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HomeMy WebLinkAbout0076 PATRIOT WAY - Health 76 PATRIOT WAY, CENTERVILLE A = v UPC 1534 �LOR MAITINISt MW Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments FYTA ,E ^M Subsurface Sewage Disposal System Form L _ `. I c� = 7 3: f i Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification -- - - Important:When / � Q When filling out 1. Property Information: forms on the computer, use 76 Patriot Way Centerville, MA only the tab key Property Address to move your Laurent Chiotasso cursor-do not Owner's Name use the return key. 76 Patriot Way Owner's Address Centerville MA 02632 City/Town State Zip Code I I Date of Inspection: 7-12-05 Date 2. Inspector: �ZH OF/�sS Roy Okurowski Name of Inspector Owws N Roy Okurowski Company Name 67 Stetson St Company Address ANAL E � Hyannis MA 2601 City/Town State Zip Code 508-776-0956 Telephone Number _ Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Ne F Irther valuation by the Local Approving Authority 02� 7-12-05 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 76 Patriot way Property Address Centerville MA 02632 City/Town State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection 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: sytem was previously upgraded B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 76 Patriot way Property Address Centerville MA 02632 City/Town State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 76 Patriot way Property Address Centerville MA 02632 City/Town State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 4 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,M s Subsurface Sewage Disposal System Form A. Certification (cont.) 76 Patriot way Property Address Centerville MA 02632 City/Town State ZipCode Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection 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 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or'privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 76 Patriot way Property Address Centerville MA 02632 Citylrown State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection 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. t5insp.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 6 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M B. Checklist 76 Patriot way Property Address Centerville MA 02632 Cityrrown State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection 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(3)(b)] t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 7 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4'M C. System Information 76 Patriot way Property Address Centerville MA 02632 City/Town State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection 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 Number of current residents: 2 Does residence have a garbage grillder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 76 Patriot way Property Address Centerville MA 02632 City/Town State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1000 tank and first pit is 1977 d-box and 1000 gal pit in 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 76 Patriot way Property Address Centerville MA 02632 City/Town State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection 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): peck rjo%W ovvtr 4e,^k Depth below grade: 2 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 ® Yes ❑ No certificate) Dimensions: 1000 gal. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 1000 gal. from town card t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form G7M C. System Information (cont.) 76 Patriot way Property Address Centerville MA 02632 Citylrown State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection 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 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): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 76 Patriot way Property Address Centerville MA 02632 Cityrrown State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: . Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert no liquid 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.): box looks like new Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 12 Commonwealth of Massachusetts Title 5 ffi 'O cial Inspection Form Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form C. System Information (cont.) 76 Patriot way Property Address Centerville MA 02632 City/Town State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ 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.): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 13 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form fly C. System Information (cont.) 76 Patriot way Property Address Centerville MA 02632 Cityrrown State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): Lt5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 76 Patriot way Property Address Centerville MA 02632 cityrrown State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. c+ 7�'� r ~ i �. ' 3� fir. c�neJ+c Yor ` I D£cEc a r 35 1 I t { I 13 r'6I t F3 e W�� t5insp.