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HomeMy WebLinkAbout0006 PADLOCK LANE - Health 6 Padlock Lane Centerville F/R A = 172 113 IN lip UPC 10259 No. H163OR �`��•. '`a N�tr�Mq! Yw � rr �� V V i /-?c?-113 a\ Commonwealth of Massachusetts Title 5 Official Inspection Form tl Subsurface Sewage Disposal System orm -Not /for Voluntary Assessments /aid' ;4-e-- Property Address e Owner Owner's Name C�r information is --- `��� /� required for every Nj ((( _ v page. City/Town State Zip Code Date of Inspettio,i Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms -� on the computer, use only the tab Vq in k-le- _ O >!/ key to move your Name of Inspector ,/// �- cursor-do not �/.//(//o 7 EG H use the return Company Name key. s ) l a J Company Address �- ,L=G G✓mil _ j�/� �����- City/To 7 09 ov0 /State fV 9Oti Zip Code Teleph&e Numbeff License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenan on-site sewage disposal systems.After conducting this inspection I have determined that the s m: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector's r ignature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. I Please note: 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. t5insp.doc•rev.V26=18 Title 5 Official Inspection Forth:Subsurface See ge Disposal System•Pagel of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I'. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Gr"1$ Owner Owners Name information is reo_ A M � /] /� O required for every _ _ Vp� OC. page. City/Town State Zip Code Date of Insp ction C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System ses: 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: 2) 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): t5insp.doe•rev.712612018 Title 5 Official Inspection Form:Subsurface sev qe Disposal system•Page 2 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form <b Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments Property Address r Owner Owner's Name information is required for eve �N q every page. City/Town State Zip Code Date of Ins tion C. Inspection Summary (cost.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.726=19 Title 5 Official Inspection Forth:Subsurface Sewage Disposal SyStern•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System F m Not for Voluntary Assessments Property Address Far le 61 Owner Owner's Name information is required for every page. City/I own State Zip Code Date of I tpectiot C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El 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 t5insp.doc-rev.7/25/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form u� Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments Property Address a Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Intectiotl C. Inspection Summary (cons.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ 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 water supply well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ �Anyortion of a cess ool or riv is less than 100 feet but reater than 50 feet P P privy 9 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 2000 gpd- 10,000 gpd. ❑ 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. 5) 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 CA. 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 t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 f Commonwealth of Massachusetts �s Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u Property Address G Owner Owner's Name information is [10 3� required for every page. City/Town State Zip Code Date of Ins ectio C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes ❑ 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? ❑ as 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)] f5insp.doc•rev.)I28=18 Title 5 official Inspection Form:subsurface sewage Disposal system.Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 1 Property Address Gr e Owner Owner's Name information is required for every ��� Q� / Ido page. City/Town State Zip Code Date of In pectin D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: o ` /J� V14rl 01.1 &2? 13 SOO � �7W� 3� ,c 1a.8 �02 Number of current residents: Does residence have a garbage grinder? ❑ Yes ej No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: 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: I Sump pump? ❑ Yes o Last date of occupancy: date t5insp.doc•rev.7126a018 Tide 5 official Inspection Fam Subsurface Sewage Disposal system•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S stem Form -Not for Voluntary Assessments Property Address 4�✓ Owner Owners Name information is required for every page. City/Town State Zip Code Date of Ins ection D. System Information (cont.) 2. Commerciallindustrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: L v Source of information: 67 Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7 12 61201 6 Title 5 Ofliiclai Inspection Form:Subsurface S—ge Disposal System-Page 5 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal Syste Fo -Not for Voluntary Assessments � Property Address vel Owner Owner's Name information is required for every Jd /ok �g do page. City/Town State Zip Code Date of Ins ctio D. System Information (cunt.) 4. Type of stem: 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): Approxim to age of all components, date installed (if known)ands rce of information: do/y la !� _. 0 1!5� AL /llelyv /�S oho Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): 10 Depth below grade: feet Material of constructi:�40 ❑ cast iron PVC ❑ other(explain): / Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc•rev.7/26/2018 Title 5 omciai Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Namn'-1WV1 /�) information is required for every Ile, — (/cia_ /j �o page. City/Town State Zip Code Date of In pei n D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet Materi 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: S Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle /1 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 DD�� How were dimensions determined? Al� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): u �✓el ftl k, C TES /✓! OO C11-AM t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts P Title 5 official Inspection Form I. Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments 7.� Property Address Grie Owner owner's Name / �� / O information is e o I/ �v` /pZ q required for every / -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 Oinsp.doc•rev.7/262018 Tide 5 Official Inspection Form:Subsurface sewage oisposal System•Page 11 of 18 C� Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Eorml-Not for Voluntary Assessments Property Address Owner Owner's Name y ) information is f*✓ ,raL Wad- page. required for every page. CitY�o� State Zip Code Date of I specti n D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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.): 4 Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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.): /Awl �lr Clf t5insp.doc•rev.712612018 Title 5 Official Inspection Form:subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts : Title 5 Official Inspection Form 1e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � Property Address Irz �a G' �i Owner Owner's Name information is ` y� required for every ✓) / /� /� o(/ page. City/Town State Zip Code Date of In pectin D. System Information (cost.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: TYPe: �� �Ildv1 �/Vlo�a �1,�/�''ti JIJ�S��••�� I ❑ 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: Oinsp.doc•rev.7/26/2018 Title 5 Official Inspection Fond:Suosurface Serfage Disposal system•Page 13 of 18 I Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address — — - Owner ��-- Owner's Name information is '*�'/��/ — `mac �- / required for every ,� _ �/ page. City/Town State Zip Code Date of Ins ction D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 0, 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool - Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doe•rev.7 12 61201 9 Title 5 OF<ciai Inspection Form.Subsurface Sewage Oisposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments Property Address Owner Owners Nam �65s" information isfrequired for every �� IIIGGG page. City/Town State Zip Code Date of Insfectioil D. System Information (cost.) 13. 