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Home My WebLink About0129 PARK AVENUE - Health 129 PARK AVENUE, CENTERVILLE A=207 027 No. 42101/3 ORA Q � ESSELTE 1 0% (a 0 0 0 0 TOWN OF BARNSTABLE LOdKnOi:i/jgA- a&�� SEWAGE # VII T,AGE O_p� JS/�.�r.l-�� ASSESSOR' MAP&LOT C& 7• 2 17VSP4C-?D/?S NAME&PHONNE� NO. 1 oe V SEPTIC TANK CAPACITY o-� C� "xS' (iJ LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER O OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 �� ..r � � � i� � � �,� �9 , �. TOWN OF BARNSTABLE LOCATION SEWAGE # q VILLAGE _ ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. 6,2 SEPTIC TANK CAPACITY wcl I size LEACHING FACIL TY:(type) �� (size) NO. OF BEDROOMS.PRIVATE WELL OR UBLIC ATER BUILDER OR OWNER , - J-n ,f �t, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No =i 1 r 1 UAf. iry Lf4 twe Town of Barnstable Barnstable Regulatory Services Department 1 BAMSTMM i639• Public Health Division 1� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1520 0001 2273 2688 February 18, 2016 Thomas F. Connors, Sr 129 Park Avenue Centerville, MA- 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5. The septic system located at 129 Park Avenue, Centerville, MA was last inspected on 1/22/2016, by Michael DiBuono a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) Due to the following: • A single cesspool automatically fails in The Town of Barnstable. • Laundry needs to be tied into existing septic or install a septic for laundry. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\Conditionally Passes Itr\129 Park Ave Cent Feb 2016 �t Town of Barnstable Barnstable Regulatory Services Department A*#AN't'f" - - 1 1 1 Public Health Division 639 �,� 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL 97015 1520 0001 2273 2688 I February 8, 2016 Thomas F. Connors, Sr 129 Park Avenue Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENV NMENTAL CODE, TITLE 5. The septic system located at 129 Park venue, Centerville, MA was last inspected on 1/22/2016, by Michael DiBuon a certified septic inspector for the State of Massachusetts. The inspection of the se 'c system showed that the system "Conditionally Passes" under the guidelines of e 1995 TITLE 5 (310 CMR 15.00) Due to the following: • ngle c spo autom ically fails in The Town of Barnstable. • Laundry needs to be tied into existing septic or install a septic for laundry. You are ordered to repair or repl e the septic system within two (2) years from the date you receive this notification. Failure to repair/replace e septic system within the deadline period will result in future en cement action. PER ORDER HE BOARD OF HEALTH as cKean, R.S. C Agent the Board of Health Q:\Co ditionally Passes Itr\129 Park Ave Cent Feb 2016 Town of Barnstable HARH3rAHLA Regulatory Services Department o� Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Richard Scab,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6,'2007 ' Rev. 7/6/15 DEADLINES TO REPAIRFAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA. ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or--cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of-the cesspool withiri*a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private-water supply Well with no acceptable water.quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO 2 YEAR DEADLINE CRITERIA Single.Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) ❑.Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) OTHER ❑ L�,��r�r- SQ �7c (fir I nJ >' �e k( r (A WA Repair deadline: WSEPTICUEADLINES TO REPAIR FAILED SYSTEMS.doc Parcel Detail Page 1 of 3 _ v ..� �. � .. F w �'ZGr • m i� �'tt � c Logged In As Parcel Detail Wednesday,February 3 2016 Parcel Lookup Parcel Info _ _... ..f Developer iLOT 22&21. Parcel ID i207-027 Lot Location�129 PARK AVENUE Pri Frontage f100 �� r• Sec Road� ~� I Sec Frontage t . Village�CENTERVILLE .a..,_._.....,.._.....,,.,..M.. � Fire District Town sewer exists at this address Mo �� Road Index 1204 Asbuilt Septic Scan: Interactive cf;a 207027 ] Map Owner Info ; owner'CONNORS,THOMAS F SR& SANDRA L Co-owner streetl;129 K AVE `?PAR Street2, city CENTERVILLE O state MA j zip 02632 country ..Land Info _. Acresfi0.22 ( use4Single Fam MDL-01I Zoning IRD-1 A _ I Nghbd Topography l evel �..� Road Utilities Public Water,Gas,Septic Location Construction Info Building 1 of 1 Year F - Roof 1955 Ext Bulit !StructBowstring Trus Wall?Wood Shingle Living R t1421 oof Wood Shingle ._.I AcNone _I • Area' Cover Type VJD style Ranch Wall i Drywall 2 Bedrooms Int" Bed ? 