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM C. System Information (cont.) 76 Patriot way Property Address Centerville MA 02632 Cityrrown State Zip Code Laurent Chiotasso 07-12-05 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: auger down 12 feet t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 ::;.. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 76 PATRIOT WAY CENTERVILLE L �--� Name of Owner COUTU Address of Owner: SAME Date of Inspection: 9/16/99 lll"i VEQ Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15,340 of Title 5(310 CMR 15.000) S EP 2 4 �999 Ma lCopany Name: n/a ing Address: n/a IL10 HfA17{{D&ST�tf Telephone Number: n/a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Furthefthe tion By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:9/21/99 The System Inspector shala copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. tem is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. I revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9/16/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: Wa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n[a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is levelled or replaced Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9/16/99 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa.(approximation not valid). 3) OTHER nLa revised 9/2/98 Pa e 3 of 11 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9116/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Wa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design Flow of 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: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. z I revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9/16/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9/16/99 FLOW CONDITIONS R ID NTIA : Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):X Total DESIGN flow: = Number of current residents:2 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): MQ If yes,separate inspection required Laundry system inspected(yes or no):-W Seasonal use(yes or no):JtQ Water meter readings,if available(last two year's usage(gpd): n& Sump Pump(yes or no): NQ Last date of occupancy: nLa COMM R IA IIND IRT. RIAL Type of establishment: nLa Design flow: nLa gpd(Based on 15.203) . Basis of design flow: nla Grease trap present:(yes or no):JIQ Industrial Waste Holding Tank present:(yes or no): Na Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:nla Last date of occupancy: Wit OTHER: (Describe) Wit Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: 1995 System pumped as part of inspection:(yes or no):NIQ If yes,volume pumped nLa_ gallons Reason for pumping: n(a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: ORIGINAL SYSTEM 1977 WITH A REPAIR IN 1995 Sewage odors detected when arriving at the site:(yes or no). NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9/16/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 14" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n[a Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: $_ Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO n[a Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: 1_ Distance from top of sludge to bottom of outlet tee or baffle: 3X Scum thickness:-. Distance from top of scum to top of outlet tee or baffle: S" Distance from bottom of scum to bottom of outlet tee or baffle: A How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTU A i Y SOUN) RECOMMEND EVERY TL^!O t Aac GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nta Dimensions: Wa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:jVa Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n[a 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.) n& t revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9/16/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nla Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: Wit Capacity: Wa gallons Design flow: nta gallons/day Alarm present: NQ Alarm level:jiLa_ Alarm in working order:Yes—No—: NQ Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and Float switches,etc.) nta DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa PUMP CHAMBER: 11LQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9/16/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number: 2-1000 GALLON LEACH PITS leaching chambers,number: 11La leaching galleries,number: 11/a leaching trenches,number,length: Wa leaching fields,number,dimensions: nta overflow cesspool,number: n(a Alternative system: Will Name of Technology: _n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PITS ARE TR TURA L SOUND AND FUNTIONING PROP R y TH NEL^►PIT HA C,NOT t,AD h^OR TF,AN 1 OF ^SAT R IN IT CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: nLa Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)D& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction:Wa Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9/16199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a c b � o� a c�� VN ��37 revised 9/2/98 Page 10 of 11 f - • ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 PATRIOT WAY CENTERVILLE Owner: COUTU Date of Inspection:9/16/99 NRCS Report name: n/a Soil Type: nLa Typical depth to groundwater: n& USGS Date website visited: n& Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised'9/2/98 Page e 11 of 11 y 7 ' TOWN OF BARNSTABLE LOCATION��J ��/� ( �SAV& SEWAGE # , A s "VILLAGE(ge*'l nQvl*/le- ASSESSOR'S MAP & LOT/PZc- `0 INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY/ LEACHING FACILITY:(type (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: l DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t4 1� 3 1 TOWN OF BARNSTABLE LfATION , SEWAG' # V111AGE l � \�� ASSESSOR'S MA & LO �`�-"� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER Q�� PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �� Feet Furnished by Decr t a AA�i m 4 PA 31 6l�� Qe 3`► NO.?$— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diripuuul Wi urk,i Tomitriir#iun Ilrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at J �.w ..... . �&.t ------ 4 a�---._e. - -------------------------------------------- ......------------....._........---•-•---- Location-Address or Lot No. �04 On.ncr .............Address Installer Address UType of Building Size Lot............................Sq. f t t., Dwelling— No. of Bedrooms.......... .............. ------------- Attic ( ) Garbage Grinder Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' 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 ( ) aPercolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ C4 ....-••-•-•------•--•...--------••-••-•-•-••-•--••---••---•••••--•.........................•--_...-•......................................................... 0 Description of Soil........................................................................................................................................................................ x w .---•--------------------------------------------------------------------------------------------------•--- U Nat ue of,Repairs or Alterations—An§wer when ap licble_- ------ ....... 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 Compliance has,been iss d by t oard of health. �/t' Signed . - ......... .........�.._.. :....:..�>s Da Application Approved By :............. - .....% ---- '------ ........-- . ....................................... `..... Ki. Dare Application Disapproved for the following reafonf: ......................................... ... ... ........... ...................................................... ...................................................................................... . ..... ............................................................... ------ .......... Permit No. .... �J...�....�........... IV.......... Issued .......... :.`��. :/1� Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tez#ifira e of Compliance THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (L� byC C O ........----......................................................._............ at ............./....b..................�/q` r.l..n�.�..... �4-%,:-u------------------- ,..................._.................... ..................... .......... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in,. the application for Disposal Works Construction Permit No. �. �6 . ... dated4.. ._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY____-- DATE................�� ''...�� �--- .._. ... "` ..... Inspect r G �! - ....................._...._... � �� _ ---_m—_.--__`_____—__,—__—__----------------, _,--_----_—_.--_-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No,. j'`� FEE.-..:`-el......... ..............•-•-- Dispnoal Workii Tunitrudion prnttt Permissionis hereby granted--------------- --------- --------------.....--------- .............................................................. to Construct ( ) or ep r ( an Individual Sewage Di posal, m ste Street A as shown on the application for Disposal \jorla Construction Permit amr`•*' , Dated ed_....... .. f. '?�. ? 1. /.' ifd! ------ Boar,oHealth -- DATE -............----....--•--- FORM 36508 HOBBS d WARREN.INC..PUBLISHERS • I No. .............................. THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH TOWN OF BARNSTABLE Appliratioit for Diri.pooal Works Tomitrnrt"ton Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at ........lt/Q . Z...... ......................................................................................... Location-:\ddress or Lot No. c� f .......... ------------------------ ............ o-ner Address Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms.......... .............. .. .Expansion Attic ( ) Garbage Grinder t(b Other—Type of Building ............................ No. of ersons----------------..---------- Showers — a g p � ( ) Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- -----------------•-------------------...--------•••---------- W Design Flow............................................gallons per\person per day. Total daily flow............................................gallons. I' W Septic Tank—Liquid capacity............gallons Length---------------- Width...