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.): t5insp.doc•rev.7/262018 Title 5 Of c:ai Inspection Foam:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments Property Address Owner Gevery ry Owner s Name information is required for eve (/! ` page. City/Town State Zip Code Date of inspectio D. System Information (cunt.) 14. Sketch Of Sewage Disposal System: Provide a view of he sewage disposal system, including ties to at least two permanent reference landmarks or nchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buildi . Check one of the boxes below: ❑ nd-sketch in the area below drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 1.2/9/2020 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION G Ya eQ la,zt:L.a SEWAGE tf dot 0- y'1 VILLAGE_ ASSESSOR'S MAP&LOTJ2 !t-S INSTALLER'S NAME&PHONE N0.Ro�i tn7`/3.O�Ai. hQ�.� -08-Yf'o- b s, o SEPTIC TANK CAPACITY lozo LEACHING FACILITY:(type) 3"S-"o`mac° cka-d em (size) ,— NO.OFBEDROOMS �{ BUILDER OR OWNER 3al,,,A R,t D✓ iz PERM DATE: 9I a f I t U COMPLIANCE DATE: /°W,110 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /✓b Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A10 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �✓� Feet Furnished byhu� 14-I = I(.'a Li 4-; A, ' A-3 = 33� Li t3 +3-1 = 3?' of o z 13-3= H,t"Y 3 D o 0 x t0pvd-_4(0,7..k O https:Htown.barnstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=172113&seq=2 1/2 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System ' F l-/Not for Voluntary Assessments .......... ; L Property Address �4✓ Owner Owner's Name information is / I I/ A14 required for every � N �{[['Lvesl�✓ /q O� page. City/Town State Zip Code Date of spedfion D. System Information (cost.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Id loy- Estimated depth to high ground water: 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 — ;'-`�Checked bserved site(abutting property/observation hole within 150 feet of SAS) wliCocal Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must descri ow you established the high ground water elevation: vu As"d4WC-40e, 114A v+ X06 - - H :6"C44C Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 OKiciai Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Ti Sewage tle 5Official Inspection Form 1. Susurface Disposal System orm -Not for Voluntary Assessments Property Address Owner Owner's NamCOO-AW information is 11-e- page.required for every __City/Town State Zip Code Date of Ins ction E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. P-- Certification: Signed& Dated and 1, 2, 3, or 4 checked Inspection Summary: 1,2, 3, or 5 completed as appropriate 4 ilure Criteria)and 6 (Checklist)completed D. System Information: For 8:Tight/Hoiding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I5insp.doc•rev.7/26/2018 Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 ;official Inspection Form Subsurface Sewage Disposal system Form-Not for Voluntary Anessments 6 Padlock Ln Centerville MA property Address Jean M O'Toole 31 Run Pond Road Owner CwneeS Nam 02638 4/30/2014 inforrnation is Dennis State required for every State Zip Code Date of Inspection page cityrrown Inspection results must be submitted on this form. inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Irnportant.when A. General lnformaition flung out fours �f C on the computer, � U use only the tab 1. Inspector. Joe Martins key to move your cursor-do not ACC use the return Name ofhspector 17 Northside Dr. key. Company Maim Company Address State Zip Code Qlylrown / \!v Telephone Nurnbe License umbe B. Cer fleation 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 ofthe 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_ 0/p/asses ❑ Conditionally Passes ❑ Fails ❑ Needs Further E luation b the Local Approving Authority 5- /a Z01 Inspec r's.Signatre 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 r,the inspector and the system owner shall submit the has a design flow of 10,000 gpd or greate 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. TM50rficlal lrspact wForm subsirrace s_vageDisimsar system•Page 1 of 17 Srs-3M3 ,5 I Cornrnonweaith of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 6 Padlock Ln Centerville MA Rvperty Address Jean M OToole 31 Run Pond Road Owner Qw nees Name information is nPnnie A�i�_ n�63�8 4/�Lll2�?4 page- City/Townd for every State Zip Code Date of fnspection page. B. Certification (cone.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: have not found any infori-nation which indicates that any of the failure criteria described in 3%CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the'Conditional Pass*section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)forthe following stateme . "not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank er metal or not)is structurally unsound,:exhibits substantial infiltration or exfiltration or,tank a is imminent. System will pass inspection if the existing tank is replaced with a complyi eptic tank as approved by the Board of Health. "A metal septic tank will pass inspection' is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank' ess than 20 years old is available. ❑ Y ❑ N ND(Explain below): Ors-3/13 Title 5 Ctficiel Inspection Form Subsoarace Swage Disposal Sydem•Rage 2of 17 i Commonwealth of`Massachusetts Title 5- Official Inspection Form "Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Padlock Ln Centen ille MA Property Address Jean M QToole 31 Run Pond Road Cwner Owner's Name A !t requiretifo is Denn1C Mom._ _ 026-IR 4/30/ .014 required for every page Cdy/rown State Zip Oode Date of Inspection B. Certification (corn.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval of pumps/alarms are repaired. B) System Conditionally Passes(cont): ❑ Observation of sewage backup or break out or high static water leveljwtfie distribution box due to broken or obstructed pipe(s)or due to a broken, sZorneydistribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ ND(Explain below): ❑ obstruction is removed Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replac ❑ Y ❑ N ❑ ND(Explain below): ❑ The system require um ping more than 4 times a year due to broken o obstructed pipe(s} The system will pass spection 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/reh d by th and of Health: ❑ Conditions exist whifurth evaluation by the Board of Health in order to determine if the system is failing pu c health, safety or the environment. 1. System will pasand of Health determines in accordance with 310 CMR 15.303(1)(b)that this not functioning in a manner which will protect public health, safety and the env❑ Cesspool orithin 50 feet of a surface water P or❑ Cesspool ettted wetland or a salt marsh privy is within 50 feet of a bordering%e g P Lars•3M3 TMe 5a ft1W 1mp=tton Farr SuE m0we wage D5p1 System•Page 3oT 17 i Commonwealth of Massachusetts Title &Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Padlock Ln Centerville MA Roperty Address Jean M OToole 31 Run Pond Road info Ouvners femme m6�R 4/30/2014 requiratfo is Denniq MA required for every State Zip Code Date of Inspection page. Cilylfown B. Certification (coat.) 2. System will fail unless the Board of Health(and Public Water Supplier,if y) determines that the system is functioning in a manner that protects the lie health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) d the SAS is within 100 feet of a surface water supply or tributary to a surface water pply. ❑ The system has a septic tank and SAS and the SAS is n a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the S 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.wat analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided at 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 ❑ fl Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ E!(' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ [3/- 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 151ns•W13 rft5official InspectonFamc Subsuface Savage Disposal system-Page 4of 17 i Commonweafth of.ws achusetts • Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Padlock Ln Centerville MA Ftoperly,Address Jean M OToole 31 Run Pond Road Owner Owner's lame information is _ RR m63� 4/ /2014 required for every Dennis g� Zip Code Date of Inspection page. Clityfrown B. Certification (cons.) Yes No ❑ �( Required pumping more than 4 times in the last year NOT due to clogged or j� 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 fleet 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 aie 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 of2000gpd- 10,000g pd. ❑ The system fps. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 surf nnking water supply ❑ ❑ the system is within 200 of a tributary to a surface drinking water supply ❑ ❑ the system is I ed in a nitrogen sensitive area(Interim Wellhead Protection Area— or a mapped Zone 11 of a public water supply well If you have ansered s"to any question in Section E the system is considered a significant threat, or answered "yw" n Section D above the large system has failed. The owner or operator of any large system c de red 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. t5irs•M3 THW50ffldal InspeetionFonrt Subsuf ea Save Disposal System-Page 50f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Padlock Ln Centerville MA Property Address Jean M OToole 31 Run Pond Road Owner aN ne's Name information is nenniq Mom— 0 638 4/30/2014 required for every page_ Cdy/Town 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 ❑ [J' 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? ❑ d 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 NIA) ❑ Was the facility or dwelling inspected for signs of sewage backup? [✓� ❑ Was the site inspected for signs of break out? ❑ Were all system components, a ig 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): Number of bedrooms(actual): Z-14 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5fre,3f13 Me5OMWattrspeclanForm SubsurfawSeva9eD4osal SyMm•Page6oM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Padlock Ln Centerville MA Property Address Jean M OToole 31 Run Pond Road Ow ner Owner's Name requiretfore Dennis MA 02OR 4/30/2014 required for every State Zip Code Date of Ir spection page. Cityrlfown D. System Informatjon Description: .4 ID oo beyff Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(include laundry system inspection ( Yes No information in this report.) Laundry system inspected? 110— ❑ Yes ❑ No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): f — Detail: �2—o ( 3 JY� 0000 0 2 , UO6? Sump pump? ❑ Yes No 3 / /14 Last date of occupancy: 2 3 Da 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 t itle 5 system? ❑ Yes ❑ No Water meter readings, if i able: t5 ts•W13 Title 5Ofridal UspstlonFom[Subsurface Savage Dual System-Page 7 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Padlock Ln Centerville MA Roperty Address Jean M OToole 31 Run Pond Road Ow ner Ow ro's Name inforrration is /�� �R 4/ 0/2014 required for every nPflfl1Q MA _ 026---- page.. Cilylrown State Zip Code Date of Inspection D. System Informatuon (coat.) Last date of occupancy/use: Date Other(describe below): General Information �p Pumping Records: �vm/' ` W 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Elm,3113 Me 5Ofdal trspecdon Form Subarfam Sewegge Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Vol untary'Assessments _ 6 Padlock Ln Centerville MA Property Address Jean M OToole 31 Run Pond Road Owner Owner's lame requtr3tfo Dennic MA_ __0 63R 4/30/2014 required for every page- Cilylfown State Zip Code Date of 6yspection D. System Information (coat) Approximate age of all components, date installed(if known)and source of information: 12- ,,420,04f 2 y��r Were sewage odors detected when arriving at the site? ❑ Yes No (y 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 on 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: J v ` J/`2// X517 6 — fl Sludge depth: t'irs,3M3 TItie5 Official I spectionFom[Subsurface SewageDispo S)rlam•Page9of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary/----.essments 6 Padlock Ln Centerville MA Property Address Jean M OToole 31 Run Pond Road Ow ner ON ner's Name requirefo is Dennis M_A 02638 4/30/2014 required for every page. C►Ily/Town State Zip Code Date of hspettion D. System Information (coat.) Septic Tank(cont.) 2 of( Distance from top of sludge to bottom of outlet tee or baffle Scum thickness fi 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, etc.): Die *1 �� c AMP & 'yPedAM&&i :Ian Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass yethylene ❑ other(explai ny Dimensions: Scum thickness Distance from t f scum to top of outlet tee or baffle Distance om bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5lrs•W3 TMe6CHh:alInspWI0nFomr Subsurface SevageDispo System•Page 10of17 Commonwealth of Massachusetts Title 5Official Inspection Form Subsurface Sewage Disposal System Form.-Not far Voluntary Assessments 6 Padlock Ln Centerville MA Ftoperiy Address Jean M OToole 31 Run Pond Road owner owner's Nam information is m.63R 4/30/?014 requiredforevery Dennis M S e Z' Code Date of tr1s n page. Cdy/Town D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or f8e condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, Tight or Holding Tank(tank ust be pumped at time of inspection)(locate on site plan): Depth below gr/ade: of constr ction: ❑ concrete ❑ metal ❑ fiberglass polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow. gapons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng order ❑ Yes ❑ No Date last pumping: Date omments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Mrs,3M3 TMOSOMcMnspectlonForm Subwface SevegeDLVosal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5' official Inspection Form Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments 6 Padlock Ln Centerville MA Property Address Jean M OToole 31 Run Pond Road Ow ner oav ner's Name requiratfo Depntc MA_ ��638 4/30/2014 required for every page. C ityfrown State Zip Code Date of Inspwtion D. System Information (cont) Distribution Box (if present must be opened)(locate on site � an P q plan)): J� De Depth of liquid level above outlet invert pl—r { 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.): Alb N/kMG' No Sa(��s gift Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump c er, condition of pumps and appurtenances, etc.): * 9 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: t5irs•3113 TM5CfkW I spacUm Form Subsuface Sevege Mpasal System•Page 12 of 17 J Commonwealth of'Massachusetts L Title 5 Official Inspection Form Subsurface:.Sewage Disposal System Form-Not for Voluntary Assessments 6 Padlock Ln Centerville MA Property Address Jean M OToole 31 Run Pond Road a aNnf�s Dennisi� MA _�26 $ 4/30/2014 informorrr ation is required for every page Cdy/rown State Zip Code Date of k spection D. System Information (coat.) Type: ❑ leaching pits number leaching chambers number. 3?SXLZ�X2 ❑ 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.): 440C- 7D 54f> IT, ::� 3•0 1 • L/nP tl�r SMa A a W h"e-L- SlvieflOali Cesspool (cesspool must be pumped as part of inspection)(locate on site plan): D6� Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensi of cesspool aterials of construction Indication of groundwater inflow ❑ Yes ❑ No Mrs-T13 Tlfle5OMciel fnspeclonFomc SubnOwe SevegeOlsposd System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Padlock Ln Centerville MA Property Address Jean M OToole 31 Run Pond Road Cwnef alvners Nam 02638 4/30/2014 required is Dennis MA required for every page. CRY/Town State Zip Code Date of Inspection D. System Information (coat.) 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 co ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _ tars W3 TNe50rfltial1n9pwfJonFom[Subsuiace Savage Disposal Sy2am•Page 14of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Padlock Ln Centerville MA Property Address Jean M OToole 31 Run Pond Road Cw ner Cw ns's Name inforrration is 02638 4/30/2014 regUired for every Dennis MA page. Cilyfrown State Zip Code Date of Inspection D. System Information (coat.) 