OUTLET TEES W/ SEPTIC SYSTEM PROFILE GAS BAFFLE AS REQUIRED BOTTOM OF TESTHOLE EL: 30.50 t SOIL ABSORPTION SYSTEM (SECTION) GW (PER GIS) 30 FT. BELOW GRADE (500 GALLON H2O LEACH CHAMBER) GENERAL NOTES: SOIL LOGS DESIGN CRITERIA - 1. 14673 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL # BOARD OF HEALTH AND THE DESIGN ENGINEER. NUMBER OF BEDROOMS: 3 BEDROOMM 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: MAY 7, 2015 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 - 310 CMR 15.405 (1) (B): WITNESS: DAVID STANTON, BARNSTABLE B.O.H. DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. 1) A 1.2 Fr. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING GARBAGE GRINDER: NO (not designed for garbage grinder) TO BE 4.20 FT (MAX) BELOW GRADE VS REQ'0 3 FT. (H20/VENT PROVIDED) 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR Elev. SEPTIC TANK: TP-1 Depth I Elev. TP-2 Depth 330 gpd x 200% = 660 gpd, USE PROPOSED 1,500 GAL. SEPTIC TANK TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE - . DESIGN ENGINEER. 42.50 FILL 0" 42.60 FILL 0" LEACHING AREA REQUIRED: (330) = 445.94 S.F. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 41.17 16" t 41.35 15" .74 ENGINEER BEFORE CONSTRUCTION CONTINUES. A LOAMY SAND A LOAMY SAND USE TWO (2) 500 GALLON (1-120) PRECAST LEACH CHAMBERS W/ 4' 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 1OYR 3/2 10YR 3/2 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 40.67 22" 40.68 23" STONE ON SIDES & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF B LOAMY SAND B LOAMY SAND BOTTOM AREA: 25 x 12.5= 312.5 SF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. IOYR 6/8 1OYR 6 8 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 39.25 C 39" 39.27 C 40" SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF 1 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED SANDY LOAM SANDY LOAM TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 10YR 6/6 IOYR 6/6 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE 36.67 70" 36.68 71" THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING C2 C2 DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd CONSTRUCTION. COARSE 4 COARSE 4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 2.5Y 7/4 � 2.5Y 7/4 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 30.50 144" 30.60 144" 73 OVERLOOK DRIVE CENTERVILLE, MA 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY PERC RATE TO BE DETERMINED AT TIME OF INSTALL Prepared for: Vazales AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. NO GROUNDWATER OBSERVED P 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. ': Engineering and Survey by: SCALE DRAWN 15. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPECIFIED) ' 1, Darren M. Meyer, R.S., CSE, hereby certify,that t am currently I MEYER&SONS,INC. N.T.S. DMM approved by MADEP pursuant to 310 CMR 15.017 PO BOX981 to conduct soil evaluations and that the above analysis has been performed by'me consistent with the 16. PERC RATE AND DEPTH BELOW LEACHING TO BE DETERMINED AT TIME E4STSANDWICH,M402537 DATE CHECKED SHEET NO. TIME OF INSTALLATION. requirements of 310 CMR 15.017. I further certify.that'I have passed the Soil Eval. Exam in October. 1999. 508-362-2922 05/1 2/1 5 DMM 2 of 2 L