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HomeMy WebLinkAbout0017 PATRICIA STREET - Health 17 Patricia Street Centerville A= 246-051 5 M E A D No.2453LOR UPC 12534 smead.com • Made in USA FWWAINnrsvMMLE SFI �� s' TOWN OF BARN_Sj.TABLE LOCATION V� e ( SEWAGE# •� VILLAGE ASSESSOR'S MAP&PARCEL 96 (y ©c5 I INSTALLER'S NAME&PHONE NO. u�n�i6S SEPTIC TANK CAPACITY 660 c LEACHING FACILITY:(type) V2tTJ (size) NO.OF BEDROOMS u OWNER ) PERMIT DATE: G COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) N N Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A or Aglgl Al !: d- 82r29 `35 814--3F �y5=�I ;Road. 4 No. 7G / �—�/ Fee G THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �— Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Bispo8al *pstpm Construction Permit Application for a Permit to Construct( ) Repair(V�Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. j Riff (,ki Owner's Nam ,Address,and Tel.No. / Assessor's Map/Parcel ��(p ^ O S ) 's k� ( �� 1�17 9 7y 7,Z. gUtaller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ,�4 &cavr 77 q Sq;009 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 Tank /S06 Type of S.A.S. Description of Soil Nature of Repairs orAlterafions(Answer when applicable) �/Q(,y .S�NIc >4 u H!o Aly-w 14 BoX 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 Environme 1 Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo Health. Sb Date _ Application Approved by Date ) Application Disapproved by Date for the following reasons Permit No.__n9Z'2 — -- Date Issued I I No. �� 51 c Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC'HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS j 01pphration for MIsposal *pstr'm Construrtion 3permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1-7 f4+t•i C Iq 5-� (aq,o,,j5 Owner's Nam ,Address,and Tel.No. Assessor's Map/Parcel �Gt }y � In taller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 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 Tank st'SD Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) IV2 c:o .S epi t C Ite/1 k /4 1Q .IAe.w PRO, D Box- 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 Environmen Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar Health. Signed Date r r Application Approved by Date 1 ! Application Disapproved by Date for the following reasons Permit No. /� f r -- Date Issued ; rj THE COMMONWEALTH OF MASSACHUSETTS N BARNSTABLE,MASSACHUSETTS Certif irate•of C'moliarrr'e THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(tV) Upgraded( ) Abandoned( )by at ��. i C)ILk has been constructed in accordance- - with the pro ,visions of Title 5 and the for Disposal System Construction Permit No_—*"L dated h /`7 Installer ie ',r4y,41Ior% -Designer #bedrooms Approved design flow gpd The issuance of this pe=iV shall not°be construed as a guarantee that the syste will f m ion �de ed. Date Inspelr No. t 1 2 Fee THE COMMONWEALTH OF MASSACHUSETTS T V,J T 0"<'`Y"' PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstettt Construction hermit Permission is hereby granted to Construct( ) Repair(v)' Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided.-Construction must be completed within three years of the date of this pennit. Date � fi Approved by`._ 4 09/07/2017 08:36 FAX -" f - R 001/001 FAX TRANSAUTTAL TO: Board of Health,Barnstable FAX: (5W 790-6304 200 Main St. Hyannis, MA 02601 FROM: Sheila Kenneally TEL 617 435 7472 (Cell) DATE: Sept 5, 2017 RE: Septic at 17 Patricia St., W. Hyannisport Dear Mr. Mckean: I bought the 3-bedroom house at 17 Patricia Street four years ago in August, 2013. The Title V passed. Because I am replacing the patio, I would like to replace the existing septic tank that is located under the patio. I have spoken with Quinn Excavating about this replacement. If the existing concrete septic tank is emptied/cleaned, can it be filled with sand and left in place, and have a PVC tank installed beside it,NOT under the patio area? The existing cesspool would be retained and used with the new PVC tank. The reason for preferring a PVC Tank is to avoid having delivery of a concrete tank drive over the existing cesspool and compromise it. My questions are: I) If a plan is drawn up for a concrete tank replacement, and a PVC tank is used, will this be approved? 2) Do you jgqUire an engineer's plan for this replacement, or could Kevin Quinn of Quinn Excavating explain the plan? 3) Is a PVC tank as reliable as a concrete tank? I would appreciate a reply by fax (617) 542-2241 with my name clearly marked) Or by email to skbronx3182ggmai1.com. Thank you, Sheila Kenneally Desmarais, Donald From: o Desmarais, Donald Sent: Thursday, September 07, 2017 4:10 PM To: skbronx3l82@gmail.com' Subject: moving septic tank Am I having a deja vu on this? You can replace the tank with a pvc tank. The old tank must be pumped and have the bottom broken,then filled with sand. Kevin Quinn can come in and pull a permit. No engineer required. As to your question about reliability,they are both tanks,they hold things. Take note:you must maintain setbacks to property lines and foundations. Donald Desmarais, IRS Health Inspector Town of Barnstable Public Health Office: 508-862-4740 Fax: 508-790-6304 donald.desmarais(cD-town.barnstable.ma.us 1 p Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M sa 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms to the computer,use 1. Inspector: -'Sill V=I[ ��lc��Y only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 'ed0" City/Town State Zip Code ,..