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 se arately IL 17rs� c�,1 =37 3 R-3 t5irs-3/13 Trd*50ffic!W Inspect mForm Sut7strface Se-vggeDtsposaf System-Page 15 of 17 commonwealth of Massachusetts Title a Official Inspection Form Subsurface Sewage Disposal system Form-Blot for Voluntary Assessments 6 Padlock Ln Centerville MA Hvperty Address Jean M OToole 31 Run Pond Road Ow ner Ow ner's Name requirafronis n nnic MA 02638 4130/2014 requQedforevery page. CRylrown State Zip Code Date of Inspection D. System Information (corn.) Site Exam: Check Slope [(Surface water IV Check cellar Vshallowwells �s Estimated depth to high ground water feet v 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) L� Accessed USGS database-explain: o You must describe how you established the high ground water elevation: 6 0 S C GY- U � - � A --,o k� obi mm s-r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5rs-3113 Td*50flickl lnspectionForm Subwxface Sevvage015posel System-Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Padlock Ln Centerville MA Property Address Jean M Mole 31 Run Pond Road Owner Owner's Name requirefo s Dennic MA 02639 4/30/2014 required for every page. Qlylrown State Zip Code Date of Inspection E. Report Complet mess Checklist Lf inspection Summary: A, B, C, D, or E checked llcf lnspection Summary D(System Failure Criteria Applicable to All Systems)completed (� ystem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file We•W13 Title50t CW IrspacllonFom[Subsvface Savage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION GQ.Caszf: 4z.�-�- SEWAGE # AU t V b VILLAGE p�v.2t,Ca ASSESSOR'S MAP & LOT ! INSTALLER'S NAME&PHONE N0. I�v�re l3•® e b&e- 50L Yea- 65 3c SEPTIC TANK CAPACITY Lo_zo csu LEACHING FACILITY: (type) .3 a 5 c'o a a,�� C�.e ,�,;i (size) `3 3°.5 `'x la'?" NO. OF BEDROOMS -'( n BUILDER OR OWNER 2YI,t,-A R e.Q D PERMITDATE: 9��I It COMPLIANCE DATE: �° ao111C3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /✓G Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A10 Feet Edge of Wetland and Leaching Facility(If any wetlands exist dl/C� Feet within 300 feet of leaching facility) Furnished by 6A4", � Y. � / A -3 33 ' Lj o ► Ka'y 3 a o I- E x.A.aa�',�,0 io00 9,J-4., la.k - fl"u- n(S3 0 t301, 3- S v o I No. O �t Fee �b� THE COMMONWEALTH OF MASSACHUSETTS•� Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYtcation for 30topogaf *pgtem Conotruction Vermtt Application for a Permit to Construct( )Repair(/)-Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. 1—a —I Owner's Name,Address and Tel.No. /J Assessor's Map/Parcel / 3-d V aH 's Name,Address,an Tel.No. Designer's Name,Address and Tel.No. o G w�-�j- o.,w�- ev- zee., t c d2'Y ,u.4 U 1 B Ci 3a-C>s 7 o is 3 nc ft . -36 Type of Building: _ o k r s T vo• �ec Ple Dwelling No.of Bedrooms Lot Size /S- >U 7 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow y gallons per day. Calculated daily flow rX0 gallons. Plan Date Y— Number of sheets t Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Rej airs or Alterations(Answer when applicable) �� S :2,w-"c j—'a' C 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 Certifi- cate of Compliance has been issued by this Board of health. Signed 3K 69.ew r- V,. Date Yo ♦e*//O Application Approved by Date Application Disapproved for th following reasons Permit No. Y/ Date Issued U / v No. c! I O 1 t y e $ � "' 's' Fee THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: AZ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS �. plication for Migo�al *peter" Construction PerrrYtt Application for a Permit to Construct( , )Repair(Upgrade( )Abandon( ) ❑Complete System ❑Individual Components J Location Address or Lot No. G �� / L,, Owner's Name,Address and Tel.No. Assessor's Map/Parcel G /i S'UT— 3cfs= 0a'35 1ptallyis Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �(3a 3 A 36-1- 1/ Type of Building: o k T Vo. See /C Dwelling No.of Bedrooms—� T Lot Size IS' 90'> sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow `y `� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title i Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re airs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of1Iealth. Signed 4_111_'_*X1 �.� 2�.. .t. Date /o "a bo Application Approved by ;n, j 0 l Date /tlr?� /� d Application Disapproved for th�ing reasons x Permit No._,� / "��� Date Issued D / v l THE COMMONWEALTH OF MASSACHUSETTS LI ���MS BARNSTABLE, MASSACHUSETTS Uk/rTM,w. plc Certificate of Compliance THIS IS TO CERTIFY,that the On-site ewa a Disposal System Constructed( )Repaired (,P�)Upgraded( ) Abandoned( )by i�. .4 3. .c,. l✓v at C has been construct d i accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2 A)- / dated u / /v Installer Designer The issuance of`this Permit shall not be construed as a guarantee that the system 11 functi n as designed. Date Inspector _ No. ) 0/G t� Fee 10v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLES MASSACHUSETTS oigw6ar *pztem Construction Permit Permission is hereby granted to onstruct( )Repair(/,,�)I/Upgrade( )Abandon( ) System located at 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 thisr Date: /d!i .3//, Approved by lM% F Town of Barnstable Regulatory Services r Thomas F. Geiler,Director • BARNSTABLE. M�: �e� Public Health Division %prFDMA'tA Thomas McKean,Director 200.Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: /d 4 y ����' Sewage Permit# Assessor's Map\Parcel /7 Z//f Designer: PE Installer: Jl„�i, �� �� �VL Address: 6,A Address: C�,e, �� On was issued a permit to install a (date) (installer) septic system at based on a design drawn by (address) dated (designer) _ZI 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. 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. '- ! "` GI�11L (Installer's Signature) N90.3s461 " (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE 4WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer certification Form Revised.doc � I FORM 30 C&W HOBBsE WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C CITY/TOWN 4 W o ARTMENT ' DRESSTLO (� TELEPHONE AddresL& Occupan Floor Apartment No. No. of Occupants '3 �- No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units N�o/Stories Name and address of owner Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows.- Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: nC�1,10 ❑ 220 Fusing,Grnd.: P: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten., as, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink ac> 01- W t/ti�r Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: /&_0 Egress Dual and Obst'n: General Building Posted Locks on Doors: S' ONE OR MORE OF THE VIOLATIOP6 CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF P UAY." INSPECTOR TITLE /40 A� -IT A.M. DATE � 1, TIME A.M. THE NEXT SCHEDULED REINSPECTION P.M. f 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and wellbeing of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning.facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). - (5). Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. CCZ) CJ X-, _ � .�) Town of Barnstable x BARNA,%' LE,MAss. • Regulatory Services y $ i639 ArEo MAC a, Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Michael & Jean O'Toole 3/9/10 31 Run Pond Rd. Dennis, MA. 02638 Jean, As per our conversation on Friday I have sent you some paperwork regarding how to fix the Title V discrepancy at 6 Padlock Lane. One option is the Deed Restriction route. I have enclosed a Sample deed restriction. Some people have used this form and just whited out where it says Sample. The Deed Restriction must be signed by a notary and recorded at the Registry of Deeds. You currently are permitted for 3 bedrooms according to your septic permit here at the Health Department. You could use only 3 rooms for sleeping and record the restriction to come into compliance. Your other option is to argue your case to the Board of Health on April 13 to allow you to upgrade your septic system to accommodate 4 bedrooms. The reason you would have to go before the Board is that the Regulation for the Protection of Saltwater Estuaries regulates the area of Town that your property is in. According to the regulation properties are allowed one bedroom per 10,000 square feet with a minimum design of 3 bedrooms. Your lot is .36 of an acre or approximately 15,682 sq ft. Your property preceded this regulation and whoever put in the 3 bedroom system should have put in a 4 bedroom system. You would mention what type of house it is, what it is assessed at ( 4 bedrooms) and what the floor plan is. If you would like to pursue the variance route you must have your paperwork in (requesting a hearing) no later than 15 days prior. You need to send in 4 copies of everything and pay a $95 variance fee. Please feel free to call me if you need anything else. Donald Desmarais RS Health Inspector Q:Health/orderletters/refuse/274 South.doc I � TOWN OF BARNSTABLE �r LOCATION /�4,0 - O C & L- A SEW GE #A a 4-� — 3 0 VILLAGE- C e Nf e R V/ L L ASSESSOR'S MAP & LOT/%A _ 1/ INSTALLER'S NAME&PHONE NO. A4 A C O A4 46 C tf SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ,0 R Y ICU e L L s (size) NO. OF BEDROOMS BUILDER OR OWNER Pf PERMITDATE: COMPLIANCE DATE: I Sgparation 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 C J L. 0 C s - -7 't- TROY WILLIAMS 7NEC lED 21 SEPTIC INSPECTIONS Q�1 - Certified by MA Department of Environmental Protection :ririNSTABLEJ (508) 385-1300 19 Hummel Drive L_...