--..-.-..---- Diameter................ Depth........... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 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...--................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------•-------------------------------•-----------•---•---•----.--............................................................. 0 Description of Soil...................-.................................................................................................................................................... W V .............................----..................................................................................................................................................................... W ------------------------------------------------------------------------------------ ----------------------- - V Nature of Repairs or Alterations—Answer when ap licable--- ................. .........4.,,...-..._.l L✓i.. =� �� �s ,/?q , .. '�------ � � ..................................................... 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 Compliance has been iss-ed by t aboard of health. nn �- Signed ...... �..... . --....... ...'- -. ..'-.7..5 Date ApplicationApproved By ........:..... .............. ...... .... .. . .. - ........................... .................Dare Application Disapproved for the following reasons: ................................. .........__.....-............. ........................................................................ .................................................e ......... .......................................... ..... ......--...--..................... ..... ...-. ........................... ` - .-- ----.............-..-................ Dam � Permit No. ..: ... .............. Issued ---------- Dam.'.. r. ���..-....._ LO'CAT/SOON SEWAGE PERMIT NO. 9 � - VILLAGE � �y INSTALLER'S 'NAME i ADDRESS J BUILDER OR 0 NER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED -17-79 L,4 7G p 79 �k . No..•••.... FEB ... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town Barnstable ...........................................OF.......................................................................................... Appliratinn for UWposa1 Works Tonstrnrtiun "fermi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Lot # 76 Patriot Imlay.... ............................ .Centerville,, MA , .02632 ocatio Add re s or It No. Suffolk Real y 'rus P.O. Box 308 Centerville ......................--. •-- ----•--------•--•-•-••-••-•--•--•-- ••--......-----•--••--•••••-...............-•••--.....•-•-----..................................•. Owner Address W Kevin Hickey 72 Carriage Lane Barnstable Installer Address Type of Building Size Lot....1.49 ac-.Sq. feet Dwelling—No. of Bedrooms............thr ee Expansion Attic �o) Garbage Grinder Rio) Other—Type of Building ...ranch No. of persons.......2.................. Showers ( 2) — Cafeteria ho) W Other fixtures --------------------------------------------------- Design Flow............110 .....................gallons per person per day. Total daily flow........ Q...........................gallons. W 10 W Septic Tank—Liquid capacity_.:.____...00 .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_..._QPt g,e. ... :... L. .......... Date......., '✓ 9........... aTest Pit No. 1..... ........minutes per inch Depth of Test Pit......... ..... Depth to ground water....none....... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' •-•••-......-•••••................ •--• -•---••------•-•••-•-•--•-•-••-••-•-_. ......_..---•-••----..........------..........-••-.•--•- 0 Description of Soil----..•----------------------------------•......0. •-- 2...•.loam- .... ubsoil--••---------••---•---•----••-•-•-•---•-••------...... x --••-•----••-•-----••--• 6-=---......Ined t--sand V W --------------------------------------------------------------------------------6......m..12.-•--•.f.ine...sand..................................... U Nature of Repairs or Alterations—Answer when applicable...___.......................................................................................... ---------------------•--•-------•---•-----------------...---------------------•--•-•-••-•--------••---------•-----------------------------------•--------..._._..._........_.......---•••--•••••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI.E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the boar of health. Si e . - June 2i.,_1979 .... ......... Date Application Approved BY = .. ��`�'}' •.......•......... ---• a Date Application Disapproved for the following reasons: -------- ---•-------- ••------------------•-----.....----•-----....----...-------------•---•-•---••-----------.....------....--•--•----•--•-•------•••--•---•--•••---_...•`•---•----•--••... ••---•......---••-••----•-•--•- Date Permit No................ Issued_...._/-_7..