1 10 Rooms s �° �_'� '"� Al' ) PO� os _ R� ModellResident _ ll-0 Half FIo,� Room . zi Heat Total Grade Plus Type Hot Air Rooms 5 Rooms ?? w GAR stories Story I HeatiGas �Found-I—Conc. BloWk�� Iyo Fuel ation _ Gros '2067 _....I Area Permit History Issue Date Purpose Permit# Amount Ins Date Comments 10/10/1998 Addition 35291' $28,500 5/30/2000 12:00:00 AM http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=l4510 2/3/2016 oFIKE'�wti Town of Barnstable Public Health Division a""-SS, 200 Main Street Y 39 0q �pEED MP'��0 Hyannis,MA 02601 Thomas F. Connors, Sr 129 Park Avenue Centerville, MA 02632 I I CO �I � .. • rrulrU For delivery information,visit our website at www.usps.coTO. ru m mIm OFFICIAL USE r— Certified Mail Fee nj nj I f1J nj nj I fU Extra Services&Fees(check box,add fee as appropriate) rl • _ —=tea ❑Return Receipt(hardcoP» $ Q _== 0 r3 Return Receipt(electronic) $ Postmark C3 • -�, 3 I O ❑certified Mall Restricted Delivery $ Here C3 Q I C ❑Adult Signature Required $ -_ ❑Adult Signature Restricted Del"$ C3 Postage N �� ru Lillo. Ln I Lrjj $ r=1 Total Postage and Fees Ln Ln I Ln Sent To arLq O . ------- - ---- ---------------•------------------------------_.. 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USPS postmark If you would like a postmark on : li ■For an additional fee,and with a proper this Certified Mail receipt,please present your 1 endorsement on the mailplece,you may request Certified Mail Item at a Post Office-for 1 the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion • ,, - of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply - You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.' +r electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Retum r Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. PS Form 3800,April 2015(Reverse)PSN 7530-02-000.9047 , { COMPLETE •N COMPLETE THIS SECTIONON DELIVERY q Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverse X ❑Agent so that we can return the card to you. O Addressee i B. Received by(Printed Name) C. Date of Delivery i ■ Attach this card to the back of the mailpiece, I or on the front if space permits. I 1. Article Addressed to: D. Is delivery address different from item 1? 13 Yes If YES,enter delivery address below: _ p No I I I I I I I I I 3: Service T I YPe ❑Priority Mail Expresso II I'III'I I'll I')I I I I I I II II(III I I"l l l l it I I I III ❑Adult Signature ❑Registered Mail" ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted: I ❑Certified WHO Delivery 9590 9403 0922 5223 8288 20 ❑Certified Mail Restricted Delivery ❑Return Receipt for I ❑Collect on Delivery Merchandise 2. Article Number(Transfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationTM ❑Insured Mail. ❑Signature Confirmation ❑Insured Mail Restricted Delivery Restricted Delivery I (over$500) ,� PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt USPS TRACKING# First-Class Mail Postage&Fees Paid Permit No.G-1USPS 0 � I I 9590 9403 0922 5223 8288 20 I United States •Sender:Please print your name,address,and ZIP+4®in this box• Postal Service Town of Barnstable Public Health Division i 200 Main Street � I Hyannis, MA 02601 M r I I I i I i Commonwealth of Massachusetts Title '5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, 129 Park Ave P rope rty.Address'.. . Thomas Connors tom. Owner Owner's Name information is �} required for every Centerville Ma 02632 1/22/16 page. City/Town ' ' State Zip,Code Date of Inspection - "- IV Inspection results must be submitted on this forrp. Inspection forms may not be aUtered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, ` use only the tab 1. Inspector: ' key to move,your cursor-do not Michael DiBuono key the return Name of Inspector Y DiBuono Sewer and Drain Q Company Name 8 Johns path Company Address B S Yarmouth MA L. 02664 u� City/Town State Zip Code 508-364.-9587_. _ S113522 =; - t Telephone Number Liceni&Number :r B: Certification I certify that I have personally inspected the sewage disposal system,at this address and that the information reported below-is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.,I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1/23/16 .,, nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1000 gallon Block Cesspool acting as a septic tank followed by a concrete leach pit. The leach pit is operating and does not meet failure criteria. The laundry is on a separate dry well. B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. . * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of'' Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): The laundry is on a separate dry well. _ t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due `to'broken or obstructed pipe(s) or due to a broken, settle—' 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 laundry is on a separate dry well. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. Cityrrown State _ Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 4,100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 99 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,..'' 129 Park Ave Property rt A p y Address ess Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. .� ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEC' certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a Ipurface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 k i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M ,• 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: 'IZ u Ex'sting 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: ): 2 N ( Number of bedrooms (design):( umber of bedrooms actual 2 9 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon Block Cesspool acting as a septic tank followed by a concrete leach pit. The leach pit is operating and does not meet failure criteria. The laundry is on a separate dry well. Number of current residents: 2 Does residence have a garbage grinder. ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 189 Gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped eve two years Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): Cesspool and leach pit t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 .� Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: over 20 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 1811 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.): System is vented throught the roof. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness Y Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection Grease Trap (locate on site plan): Depth below grade: NA 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 I Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑' Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.):, *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,M ,•''t 129 Park Ave Property Address Thomas Connors Owner information is Owner's Name required for every Centerville Ma 02632 1/22/16 page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: El Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5in's-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form a _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•'" 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is Centerville required for every Ma 02632 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: I ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of carry over and no signs of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Block 6x8 " Depth—top of liquid to inlet invert 13 ' � Depth of solids layer 3" Depth of scum layer 101, Dimensions of cesspool 6x8 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydraulic failure Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 4 f Assessing As-Built Cards Page 1 oC2 TOWN OF BARNSTABLE LOCATION4a�9/94—dzz P- SEWAGE d VILLAGE 2d/lt lr/ 211� ASSESSOR' MAP&LOTQ7. 2 JvSP�=7ZJR5 NAME&PHONE NO.�Cr T;OYZ � ��e e gy& SEPTIC TANK CAPACITY ! 6'X5-' (1) LEACHING FACILITY:(type) /_Ly r!// (size) le)OD g]�. NO.OF BEDROOMS 1�2 BUILDER O!Z OWNER UtLrCt/fGPfQh!/k1 G[�r.C�1iV% / PERMTf DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 fleet of leaching facility) Feet t Edge of Welland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) F!!m Furnished by i �V) i$ l� i bttp://www.towiiofbariistable.us/Assessing/HMdisplay.asp?mappar=207027&seq=1 1/2l/2016 Commonwealth of Massachusetts Title 5 Official Inspection Fora a s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,• 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 1/22/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property sits well above local ground water Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 129 Park Ave Property Address Thomas Connors Owner Owner's Name information is required for every Centerville Ma 02632 _ 1/22/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ 'Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file z t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION t:A SEWAGE# VILLAGE r� t_L t.r ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 2a Z:�- 1• ,7®T=44-T- E'444— SEPTIC TANK CAPACITY C-dJ-Pen_— LEACHING FACILITY:(type) WA — NO. BEDROOMS ..'I— OWNER C,p�e.i �^f t d�t e� -o *--J.art►4 PERMIT DATE: COMPLIANCE DATE: 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 � I ►eve. Ce4e V14 �G11b -b3 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYicatiou for Misposal �&pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System 0 Individual Components Location Address or Lot No. /j ! / 2w�ner's Nam Address,and Tel.No. Assessor's Map/Parcel V U� Ce1'1�u al`ice /�0 'S j`�g)&k-A� ' O Co 3;L OF Instal}e 's Name t'� Address,an�Tel.No. So$' 3� Designer's Name,Address,and Tel.No. �pPiO�D"I� &'-'�fl t= Ci�rlv�c -0. x 90� n Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank4'ZlCf 141 plc, J Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir de and not to place the system in operation until a Certificate of Compliance has been issued by this Board o ealth. Signed Date a Application Approved by Date Application Disapproved by Date for the following reasons Permit No. C Date Issued 2 r7`(fo N No. �0 631�6 ! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS RppliLation for Disposal *pstrm Construction permit � Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ®Individual Components Location Address or Lot No. /j / tA�e O_wner's Names Address,and Tel.No. y53�_ cn�'a a C�r��ru, 1(� /�io"S 6a n�Ors l�9 �k�e _- - .