___. '17AL!'H DEPT. -. ., ._.. South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE. OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION uo_ FAILED INSPECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMEN SUBSURFACE SEWAGE DISPOSAL SYSTF. 'OWCEIVED PART A CERTIFICATION SEP 3 2OOZ Property Address: 6 Padlock Lane Centerville,MA TOWN OF BA RNSTABLE Owner's Name: Robert&Edith Simpson HEALTH DEPT. Owner's Addres,. 6 Padlock Lane Centerville, MA 02632 O Date of Inspection: August 27,2002 Name of Inspector: Troy M. Williams O Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis, MA 02660 Telephone Number: (508)385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal systein 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv�tem Passes Conditionally Panes Needs Further Evaluation by the Local Approving Authorni) Z Fails Inspector's Signature: '� - ��..� Date: 8/z-7 /o -.j,- The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition Of system,piping or components. This Inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. l his 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 pace I Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Padlock Lane Owner: Centerville,MA Date of Inspection: Robert&Edith Simpson August 27,2002 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 thapdny of the failure criteria described in 310 CNIR 1).303 or in 310 CMR 15.304 exist. Any failure criteria 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 o iealth,will pass. i Answer yes. no of not determined(Y,N,ND)in the_ for the following explain. statements. "not determined"please The septic tank is metal and over 20 years old* or the septic tank:(w her metal or not)is structurally unsound,exhibits substantial infiltration or extiltration or tank failure is ' minent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by a Board of health. •A metal septic tank will pass inspection if it is structurally sound of 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 or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled uneven distribution box. System will pass inspection if(with approval of Board of Health): b en pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The syst required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspect' if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Padlock Lane Owner: Centerville,MA Date of Inspection: Robert&Edith Simpson August 27,2002 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. L System Hill pass unless Board of Health determines in accordance with 310 CMR 15. 3(1)(b)that the system is not functioning in a manner which will protect public health,safety.and a 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 t marsh 2. System will fail unless the Board of Health(and Public W er Supplier,if any)determines that the system is functioning in a manner that protects thepublic alth,safety and environment: _ The system has a septic tank and soil absorptio system(SAS)and the SAS is within 100 feet of a surface %kater supply or tributary to a surface wat supply. _ The system has a septic tank and SAS d the SAS is within a Zone I of a public water supply. — The s�stem has a septic tank an AS and the SAS is within 50 feet of a private water supply well. — The system has a septic t • and SAS and the SAS is less than 100 feet but 50 feet or more froth a private water supply well"* ethod used to determine distance ""This system passes ' the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volat' organic compounds indicates that the well is free from pollution from that facility and the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crite ' are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 f Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Padlock Lane Centerville,MA Owner. Robert&Edith Simpson Date of inspection: August 27,2002 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 PlIq Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or- cesspool ✓ _ Liquid depth in t:ettVOW is less than 6"below invert or available volume is less than'/,day flow Required pumping more than 4 times in the Iasi year Vj„rOT 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. — 11!�& Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a1surface water supply. , -19 Any portion of a cesspool or privy is within a Zone 1 of a public well. i.o Any portion of a cesspool or privy is within 50 feet of a private water supply well. vi ea 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.) Y'C S (Yes/No)The system fails. 1 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 de 'gn now 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 criteri above) yes no — _ the system is within 400 feet of a surface drinkin ater supply _ ^ the system is within 200 feet of a tributary t surface drinking water supply the system is located in a nitrogen se tive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply 1 If you have answered"yes"to any qu ion in Section E the system is considered a significant threat,or answered "yes"in Section D above the large stern has failed.The ovyner or operator of any large system considered a significant tbcyat under Section or faild under Section D sha)i upgrade the system in accordapce with 310 CMR 15.304.The system owner s uld contact the appropriate regions)office of the Department. 4 f Page 5 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 Padlock Lane Owner: Centerville,MA Date of Inspection: Robert&Edith Simpson August 27,2002 Check if the following have been done.You must indicate"yes"or"no"as to each of the followinu Yes No information was provided by the owner. occupant, or Buaid of 1 ieald, _... 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? 9 ✓ — Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? Were the septic tank manholey 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 Page 6 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Padlock Lane Owner: Centerville,MA Date of inspection: Robert&Edith Simpson August 27,200FLOW 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): 3 3 u Number of current residents: 02 Does residence have a garbage grinder(yes or no): VF s Is Iaundn on a Separate sewage system (yes or no): f if yes separate inspection required) Laundry system inspected(yes or no): N/� Seasonal use:(yes or no): Aia Water meter readings,,if available(last 2 years usage(gpd)): d 1 = S-6 Sump pump(yes or no): iyo Last date of occupancy: 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 es or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: t2u9 y _ Wass stem pumped as part inspection Y P P P p (yes or no): �% If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: — TYPE OF SYSTEM Septic tank,dnti-M-bex,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: Were sewage odors detected when arriving at the site(yes or no):M 6 i Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Padlock Lane Owner: Centerville,MA Date of Inspection: Robert&Edith Simpson August 27,2002 BUILDING SEWER(locate on site plan) Depth belu�� grade: h?" 4 Materials of construction: ,'cast iron _40 PVC_✓other(explain): Dklancr from pirate water supply well or suction line: _ ,114 Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: 1 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: s Sludge depth:_ y-- Distance from top of sludge to bottom of-outlet tee or baffle: 2 8 Scum thickness: 2 Distance from top of scum to top of outlet tee or baffle: C Distance from bottom of scum to bottom of outlet tee or ba_ffle: r t I low were dimensions determined: ?*,-�I.— Comments(on pumping recommendations, inlet and outle_t tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): C GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_pol ylene_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 to r baffle: Date of last pumping: Comments(on pumping recommendations, ' t and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of le e,etc.): 7 i Page 8 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Padlock Lane Owner: Centerville,MA Date of Inspection: Robert&Edith Simpson August 27,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of in ection)(locate on site plan) Depth below grade: Material of construction: concrete metal fibergla _—polyethylene other(explain): Dimensions: — Capacity: gallons Design Flo%►: gallons/day Alarm present(yes or no): Alarm level:! Alarm in working o er(yes or no): Date of last pumping: Comments(condition of alarm and at switches, etc.): DISTRIBUTION BOX:,&//,a_(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.): -L- PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,co tion of Xpumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Padlock Lane Owner: Centerville,MA Date of Inspection: Robert&Edith Simpson August 27,2002 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why Type leaching pits. number: I- S 'XC leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: inn ovative/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)(I ate on site plan) Number and configuration: _ Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum la.er. _ Dimensions of cesspuol: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of draulic 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 f ' re, 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: 6 Padlock Lane Centerville,MA Owner: Robert&Edith Simpson Date of Inspection: August 27,2002 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. 1 � I 1/ I p(y LK. 1 z z' /000 �3 ' Page 11 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Padlock Lane Owner: Centerville,MA Date of Inspection: Robert&Edith Simpson August 27,2002 SITE EXAM Slope Surface water Check cellar ✓ Shallow wells Estimated depth to ground water /2- '_ feet Adjusted high ground water elevation feet Please indicate(check)all methods used to determine the high ground %+ater ele%-ation: 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: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: S v- •L s-L Zv„�= You must describe how you established the ground high g g nd water elevation: S. - US y> s �o✓ ✓.� � w.��--�..i- cam._-t ` w�S 7-y' ✓.rl--c✓ � -cam/�. /�t.o✓c�/1 w�,-d'.cr_ _ w i Y rL...rv� c / l A�-.. ��/r'1 �..v .+. �/-�s 4•-.{a [ati i�. 4- 5✓u'�i^.�V..i-.�� c., .a.•c wV l J[�,,, _ 1 of vJ 7 o $.O 11 n / TOWN OF BARNSTABLE, z.;OCATION 6� �A U L- O C �C L-_ SEWAGE #A Q O 15 IVILLAGE C e AlT e k V 1 L L 2 ASSESSOR'S MAP & LOT/%L �,5 INSTALLER'S NAME&PHONE NO. ® ' /A4 A C O ,/f4 P e R f S OAI SEPTIC TANK CAPACITY /J00AX QL 2 LEACHING FACILITY: (type)." Z7 PY LU e LL 5 (size) `� X NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 1p'z COMPLIANCE DATE: 11 th ILO.'2 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 1. a I 1 Cl I fit,\ IVAPL © CR Lis TOWN OF BARNSTABLE I. F.VOCATIO& a rxto,?,)EWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.\J, P bUQc ' SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (sizes; NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER ��i BUILDER OR OWNER �(�`y DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: vV� / VARIANCE GRANTED: Yes No .a. ��fl` �r9!'� s� lam. i���' i �` ., l V- V �® ' r ,�('1 � �� (��' , � No. ...--...--- Fl�s..... ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD AF HEA TH ... OF.......................... ... .. , - ................ Appliration for Uitipuiittt Workii C owitrurtion Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ),an Individual Sewage Disposal System at: ._ oL�...�✓�9G�_l0/LL/4{� -- Location.Address or Lot No. FFNI Ec. � ROWS..-4 t..�' ......... �..... �'_��/C! , 1 .. !.... IPF)/n - ------ Owner _ Address P� Installer Address Q Type of Building Size Lotj.A, 212 7-.-____Sq. feet U Dwelling—No. of Bedrooms..............____ .._.Expansion Attic ()4%) Garbage Grinder (� Other—Type of Building ------ ------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... .. W Design Flow..............v�—©......................gallons per person per day. Total daily flow.........-. D ------- W Septic Tank—Liquid capacity.Llsa__gallons Lengtly. ............ Wids ......... Diameter........-_.-._- Depth_............ . x Disposal Trench—No. .1'_tf_6QO 440CA"j-./1%= P ___________________ Total leaching area-------------. -----sq. ft. Seepage Pit No..................... Diameter.................... Depth below i let..... __..._.. . Total�lej�c iiig ar I------------------sq. ft. Z Other Distribution box %) Dosing tank ( ) f9 �C ` 'z��� ey s Percolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------.-_....-.. a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water_...---_---_---.--.. Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water:_.....__-_-----......-. r `-----.....-•----.. Description of Soil-----------_------- -a-...-�------ ---- -- --------------- ~ ...... - ----- x W 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issued t bo d ealth.,�� Sig j :- /�-- Date Application Approved By. v .... -------------------- ----.•--.��... -A-4+ -- Dat Application Disapproved for the following reasons:................................................................................................................. •---••-•-••••••-•••----•----•-------•-------------------•------•-----•----••-----•--•-•--••--••------•---------•----•---••-•--------•-•-------- ----• -- .._. ..-------------------------------- Date Permit No......................................................... Issued .._l. .._ �� ------------------------------ Date J" r- -o t r No......................... FED.-:.. d............... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA ,TH - Apli iratinu -fur Di-spuiitt1 Murky Towitrurtiuu Prrtuit Application is hereby made for a Permit to Construct ( ) or ,Repair. ( ) an Individual Sewage Disposal System at Location Address _ . �I/Yl�./ -..1 t/[%:r L�_ p• 11�//C� In+- '{— I /� f owne Address Installer `' Address -«._ Type of Building Size Lot____________________________Sq. feet Dwelling—No. of Bedrooms----------------_1 .....y--------------Expansion Attic ( ) Garbage Grinder (N) aOther—Type of Building ___________________________ No. of persons_.--------------------...... Showers ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------------------------•---------•-----•--•-------------•---•-•----••-------------•--------- W Design Flow____________........................gallons per person per day. Total daily flow-------------q1Q Q-••----•-----_-__•__--_gallons. A,' Septic Tank—Liquid capacity t9''0__gallons berth________________ Width............---- Diamete � - -___- ___ Depth-__-_-__ _--- Disposal Trench—No. ..._ -___________ I/(�01� £frC `%/V ��ac 11 mg X -----------_-----sq. ft. Seepage Pit No..................... Diameter.................... Depth below i let_____. _______ __�Tlotal le cl illg are•------------------sq. it. Z Other Distribution box (' Dosing tank ( ) G� "�'�'7 4 r"1' e a Percolation Test Results Performed bY-------- ----------------------------------------------------------------- Date----•---------------------------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit__-_________..______ Depth to ground water--_____-_______-__----_- fXq Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water...------_.............. IX ------------------------ 10 f:� ' D Description of Soil--------------------�- -----------� kr',� !�'�Zd.C..� � x ----- --••-------•--•-(------ V ---------------------------•-----------••------------.....--•------------•-----•••-----••-•--•-•••---•----------•----•--•---•----•----•--••---------•---------•------------••--------._...----_...----- W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b.', n issued b hey o d of lth. Application Approved B ................... . Date s� Date Application Disapproved for the following reasons:---•--•-------••--•-----•----J--•••-------------••-•---•-------••---------•--••------•••-•--------•----•------- --•-•--•-•--•-•--•--•--------•-•••--•------•----------------------------••--•-------•--•••-----•----------•-•-•--------•--------••---•----•---------------- ------------------------------------------- _ / D t Permit No.