✓ 7 Date ................... . THE COMMONWEALTH OF M'ASSACHUSETTS BOARD OF HEALTH O! ........., _.......Town Barri'stable (9rdifirate of Toutpli'mrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed OC ) or Repaired ( ) by-------------------------------------$-----Kevin_.H eK y........•-••--•-•-•-•---------------•---..........••-•...............................................--••-•-•-••---- Installer at................Lot # -76_.Patriots Way Cdntery�ile.... has been installed in accordance with the provisions of j of«The State Sanitary Code as described in the application for Disposal Works Construction Permit N ..... ..."' _,2.----------- dated__����►_7,0";------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM W LL FUN CTION SATISFACTORY. DATE.... Insp.ec"t'o............................................ .......................41.m...... ....._...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `7� 77 Town.................oF..--- Barnstabld s� N ..:....:�.7�. ........ FEE... S ......... Permission is hereby granted......................................evin Hickey ..; to Construct (X ) or Re air ) ark Individual Sewa a Dis oml S stem at No_________________LOt # Q76 atriot Way Certeriill , MA 02632 • - .. Street as shown on the application for Disposal Works Construction P mit o .__. ........ Dated.......................................... ---•............................... �.� Board of He th DATE....- ... •-----... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS No......... . Fine THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable . ......................... .............OF..........................._............................................................ Appliriffivit for ElIm pas al Works Tonstrurtion Permit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: - . Lot # 76 Pati'lot Way I Centerville, MA 02632 ............................................ ......................................... Suffolk Realify titair �EnOq Box 308 " e6i�terville ...............................................................................1................ ........................................................................................... Hickey wner Addre& Kevin Hick 0 72 Carriage Lane Barnstable ......................................................................r .......................... ......................I............................................................................ Installer Address 1.49 ac, Type of Building three Size Lot...........................Sq. feet U Bedrooms..........` Expansion Attic �0) Dwelling—No. of Bedr Garbage Grinder 40 Other—Type of Building _ra.nch........... No. of persons.......a.................. Showers ( 2) — Cafeteria 6o) .......... Otherfixtures ......................................................................................... ............................................................. Design Flow...........11.00..................�,...gallons per person per day. Total daily flow........13.0............................gallons. 9 Septic Tank—Liquid capacity!OOO.gallons Length................ Width................ Diameter..._. ......... Depth................ Disposal Trench—No...................... Width.................... Total Length............__...... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.._:............... Depth below inlet.........._..._..... Total leaching area..................sq. f t. Z Other Distribution box ( ) i." Dosing tank ( ) 0-4 Percolation Test Results -Y Performed by......961VAh0.J9.-..6 ............... Date.... ----_------- 4 .f none Test Pit No. I..... ........minutesperinch Depth of Test Pit........;11.... Depth to ground water.._..................... (T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.__.._........_......... ............ -------- -- ------------------- 0 Description of Soil..... --------------------------------- -------ioam---&----subsoil----------------------------------------------------- ----------------------*"'*-----------------*---------*---------------------------------------------------------­-------------- -------------- e" ....2.1 — 6# med, sand -------------------------/'"---------------------------------­­...........6. -----------I...2...I-----------------------------------------------------------------*------------------------------ .......................... ........................................... ........fine—sand.................................................................. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ........................................................................................................................................................................................................ 't. Agre,effient: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ..the provisions of TLITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board qf health. S' n .... ... ..... ....... ......... ................. ...June....21..0....1979 .............. ..... .......... Date Application Approved By....!. ... .. .. . . . .. 