• Assessor's Map/Parcel Qi?j ) ' , AA 14 o a CD 3-- Installer's Name,Address anld Tel.No. 5G$-'?� 93/ Designer's Name,Address,and Tel.No. njprf0'O�ConS�-fL.,--k "l7zrlC• }?.0. X 70 /� rtlGt v,s�l�lls . MA oacoY� /`'y Type of Building: Dwelling No.of Bedrooms a Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic TankeYU 54 I YK I UC=, Type of S.A.S. JU6-04rtQ PV_� t A Description of Soil J Nature of Repairs or Alterations(Answer when applicable) Tna-, 0 el , po.1pwh e � C'.-1�`�►�'n�Qtl '�y t'rU�,,yiN� t �X►S�'i n� �t',t�nc�rum.imp -��C��1 �LY11.r. C_�e55�1 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 EnviroDmental-eode and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal Signed e2 __ Date Application Approved by Date Application Disapproved by s 1 Date for the following reasons Permit No. �0 Date Issued 2�2 ---- ------------------------------- ------------------------------------------------ (or r ct !c-ww df y THE COMMONWEALTH OF MASSACHUSETTS Se ,� 9 BARNSTABLE,MASSACHUSETTS Certificate Of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(3<) Upgraded( ) Abandoned( )by 1 JA , <- at /a 9 a rg AGP° - 0En rUr � has been constructed in,,,accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.;_W0 6dated Installer_ R() i ,,)y)C'hr(JX1'ICM -L X1 C Designer /U'; t , R c// C r 7!1 f #bedrooms roved A n flow (/ d a pp design gP The issuance of this permit shall not be construed as a guarantee that the system will fun ion as d signed. Date I I i 6 Inspector -- - _ - ---------------------------.-------- -------------------------------- --------- - No. (90t� 0 y Fee "y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal *pStrm Const ction permit Permission is hereby granted too Construct( ) Repair(� Ile- and ( ) Abandon( ) System located at 1 07 7 /�i�� 'L� N)-,c, rj/il��' and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. k( Provided:Construction must be completed within three years of the date of this permit.�— Date 21 Approved by _ a IrIc3 N RECE vEO � �.. BORTOLOTTI CONSTRUCTION, INC.. MAR 9 1997 of 765 WAKEBY ROAD, MARSTONS MILLS, MA 02648 NOP 508-771-9399 508-428-8926 FAX: 508428-9399 �� k6AtA DEft, E �� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Qp � PART A 6 ; CERTIFICATIO Property Address: ' Date of Inspection: Inspector's Name: Owner's Name and ysAddress. ClUn a e, y �h1P CERTIFI ATION 4TAT M NT. I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true, accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and ruaintenance of on-site sewage disposal stems. The System: Passes Conditionally Passes Needs Further luation y e Local Aproving Authority Fails _ Inspector's Signature: �'� �1f�-' _ Date: Z7�9 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION 4i M ARY - A)SYSTEM PASSES: �! I have not found any information which indicates that the system violates an)of the failure criteria as defined in 310 CMR 15,303. Anv failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all in not determined", explain why not. stances. If The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The systent will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed Pipe(s)or due to a broker, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - . y t SUBSURFACE SEWAGE DISPOSAL SYSTEM INS r.,ECTION FORM PART A CERTIFICATION (continued) Broken pipe(s) replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four.times a year due broken or obstructed pipe(s). The system will pass inspection if(with approval of The Boar of Health): Broken pipe(s)are replaced Obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD Of 1EALTH: Conditions exist which require further evaluation by The Board of iealth in order to determine if the system is failing to protect the public health, safety and the a ironment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE'. MINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH ' ILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEN : : Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated ietland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH i iND PUBLIC WATER SUPPLIER, IF APPROPRIATE ) DETERMINES THAT THE :SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEAL? HAND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system air:. s within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption systern an, s with a Zone I of a public water supply well. The system has a septic tank and soil absorption system an :s within 50 Feet of a private water supply well The system has a septic tank and soil :absorption system ape+ is less than 100 Feet but 50 Feet or more from a private water supply well, unless a --A in:I water analysis for coliform bacteria and volatile organic compounds indicates that the .cell is free from pollution from the facility and the-presence of anunonia nitrogen and niti,�te nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the folLr..ving failure criteria as defined in 310 CMR 15.303. The