--- ---••--•-----•-•-•--------•---••----•.............. Issued.-•� ---• /... .�------..._ Dat THE COMMONWEALTH OF MASSACHUSETTS BOARD �LT j L �t,..: ....OF........�,,�. ...........:........-..-...� rrtifirate of Tontpiiatta TH IS TO CER Th t he dividual Sewa D posal S or R m constructed ( epaired by..... ( ) t n r In�ar. - - -- .�., --- - ••---...--- has been installed in accordance with the,provisions of Article I f he State Sanitary o le s descr• ed in the application for Disposal Works Constructi.bn Permit No...._:____ .___ __ J ----'--------._. dated---.. ..��---�-�. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GU ANTES THAT THE SYSTEM:WI FU CTI N SATISFACTORY. � DATE-- ..................................... Inspector-- THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH .L!'!j......OF-...-...... .. . �f " ........................... No.•--- f FEE_- • -----•--•-•-•--- Dt- Volitt1 Porkp QITn ur • it rrud Permission -s ereby granted___""___ ___ ____ _______ ____ _____ _ _________ _ _____ ___ ___ *I......./� to Construct/ or a air ( an I idual ewage posa ys G�f�'/ atNo.- ✓r ------- ----... ------ ----------------- .----•---------•---- Strcet y � 'as shown on the -pplicati n for Disposal Works-Construction P r it _._---- __________ Dated........ _._Z�d_ - - ----ram---- -� --• ---•---•---..._ --- �w ....... Board of Health t' DATE.--- __... . --- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ` I .- ti Z� ' �- � . . �2 S 2 � . i i 36 QUINCY AVENUE. EAST BRAINTREE. MASSACHUSETTS 02184 • TELEPHONE B43-�000 DAN/EL A. BROWN, JR., FNC. Y REALTORS & BUILDERS Complete Real Estate Service O rn a C. �I 'o 7i{ . 1+ -F a, No. aooa— 636 ` s Fe$50. 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS es Application for Migooar *p5tem Cop5truction 3dermit Application for a Permit to Construct( )RepairXX)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or LotNo.6 Padlock Road Owner's Name,Address and Tel.No.Robert Simpson Centervllle,Mass. 02532 6 Padlock Lane Assessor's Map/Parcel Centerville,Mass.0 2 6 3 2 .172-113 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5 —3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—2 7 3—O 3 7 7 J.P.Macomber & Son Inc. JC En.gineering, Inc. Box 66 Centerville,Mass. 02632 East Wareham,^1ass. 02538 Type of Building: DwellingXXXNo.of Bedrooms 3 Lot Size 1 5, 9 0 h sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 5 0 gallons per day. Calculated daily flow 3 X 1 1 0=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 10 0 0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)Adding twe 500 gallon leaching chambers_ 25 'X12. 9 'X2 ' 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 th nFHh. ental Code and not to lace the ystem in operation until a Certifi- cate of Compliance has been issue this B �of Signed Date 1 1 /1 2/O 2 Application Approved by Date Application Disapproved fo a following reasons Permit No. Qoap—5-3 6 Date Issued ,/��/(///} ^q� gyp. NO. .V``n'Y�• 5✓.�: ..r ,L J.fr.�`� � 1 )'i'CC-•f 5 0 0-0 ah , " Entered in corn uteri THE COMMONWEALTH OF MASSAGHUSETTS p es • ' PUBLIC HEALTH DIVISION -TOWN OF�'BARNStABLEs MASSACHUSETTS: : Zipplicati®n for Miopooa *p5tem C®n5trguction Permit-. Application for a Permit to Construct( )Repair'((X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.6 Padlock Road Owner's Name,Address and Tel.No. Robert Simpson Centerville,Mass, 02532 .6 Padlock Lane Assessor's Map/Parcel Centerville,Mass,0 2 6 3 2 Installer's Name,Address,and Tel.No. 5 0 8-7 7 5 -3 3P 8 Designer's Name,Address and Tel.No. 5 0 8-2 7 3-0 3 7 7 J,P.Macomber & Son Inc, JC Engi•neering,Inco Box 66 Centerville,Masso02632 East Wareham,Masso02538 Type of Building: DwellingXXXNo.of Bedrooms 3 /'Lot,Size 1 5�. 906 sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i r Design Flow 'i S 0 gallons per day. Calculated daily flow 3 X 1 10=3 3 0 gallons. Plan Date Number of sheets Revision Date xr. Title " Size of Septic Tank 1 000 Type of S.A.S. Description of Soil • ZC d4: ` h'7 Nature of Repairs or Alterations(Answer when applicable)Ada a .,� t.,n rz.h n ga 1 1 on 1 as nh i nr'r chambers, 25°X12,9 °X2° - - y 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 thug nviro ental Code and not to place the ystem in operation until a Certifi- cate of Compliance has been issued,,by this B and of 7H alth. �'' " Signed Date 11 /12/0 2 Application Approved by 1 '1 Date Application Disapproved fo the following reasons Permit No. C2000— 53 to `' Date Issued tN THE COM MONWEALTH OF MASSACHUSETTS ¢ ; BARNSTABLE, MASSACHUSETTS w Certificate ®$ Compl.i4nce THIS IS TO CERTIFY, that the On-site Sewage Disposals System Constructed( )Repaired}(XX)6Upgrad( ) Abandoned( )byj. J,P,Macomber- & Son Inc. at 6 Padlock Lane Cranl-�r�si 1 1 a ni n�aca has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. `_53(�dated Installer ,T_P_Mar-nrnhar P. San Tnr, Designer JC Enaineerina Inc. The issuance of this permit shall not be construed as a guarantee that the systohi�will function a's designed. Date l 13 -0 a Inspector S No., a00P- 53f9 Fee$50,00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION,-,BARNSTABLE., MASSACHUSETTS , Mi.Zp®5at bp5tem Con5tru ction permit Permission is hereby granted to Construct( )Repair'(XX)Upgrade( )Abandon( ) System located at 6 Paialrlcr� 7teT'Cn �vil le,Mass o 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 withinjlheee.years of the date of this permit. Date: I Approved by C. Kam- ' Pcd Locic La-,A� r 9 mow.✓ 4 i IL 1.1 d I 1 to 1 li V R 5" DIA. OUTLET(S) FINISH GRADE OVER CHAMBERS = 94.5'-95.2' GENERAL NOTES TOP OF FOUNDATION = 95.11 ' REMOVABLE COVER " SLOPE @ 2% MIN. OVER SYSTEM " "f 4 SCHEDULE 40 PVC MIN SLOPE 1% 3/4 TO 1-1/2 DOUBLE WASHED STONE TO CROWN OF PIPE FINISH GRADE OVER D-BOX= 95.0' 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE @ FND. EL.= 94.0' FINISH GRADE OVER TANK EL.-_ 94.2' 2" OF 1/8" TO 1/2" DOUBLE WASHED STONE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES. 20" MIN. ACCESS COVER 12"MIN. I TOP OF SAS = 92.23' PLACE RISERS ON ALL CHAMBERS EXISTING 4 (TYPICAL FOR 3) 36" MAX. 36"MAX. 9" MIN TO 6" OF FINISHED GRADE 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD 91 .40 36" MAX. BREAKOUT EL - 91 .90' OF HEALTH AND THE DESIGN ENGINEER. PIPE 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL 2" DROP MIN. - - � PROVIDE WATERTIGHT BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED. 3" DROP MAX. 3,. 9 6" 3" JOINTS (TYP.) io0 oo�Q 0000 0� 4" PVC IN FROM ! 4. TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE LESS THAN 0 14" �91 .81' SEPTIC TANK 4" PVC OUT TO o 0 0 T000 pp O oo ELEVATION = 91.90' FORA DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS T LEACHING FACILITY Tc)c) = = = = = = = 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. ' O OUTLET TEE 91 .67' MIN. 2 0 0 0 0 0 �� 0 0 0 0 0� 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 48" 91 .50 � 000 � ,�0 6" CRUSHED STONE o 0 0 0 0 0 00 0 0 0 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. 23.4' 22 ZABEL FILTER4 OVER MECHANICALLY O p (APPROX.) MODEL#A1801 HIP COMPACTED BASE 4 I _ 7. LOCAL BOARD OF HEALTH TO BE NOTIFIED (GAS BAFFLE ON f� 8.5 4' 4' PRIOR TO BACK FILLING WHEN SYSTEM IS NEARLY COMPLETE AND BOTTOM) 5 OUTLET DISTRIBUTION BOX 25 ~_ (TYP.) �i READY FOR INSPECTION. SYSTEM IS NOT TO BE BACK FILLED p TO BE INSTALLED ON A LEVEL STABLE < $2 S0' 12 9 WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH. BASE. FIRST TWO FEET OF OUTLET 89.40' GROUND WATER ELEV.= EXISTING 1000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. 2 - 500 GAL. CHAMBERS 5' MIN. 8. ELEVATIONS BASED ON ASSUMED DATUM OF 100.0' MSL OBTAINED LENGTH 9' WIDTH 5' DEPTH 6' CROSS SECTION VIEW FROM NAIL IN TREE AS SHOWN ON PLAN. SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL TYPICAL CHAMBER PROFILE CIA SER DETAILS CHAMBER END VIEW 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION NOT TO SCALE NOT TO SCALE NOT TO SCALE THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY n`,�,�� '�� f ry ��r` t � ���� � TEST PIT DATA DISCREPANCIES TO THE DESIGN ENGINEER. $ ° 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE Fr Er � STRUCTURES SHALL BE MADE WATERTIGHT. � i INSPECTOR: y 5 SOIL EVALUATOR Samuel Philos Jensen 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR N. �� ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN th a DATE: October 2, 2002 SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. TESTPIT#: 1 ELEV TOP 94.80' 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS m �.� LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH * ' * ELEV WATER= >12' BGS CASE THEY SHALL WITHSTAND H-20 LOADING. 00 W. E. N b '`.. � I ,; °u PERC RATE = <2Min/In (Assumed) 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND (6 .' .." "� �{ `fir w - FINES. .It DEPTH OF PERC - N.A. M,n3 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND U � rt �� � " TEXTURAL CLASS: 1 UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES ,.. ` S kr c+ N. -.. �' OF LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN J COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN : ACCORDANCE WITH 310 CMR 15.255(3). s. n #.. � 0 94.80' :. an . }, Sandy 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES O-A Loam FOUND IN SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. �� 10YR 3/2 " k R A j 4" 94.47' 16. PROPOSED PROJECT IS LOCATED WITHIN: Sand Loam B.M. ",° P �� r y ASSESSORS MAP 172 PARCEL 113 NAIL IN TREE ) B 10YR 4/6 Elev. = 100.0' qP m Assumed ,F. qFFjTl Fit, �i 17. OWNER OF RECORD: ROBERT L. & EDITH M. SIMPSON = 20" 93.22' to .RFC {r ` 0 "` r � ADDRESS: 6 PADLOCK LANE 7 CENTERVILLE, MA 02632 IF F-C Sand (� 12500, �fl r� r �« 1,.o ,�r. r aw j �,�; 2.5Y 6/4 �' '�� �'; '�' `v. WIM"""5 rr k. 4�N!P,"� G` ���w'`# � 1 k :, 18, PLAN REFERENCE: LAND COURT PLAN 328518 (SHEET 2 OF 2) v, Q ,4� r ,. r 134 ry 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. 6 „ PINE 6�" OAK j No Groundwater or j !u ~`�� o) Weephg Observed 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY ``X LOCUS PLAN FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY Z ^ o f ". - -- - 4 TWIN`" 144" 82.80' Q CFO LILAC- OAK FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. NSTALL TWO 500-GAL - _ INFILTRATION CHAMBERS SCALE: 1" = 1000' ' GARAGE _ EXISTING r129�- DESIGN DATA c.� IIIVIwWY . y LEGEND O O . ... cr 6 PI o x 50 EXISTING SPOT GRADES J ✓- DECK 50 EXISTING CONTOUR Q #6 O ` : 10" OAK ISTRIBUTION BOX �C EXISTING 3 '""'`' - 3 5 PROPOSED SPOT GRADES _ �2" OAK NUMBER OF BEDROOMS (ASSESSORS) F BEDROOM .2' TP 23'4 ,t NUMBER OF BEDROOMS (DESIGN) 3 (MIN PER TITLE V) CB (FND) DWELLING PROPOSED CONTOUR 20. � NUMBER OF PERSONS 2 94x80 0 o DESIGN FLOW 110 GAUDAY/BEDROOM - E ,.. EXISTING ELECTRIC AND CABLE UTILITIES T.O.F. = 95.11' � 24" K M o TOTAL DESIGN FLOW 330 GAL/DAY $" OAK i t:,,...i:.. - EXISTING UNDERGROUND TELEPHONE LINE Co J -�- - `�1` -'- EXISTING WATER LINE `. 6 BIRCH DESIGN FLOW X 200 % = 660 GAL/DAY if USE 1000 GALLON SEPTIC TANK TEST PIT LOCATION EXISTING 1000 (EXISTING TANK) 0 "� MAP 172 GALLON! SEPTIC TANK Q 0 EXISTING 1000 GALLON SEPTIC TANK o, 1 '` PARCEL 113 INSTALL 2- 500 GAL. CHAMBERS XISTING LEACHING PIT 4" SOLID SCHEDULE 40 PVC PIPE TO BE PUMPED AND 1 151906 SQ. FT. ± FILLED WITH CLEAN SAND SIDEWALL CAPACITY Cl DISTRIBUTION BOX (L+W) (2 SIDES) (2' HIGH) (.74 GPD/S.F.) = GAL/DAY N�S'223o � (25' + 12.9') (2 ) (2' ) ( .74 GPD/S.F.) = 112.2 GAL/DAY 500 GAL. LEACHING CHAMBER O 8S.p0, vTpos BOTTOM CAPACITY T(4�-FT�gY (LENGTH x WIDTH) (.74 GPD/S.F.) = GAL/DAY REV. DATE BY APP'D. DESCRIPTION (25 x 12.9) (.74 GPD/S.F.) = 238.7 GAUDAY _ _ _. ________ __ �VF PROPOSED SEPTIC SYSTEM UPGRADE TOTALS: PREPARED FOR: TOTAL NUMBER OF CHAMBERS 2 ROBERT SIMPSON TOTAL LEACHING AREA 474.2 SQ. FT. TOTAL LEACHING CAPACITY 350.9 GAL./DAY LOCATED AT h 6 PADLOC CENTERVILLE, MA 02632 SCALE: 1 INCH = 20 FT. DATE: OCTOBER 16, 2002 0 10 20 40 80 FEET OF 44A, T° JOHN L. PREPARED BY: o CHURCHILL a JC ENGINEERING, INC. � J R. °J CIVIL 5 ROUNDHILL BLVD. No 41 EAST WAREHAM, MA 02538 SITE PLAN - __._�____._.. . 508.273.0377 SCALE: 1" =20' ___ _ _..._.. _- .____.. Drawn By: JLG Designed By JLC Checked By: JLC JOB No.314 ACCESS COVERS MUST BE WITHIN 9- MINiMUM• IN VER T EL E VA T l ONS : DES l GN CR i TIER f A : GENERAL NOTES : 6' OF FINISH GRADE TO 3 ' MAXIMUM COVER INVERT OUT SEPTIC TANK: 91 . 8! DESIGN FLOW: FIRST 2' TO - - BE LEVEL M/N 2' OF PEASTONE INVERT IN DIST. BOX: 9i . 67 4 BEDROOMS AT / /0 G.P.D. PER I . THIS PLAN IS FOR THE DESIGN AND CONSTRUCTiON' OR F I L TER FABRIC INVERT OUT D i S T. BOX: 9/ . 5 BEDROOM EOUAL S 440 G. P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4- DIAM _,�..� 314' - 1 //2- DIA. INVERT IN LEACH CHAMBER: 91 4 R$� _ 89. 4 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED, FOR BENCH MARKS 19/ .Br 9 .5 2 ' BOTTOM OF LEACH CHAMBER SET, SEE SITE PLAN. •{ �,B DOUBLE WASHED STONE GA Cpop 89. 4 BAFFLE_1 9/. 9/ .4 -- ADJUS TED GROUND WATER: N/A — SEPTIC TANK REQUIRED: EXISTING 3-500 GAL LEACHING CHAMBERS OBSERVED GROUND WATER: N/A 440 G. P.D. X 200% - 880 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND EXISTING 0-BOX W/4 ' STONE AROUND. 12.8 'r x 33. 5' 1 x 2 "d BOTTOM OF TEST HOLE #l : 82. 8 SEPTIC TANK PROVIDED:: 1000 GAL . EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1000 GAL TWO EXISTING. ONE PROPOSED CONFORM TO MASS. D.E. P. TITLE 5 AND LOCAL SEPTIC TANK SOIL ABSORPTION SYSTEM REQUIRED BOARD OF HEALTH REGULATIONS, DESIGN PERC RATE l 5 MIN/INCH PROF L E NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE_ - 0. 74 GPO/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 440 GPD / 0 74 GPD/SF - 595 S.F. REQUIRED THAN 3 ' IN DEPTH SHALL BE CAPABLE OF WITH-STANDING H-20 WHEEL LOADS, PROVIDED: 3-300 GAL LEACHING CHAMBERS UP1125111 W/4 ' STONE AROUND, A-614 S.F. 5. ALL. SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 614 S.F. x 0. 74 - 454 G.P.D. APPROVED EOUAL . a 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED \ / SOIL TEST P I T DA / A PRECAST CONCRETE OR APPROVED POLYEThYLENE. \ S '-S° / INDICATES IN[ 'CA TES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER ?? / PERCOLATION OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE 0.E TEST - GROUNDWATER OUTLET. zs oo • I _ 1 ,\\ I / TP *1 7. BEFORE CONSTRUCTION CALL 'D 1 G-SAFE-. `` "Ei33f' :n HORIZON' TEXTURE COLOR 94 8 i-888-DIG-SAFE AND THE LOCAL WATER DEPT, Q` FOR LOCATION OF UNDERGROUND UTILITIES. 0/ ^ SANDY /0YR o \ S T�AD�' 9-1 LOAM 3/2 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE !7 BM. SPIKE IN 12' OAK 4 94.5 � o ` EL-(oo.oo DESIGN' ENGINEER TWO DAYS PRIOR TO CONSTRUCTION' ,• J ADD ONE 500 GALLON SANDY 10YR OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE 111 ""�����,I LEACHING CHAMBER LOAM 4/6 CONSTRUCTION INSPECTIONS V _ GARA6t 22• W14- STONE AROUND 20- 93.2 FINE-COARSE 2. 5Y 0 n�(;)� l SAND 6/4 9. ALL UNSUITABLE MATERIAL (A 6 B HOR I ZONS) ' PAVED pR Vf. -� * ENCOUNTERED BELOW THE INVERT OF THE LEACHING Q FACILITY TO BE REMOVED FOR A DISTANCE OF 5 AROUND AND REPLACED WITH SAND IN ACCORDANCE DECK , D W I TH T I TL E 5. ? EXJSTING 500 GALLON= LEACHING CHAMBERS W14 STONE AROUND FpGR � +� CATCH BASIN EXISTING FOULING D TP#I O' HR gEpp�M EXISTING & 1� I 14 4 NO WATER 82. B SEPTIC TANK ; -- a_. r 11_ 3•7 OA.r ' DATE: OCTOBER 2. 2002 yt 1 TEST BY' SAMUEL PHILOS JENSEN CATCH BASIN t PERC RATE: C 2 MIN/INCH /' ® ��• t � ,fir <,. A-A OF A! STEPH �.� 1 1 t aTF�l�ilr. ?. } , A. HAAS ?� N ! '� �-; �i.�, ". LJ. ���NO�35446 k � R. 1 I a` o. r �r �Q 017 2 ' � q �`•_ ;5, 907± S. F. ' \ \ _ es oo SE S v //\ ow S S TE OE \• OV TPG T 6 P,A O L. O CK t'— ,A iVE- . "A P / 72 PA R CE! ! 3 CATCH BASIN B A R N S TA S L E • "A . 11 YY < CE;�,� TER V / L L E I PRE,o,A EEiJ F-O,,? LEGEND /1/l / C f--/,� TOO ! E ,RCl/,/ PO/VZ-) RO,AO CUB=/VN / .S A ,A O2638 , T II ■ CB CONCRETE BOUND LOCUS i' --W_ WATER L I NE ova m Qtv L4 0 HYDRANT _5' CA i/ 0/V E E / _ 2 O .J ly 'Vk G GAS L l NE E A G 1 �) R �� I N O , I NC OHW— OVER HEAD WIRES n # LIGHT POST 923 Ro u t e 6A -t"— UNDERGROUND ELECTRIC LINE ` Y a r rrio La t h p o r t MA 0 2 6 7 5 b T— UNDERGROUND TELEPHONE LINE/i� 11It 1�I�;�~ 5 O 8 3 6 2-8 1 3 2 —CTV— UN'DERG/t0UN0 CABLEVISION LINE �i��/ -I 508 432--5333 + 40. 4 SPOT ELEVATION -,-40, EXISTING CONTOUR L O C U S MAP 0 I o 20 40 r0� PROPOSED CONTOUR f SOB ND : l 0-045 r—FIELD:CFW/RBW—T CAL C: SAH/CFW CHECK: CFW T DHN: SAH 4 s • �,. , vah _ L -k :-