� 508-420-4534 S14297 M Telephone Number License Number t �i � ¢? 4T.Jv 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. Thejnspe,�tion was performed based on my training and experience in the proper function and maintenancei'of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �,/2—� 7-6-13 Ins�s Signature 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. 7/1 t5ins•3/13 Title 5 Official Ins 6ion Form:Subsurface Sewage Disposal System•Page 1 of 17 'f �'1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M y< 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owners Name information is required for CENTERVILLE MA 02632 7/6/13 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM CONSISTS OF A MAIN CESSPOOL AND A LEACH PIT BOTH WERE OPENED AND FOUND TO BE EMPTY WITH NO SIGNS OF FAILURE AT TIME OF INSPECTION 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every 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, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the.Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every 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 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool , ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every 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 DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 I Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ❑ ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. City/Town State Zip Code Date of Inspection D. System Information Description: A MAIN CESSPOOL AND LEACH PIT WERE FOUND NO RECORDS WERE AVAILABLE AT BOARD OF HEALTH 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? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail 2012---108 2011----97 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: . gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): CESSPOOL AND PIT t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 ,I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every 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: CESSPOOL APPEARS TO BE ORIGINAL PIT APPEARS TO BE NEWER Were sewage odors detected when arriving at the site? ❑ Yes ® No 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: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. City/Town 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: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. CityrFown 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: ❑ 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.): PIT WAS OPENED AND FOUND TO BE EMPTY AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool AROUND 6X8 Materials of construction Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): CESSPOOL WAS EMPTY AT TIME OF INSPECTION 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. Cityrrown State Zip Code .Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r- - Commonwealth of Massachusetts G W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM , 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. City(rown 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: AT LEAST 4 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: AUGERED IN BOTTOM OF EMPTY PIT Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 PATRICIA ST Property Address MAUREEN SHEA Owner Owner's Name information is required for CENTERVILLE MA 02632 7/6/13 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �� I ickC,� \c 2 �t 2_ �� 1t LOCATION SEWAGE PERMIT N0. ,A VI L 1,AG E - � INSTA LLER'S NAME i ADDRESS U I L D E R OR OWNER DATE PERMIT ISSUED �� �d DATE COMPLIANCE ISSUED ��3_�� pl,� ,/� \ ��'� �3 I �' � ` � �.3 � � - t Fics......$...5-00-..._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................Town.....OF.....:BA. table....... Appliration for Biopoiia1 Works Tonstriirtion ramit Application is hereby made for a Permit to Constr t ). /or Repair (X ) an Individual Sewage Disposal System at: .l?.. t�ic .a. teet;..W .HY. b7dJtS�� -•--•------ --•............................................ -----•....................................:.... Location-Address or Lot No. Ms. Maureen She4.....-•---•...............................•----. 1 Z-Norforl __St,.,..Wollastori,._ ....021M.... W A & B Cesspool,Seraice� 128 Bishops Terrace,..gyannis_,___MA_.82601..____ ,.a ...................... .... ... Installer Address Q Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms...............3..........................Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ---------------------------- No. of persons........... ------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures . -•---•--------------••-•--•--•- -•-•---•-...........-•••.....••....-- 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 ( ) Percolation Test Results Performed by-••••-----•-••--••---•••-••••-•-.....--••-•••.....--••-•-••-•...----..... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... ts, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------•------------------------------•-•-----------...-•--•----.............-•-•••......•--.••.......................................................... 0 Description of Soil....... abd...................................................................................•--------........--------........----•-----------------•-•----•...... x U ...............•-----•-•••••-••---..........-••--•--.....--•-•--••-.......••-•••••-•---••••.....•-••--•-••-•••--••••••••----•-••-•--••----•••••-•--•••---•••••••-••••••••••-••......--•-••......