basis for this determination is identitI :9 below. The Board of Health should be contacted to determine what will be necessary to Corr(.,.t the failure. Backup of sewage into facility or system component due , an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the groin. d or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet in,, : t due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less tlaaa 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year lY(2" due to clogged or obstructed pipe(s). Number of times pumped - 2 - I _ / c1 SUBSURFACE SEWAGE DISPOSAL_SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. if the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 260 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. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEINI INSPECTION FORM PART B CHECKLIST Check if the following have been done: ✓Pumping information was requested of the owner, occupant, and Board of Health. _None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓As-built plans have been obtained and examined. Note if thev are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _2The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _/All system components,excluding the Soil Absorption System, have been located on site. _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. —lie size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CFIECKLIST(continued) 1, he facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -SYSTENI INFO RMATION FLOW CONDITIONS RESIDENTIAL: Design Flow: 33P gallons umber of Bedrooms:_ Number of Current Residents: Garbage Grinder:_ aundry Connected To System:_P""' Seasonal Use: Water Meter Readings, if a ailable:_ _ Last Date of Occupancy, � _ C��2 COMMERCIAL/INDUSTRIAL: /vU Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no)_ — Industrial Waste Holding Tank Present:_ Non-:.unitary Waste Discharged To The Title V System:_ _ Water k,feter Readings, If Available: _ 1—ist Date oi'Occiipanc% _ OTIIER: Describe) Last. i..ai.e of Occupancy:_ GENER INFORMATION PUMP.LNG RECORDS and source of i.nforntalioiv-. System Pumped as part of inspection: if yes, volutQ pumped: gallons Reason for pumping: TYPE OF SYSTEM: — Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If ,es, attach previous inspectio ecords, if anv) _�ther(explain): A,A I P �S-4S AW ROXIMATE AGE of all components, date installed(if known) and source of information: Se age odors detected N en arriving at t e site:_ -4 - SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FO RM ORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete metal FRP Other (explain) Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: . Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP r Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or,baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity.evidence of leakage. etc.) TIGHT OR HOLDING TANK: Q -- Depth Below Grade: Material of Constniction:__concrel.e_metal __FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float switches. etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carr},over, evidence of leakage into or out of box,etc.) PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOEL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible, excavation not required, but may be approximated by non-intrusive. methods) If not determined to be present, explain: Type: Leaching pits, number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: _ Leaching fields, number, dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure level of ponding, condition of vegetation, etc. Q Q L CESSPOOLS: t/ Number and configuration:�-�I15 • Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum laver: Dimensions of Cesspool:Cd 'Dy 5 � Materials of construction• '(p yf!e? Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note conditio of soilk. signs of hydraulic failure, level of onding, cppdition of ve etation, etc. CL �o - ii i/ .i PRIVY: A U Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of lydraulic failure, level of ponding, condition of vegetation, etc.) -6 - V r , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. DEPTH TO GROUNDWATER: Depth to groundwater:__ 17 Feet f _ Method of Determination or.Apprgximation: 7 i. No........./ . Fss . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Toustrur#plan 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat: G ........ ........................... ......... .......... .................. --.---------------- ----- ------ oca' n:- dress 4 .. or Lot No. .........•- -------- --- - .... .....-- -------------------------- .........--......... -- ...... O - n l� Address W f ..A staller Address of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms....-3..................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............................ No. of persons_______________-_..__-.. Showers — Cafeteria PLOther fixtures ------------------------•------•-------•--------------.----•----------- d W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--------_------- Depth................ x Disposal Trench-No..................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.............................--------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - ---- .......-- O Description of Soil.. ........... ..r�`�. x x -------------------------------------------------------------------------------------------------------------------------------------- -/,j' ----------------------- U Nature of Repairs or Alterations—Answer when applicable._--__---_�.00-__:____ - --- ._. ::................................. --•-----•-----------------•-----•--••----------------------...----•------------------••---•---•---------•----------•---------------------------------.................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Cer44F been i sue y t oard of ealth. .--------- -- q Application Approved By ._-- c?... '�_-L`...... ..........................................................-- ------'-------- Date Application Disapproved for the following reasons- ............................................................... ................ ---------------- at Permit No. pp ; --------. Issued .. ."� � -_-e.. Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ger#ifi ate of Gutplinurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( f) by--------- ........ ��d -----------------------------------------------------------------------...-------------------------...------------------------------------------------ _... //1 Installer f///� \ �.,../7 �// A a ------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental C,o"de as described in the application for Disposal Works Construction Permit No. .. --...p-. � dated .J %� -Q'!................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BCE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... 1 Inspector -- ------------- � ----------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF B_ ARNSTABLE FEE._,�....�...... Raposal Wore Tons#rur#ion Vprrmit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ,.,)'an Individual Sewage Disposal System 7 n n/ % A /J r+/.O at No lz! ---- v ..1..,..._....-`.fie 3r��tidi.y.... ,. ..................................................... d / �'•-....._..---•---Street-•......................... as shown on the application for Disposal Works Construction Permit No... �.=.._K___._ Dated....�,3 !�.' ............... ......................•---•--------•X)v_ +!._s �---•--........._ �� oaofl Hea14 DATE.. ----------------------•-------------..........-•--.._..... FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS /-30 No------------------------- Fss... , ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , Appliratitun for Ui4vsal Works Cnnnstrurtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal 4 System at: 1.. 4--------------------------- ------------------------------------------- ------------....-----•---.....----------- �`� Locat�gn- dress¢ or Lot No. (� caner Ad .dress .._..: e ,/4 - 'dress Iaystaller Address d TT of Building �/ Size Lot............................Sq. feet U Dwelling—No. of Bedrooms._._.:__________________________________Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building No. of persons___-___•••__•--------------- Showers — Cafeteria Q' Other fixtures ---------------------------••--- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 0; Septic Tank—Liquid'capacity_______-----gallons Length-------_------ Width................ Diameter................ Depth................ W Disposal Trench—No.-------------------- Width....._.............. Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No-------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ ,4 Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ (T, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a 0 Description of Soil..,..-.,, U ........................................................--.----------------------------------........------------------------------------... � ---------------------- -- -----------------------------------------------------------------------------------------------------------------•--- �.. U Nature of Repairs or Alterations—Answer when applicable......... . �? ___: t_�.._.. 11��,�................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian has been issued by the /board of health. Signed-. �� -; �d� --�- Application Approved By � '��. e ---------------------------- ------------------------ W ( � -: ----... Application Disapproved for the following real nf: --------------------------------------------------------- ------------............................................................ --............................................ .........-....---..-........... -------- .---....Date------------------------------ — .+ p PermitNo. ------------------�1---�----...--------------- ------- Issued --. ----...-�).'_....q....-.....---....--------.........- Date