7 Date Application Disapproved for the followi"i'ig reasons:........... ................................................................................................. ............................. 7........................................................................................................................................................................ Date PermitNo:.... ...-•--:. ...i---- -------- ---• Issued....................................................... Date A. LO,.CATION S�7,7) WAGE PERMIT NO. 1°LLAGE IN/ST�jALLER'S N,A/ ME & ADDRESS B U f'L D E R OR O N ER DATE . PERMIT ISSUED r DATE COMPLIANCE ISSUED ;r � _- � -�� �� � � . .�� u; � , � ,� 0. Ire THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - %/.a«.,.!_ ....'.-..--..-.-.OF......... rs� �?.b.� ...... ......._...................... Appliratian -fur 43iiiVatitt1 Works Tot tiitrnrtian Prrntit Application is hereby made for a Permit to Construct �r Repair ( ) an Individual Sewage Disposal System at: oecation-Ad es4 � s' o/r Lot a /� .. [=� ✓�-.. 2�1�,a.iaadsti. ------_---------------- •...G� + .[!a? /...._ G. l �F Ldll�.. •------ Owner " ------ - -- -------- ---- ---------------------------- Installer o Address �. UType of Building Size Lot... _40 --------Sq. feet Dwelling—No. of Bedrooms____,/_��-_______________________Expansion Attic ( ) Garbage Grinder ( ) a, Other—Type of Building e�FrisaC.._.._ No. of persons._____ ................. Showers ( ) — Cafeteria ( ) .< Other fixtures .. /.------•---------.-•---------------•-•----•-------------------..-.-------•--•--•--------------------------•-------------- W Design Flow--------------- '� --..----.-gallons per person per day. Total daily flow......... `1 -_________.._.-_.-__gallons. WSeptic Tank—Liquid capacity fk ---gallons Length................ Width.____.._........ Diameter-............... Depth.-..______._.... x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area-.-_._____--.._____-sq. ft. Seepage Pit No'./. `6,rDiameter.................... Depth belo inlet Total Total leaching area......___._.._._.sq. ft. Z Other Distribution box (� ) Dosing tank ( ) O; A °'`/!— "/— 77 Percolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------.. Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-.------------------ Depth to ground water-...._-.____.._._.._-- L=, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water.......--______.____---- ` __ x Descripti2 o�Soil---� `-. —�ci.._ - f.!/_- -`� �: -- ---- a2 , ? x -------•----------------------------- ------------------------------------------------------------------------------------------------------------------------------------- ------------------------- U Nature of Repairs or Alterations—Answer when applicable.-______________________________________________________________________________________________ .......................•-----•--•---•--...---- ------------..--.----•=--.-•----.•----------.-----------_-----.-.----.----•--------------....•..-----....-•-.----------..--------------- ----------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee i d the;bor f healthSi neg ----•----------•• 4 e Application Approved B — -- . �, f Date Date Application Disapproved for the following reasons----------------------------------------------------------- ------- --------------------------------------------- -------------------•-----------------------------------------------------•--------• ----------------------------------- 04 ����7 Date PermitNo. Issued ............................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OE HEALTH 9011�. ......OF.........oosi� ...!r�........................................... Axr if tratr of Individual Sewage Disposal System constructed (4<0r Repaired R 7 the I! .. ........... ../-----------.............. --------I------------- - - ----------------------- .................. talle at...... .. .... —.0.... . .. . .. .......... --Xi has been installed in accordance the provisions of XI ti e of The State Sanitary Code as described in the application for-,Disposal Works Construction Permit No. -- -------- t.?............. dated__. "' -------------- THE ISSUANCE,.OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL, FUNCTION SATIS'OACTORY. 12 DATE-------- .................................. Inspector ,-. -- ------ .... .... ... -C� . ............................................ THE 'COMMONWEALTH OF MASSACHUSETTS BOARD 06 HEALTH ...........14111k ..... . - .....OF...... .................. No............... ........ FE*E.... ............. Permission at N 40 A is granted—ee'y -------- -- oo j -�------------- ---- ------ ----- to Confsuct (Myv' Repair Individual Se apD p)sa��ystem ----71------ . ...... Street -------------- --s I i as shown on the application for Disposal Works Construction 'Pe dt o... ated...... -7 7........... ------ ------ .......... .................... DATE. `5~ ! ,r-X*---7.7�,!.................................... Board of Health 0011"� ........ --- ----- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS HERS THE COMMONWEALTH OF MASSACHUSETTS •kn� : .. „•_ BOARD OF HEALTH x �f �}.. - .1.. ------------------OF �trttt��an f nx'v t u ttl parks Tonotrurtion Vrrnift Application is hereby made for a Permit to Construct (Ae<or Repair ( ) an Individual Sewage Disposal System at: r- - _ y / / ...................� _1'%/____ s.e'�---------------------------------- ------••- `•'G(�--.�_._l_..�: s 1 ,Location-Add?ess-,.�.» or Lot kill.t / I ,jy/ y-��•'''J Owner Ad�,dr,ss _____rJ-/ '�•;•,•f E--y.- �Ate_.. - 'F== r _'.eowC ,��_,�./6-------- Installer AAdress UType of Building Size Lot....1:._rZQ ------ feet Dwelling—No. of Bedrooms_..._, ! fe.-i . _ ..___.___.Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of ersons.______r}________________ G, YP b' '-==•'l�-��='..--- P Showers ( ) — Cafeteria ( ) Q Other ''fixtures -----------------------------------•-•-•------•••----•----------------------------------------------------------------------- W Design Flow-----------­ `� V.........gallons per person per day. Total daily flow---------_�+�_.•_.&V-__-___-_-.-._-.._..gallons. WSeptic Tank—Liquid capacity_ r..•r._*_gallons Length-----------_-- Width------.......... Diameter---------------- Depth-----........... x Disposal Trench—No_ __________......... Width__._,._-_-___----___ Total Length_._-___-_________-_ Total leaching area....................sq. ft. Seepage Pit __________- ------- Depth below inle��jj______ __________ Total leaching area---__ .-----_.__--sq. ft. z Other Distribution box (� ,),. '+, _ Dosing tank ( ) .G ! Y'G Percolation Test Results Performed by------ -------- ------------------=--------------------- --------- Date:-•- ----- Test Pit No. 1................minutes per inch :Depth of Test Pit-------------------- Depth to ground water.........------------- Test Pit No. 2________________minutes per inch Depth of 'Lest Pit-------------------- Depth to ground water......................... WK _________________ ..................... _ _... s a - » �r 7 - - --- - O Descriptio of Soil--- 0-_--�----—-------- . �t`�� ld_ x ---------,.. -� 11,,, �" 1+�.P - ar�-'�r--•-.. .��'�!�'' 1'•L ',, c Lts� C •{�": W .. �{ x --_- -• ---------- - ----- ----------- ---------_-____ --•---•--------------------------------•--------------._-------------------------------------'` :--=--=-------------------------- V Nature of Repairs or Alterations—Answer when applicable---------------------_------------------- --__-_.--.__-_--..----__-_-----_--.-.----.-.-_---.-... ------•----------------•----•---------------------_.--__---- =----------------------------------- Agreen ent: The undersigned agree's"to install} the aforedesci b1 Individual: Sewage Disposal'Systerrr in accordance with the provisions of Article NI of the Stafe Sanitary Code— The undersigned further agrees not-to place the system in operation until a Certificate of Compliance has been*is ued by the board of health. igne '" / i'f• ! „ D to Application Approved B �* Date Application Disapproved for the following reasons':: - ..-_... ------•--------------•---•--- -.•------•-••-........................... ------------•----------•---•--------•-----•--•------•---•------------------------•------------------------------------------•----------------------------•--------------------------•------------------- Date PermitNo------------------------------------------................ Issued................................= ........................ Date I II J 1,00Q GA L.. F r„ r "lJt Q(JN©. to, a. l SPTit TAMUL ) S„1) N to M 114, (.46 f! � IRnC Ft PIT J f A7 �XR ff � t0 OF WILLIA.:.1 ' '. CEQTtFtET� Fl..bl" PL.�a1.1 ! C. 17 o NYE y1 -0p No. 19334 , LbCATIC)" C B T E.. R I C 6R T i F Y Ttr••I AT T F 0 U N DAJ k0o A-5Wow Q PI--A►.1 R � Nr-eEmt4 C0AAPLYS W tTN 'rWG: S1per.t_J►-.tE L O f �"I AWcp, SeTje'ACtC QEQUt¢EN«NTS �F TNT �owU OF B�RNSTA6�.- 13k • tg '� Pf�• i Z7 Y DATE f�l PJ7 1 E�,e.XTEtZ . 1.1YE 1 w.iG. �ZEGlS"�D 4.�fr.1p SV�vcYotzS THIS C7`LA�-1 IS ynT BASE'0 v'� pN 04STF- v%L-Le titaSs. ll.ls("i2UMEk.�T SU¢v�`f T�{E c�F�S�TS S�aaw� APPt_I GAN"T' f\RT N UR I�IbT gE USCo To DM:revMjQ& L0-r t_itJ�S TOWN OF BARNSTABLE LOCATION 2� 29�x�U s l�l��C SEWAGE # VILLAGlj G LZ-4-- ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. A & B CAN00 775-6264 SEPTIC TANK CAPACITY ZO/A0 LEACHING FACILITY:(t,) Aid c,4 / ; (wlze) No. OF BEDROOMS_PRIVATE WELL OR PUBLIC WATER_ BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �""'� so— VARIANCE GRANTED: Yes No 4 LOT 7 5" LOl A4, 97'9 peep , /oa71, � SPAN MED. ' 9q •S c .� o' PeoP �0P 00 ST J G 100'3 i00�1L h AJ ET 0' h .SAND ve6 \� T 76 B Z /z No �/f�i'E2 E/ticOuti/Tf2� TEST HOLE /eE5 L11L T,5 PER TO h//`/ RECORDS D P TE : MFJ,ecH Z8 /979' / SCALE : Pv TOG.// / WATEP. / S /9 VQ / L Fq 3 L E //vSP. P. 9U ,ePeHY M / n///`7 U ,^7 BUILDI /\!G 5ETL3/9Cf< J2EQU/ ,eEP-7E/V7-5 F/eOA-/ 7- ZO ' S/DE / O ' /2EF3 /2 IO D2Ivz---z y A/ 07- To BE LOC '-? Tc-D P� O>� QED Z� ED2ooM5 3 OVE /e UA/LE5s 330 G/�L /DF3y H-20 DES / GAJ LOAD //VG /S USED p,�poOSED LE�3CN F�,�E� 000 SEPT/e SyS 7 )- 1-I COA/FO /eM TO /-I ASS EtiV/ROA-/ME/Ll7TF� L PERCOL �7T/ On! TEST C O D E Q D F9 T E.D TUL Y 6 /9 77 f9/\/D TOI�/A/ OF "9,eAA-5 r3c.E HE/e�? L7-N 2EGU1- ,4? T/ 0/`!9. SILL ELE✓. 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