•--•-•••. w U Nature of Repairs or Alterations—Answer when applicable... ir�stllato -.off--a-1-,000--galo�-_pre-east stone_•packe...-leach__pit.._.averflow)......................................................................................................................... Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to ace the system in operation until a Certificate of Compliance has been is ued by the board . .. = Q�A .80--••-.•- DateApplication Approved By...:4,Signe �= 1d?✓l- . .. ..- Q�43/$e......... .� Date Application Disapproved for the following reasons: ----------•----•--------------------------------------•••--•••--••••-•...••••-••...-- ......••••--•-•-•-••-•--•----••••--.......•••-••••-••---•-•••--•••••.......•--•...............•••---.......••--•......••-••--••-•••--------••----•••-••--•••-••-•••••-•-•-------•---•-•-••-•••••••••••--- Date Permit No..••-=•80-•••....................................... Issued_..................6,</23/80--------------•---- Date No.---- ?-. -. .. Fics......$...,.��f DO:..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a ...........................TM.....OF......� UQ...... ............................................... Appliration -for Disposal Mods Tonstrurtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair' (X an Individual Sewage Disposal System at: j EJ +�trG ji/" ►---------- -----•--•---------•-----....--•-------...---------•------•-------.............----................ Location-Address or Lot No .... ......... aee .............. .... Owner Address A.& B.EiL?t £l�Iftl!bl_Se v1C� .:......:........... 128 Pishow Terrace,- T1�8X..MA 02601,.... Installer Address � Type of Building �. Size Lot...........................S q. feet Dwelling—No..of Bedrooms__............. ..........................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building............................. No. of persons............i............. Showers Cafeteriato is ( ) •� dOther fixtures :------••......-•-=------------------------•----------I-----------=--------------------- ......................................................... Design Flow.............................I........_.._...gallons per person per day. Total daily flow..................._........................gallons. W � _ 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................:7sq. ft. Z Other Distribution box ( ) -Dosing tank ( ) 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........................ a -----------------------------------------•---.....----------........--•---•-------......................................................... ODescription of Soil.......SIM---- -----------------------------------------------------------------------------------••---------------------- x U W U Nature of Reppai�rs or Alterations L Answer hen applicable_._ nS'a�'ti�_.Afa Zr00p gallon pre-cast + t st ked 38ach i t aa►Q�!'S c .., 4 -- ':..:.......:.:.... ------......:------------. --------....._........... Agreement The undersigned agrees to..,-install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to ce the system in operation until a Certificate of Compliance has bee is ued by the board 90 hglth ' g 6 2 8Q Signed. .:_.. ..... ........................... ... / � ........ Application Approved B - - --- •-- ------------- ------ ----6� �8fl �+ .... _ -------- Date Application Disapproved for the following reasons:.. -------------------------------••--------------------------...---•--------------. ..........................................:............................................................................................................................................................... Date Permit No..........80........ 6 2 8t3 -..__. Issued... /- �--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................TowII.......OF......... %�."taI ..8A3............................................... (Irrtif iratr of Toutpliatnrr THIS IS TO CERTIFY_That the d vidual Se a e.DisposalSystem construct d_�;, ). or Re > ( X) by A B Cesspool Service, 12 >�i skimps Te ae® nniB, IAA 0�6(}� - 715-�_ --•--------------------- ------- . ].7.i atricia St W-H is ort, �i - ' '60en Shea at .............................. - . ------. ..--------I------. has been installed in.4eeordance`with the provisions of TI1LE 5 of The State Sanitary Cady, sf��scribed in the application for Disposal Works Construction Permit No.._._.___w_..12_.`�. _......... dated-__..•-CC-�--------_//............................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS E® A A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....6/23/84 .----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tom Bmstable ......................................... ..................................................................................... $ 5.00 No...34.. 2 9� OF FEE........................ Disposal Works Tongr�at rrntit A &_B_Ceiasps�©1 Service, Bis ps Ten=e, Hyannis, PEA Permission is hereby granted.............. ........................................................................................................................ to Const��yct�� C R ai; (W� n di Wg.S v sage Dif� Sgxst II at No ( ..... Street as shown on the application for Disposal Works Construction Permit'No..�/��Z Dated..........6/23/80.............. ---...... i' _.--------------------------- - 6/23/8O Board of Health DATE............................................................................... ' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS