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HomeMy WebLinkAbout0179 PATRIOT WAY - Health 179, Patriot Nay Centerville A= UPC 12534 1 2.153L �wa�r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name Information Is ,e N�✓I/i l t J required for State Zip Code Date of IhWectfon every page. City/Town 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: A. General Information When filling out forms on the computer,use 1, Inspector: only the tab key to move your ----- cunw-do not Name of inspector use the return key. ll/yam Company Name - VQ _ --- ,/ Company Address (( /" �G'S f n a✓� nay CKytTown i-O� h-� J� ^� /' State 'V0 Zlp Code Telephone Nu r License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training Pnad experience ved system Inspector pulon and rsuant t ait�te on 15�3of e o sewage disposal systems. I am a D pp Y ' Title 5(310 15.000).The system: Conditional) Passes ❑ Fails' r, t �' Passes ❑ Conditionally v ❑ Needs Further Evaluation by the Local Approving Authority tl-- Inspector signahue - Date The sy tem 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. �Im �13 T&5 omcau 8utrowteoe t3rwps'DNpowt tiy�ttm•FW 1 a 17 Ma•1WO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Addressel- owner Ownees Name C iGl h !/i I/E ___ /4 Oa 6�s2. c2 /� /3 Information Is required for CriyRown State Zip Code l)ete o Inspe on every page. B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced 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): TWO 6 OMOW kmped_Form:Subsudsw swaps owpsal sydem Pop 2 d iT 15ins 1MO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Prop"Address Owner Owners Name Information Is oa 6 ?c)- �- 3 required for State 2i Code Date of I every page. City/Town P ftedeb B. Certification (cunt.) B) System Conditionally Passes(cunt.): ❑ 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 16.303(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 MW•r Mo TWO$OO W Impsdm Form:8ubauMaa$wmp.DMpoW sydsm•A v a a 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 19 129 Property Address Owner Owner's Name Information is required for - State Zip Code r Date of frispeaon every page. CRY/Town S. Certification (cunt.) 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 DIM Indicate"Yes"or"No"to each of the following for an 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'A day flow •t vto Trot a ornaW Ins adN Fam:smuurfM sWMP okWW splwe•Pa,d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 09 Property Address Owner Owner's Name ' //J�Informatlon is �-vo//-e- ALL Qo��oZ a' tx /required for ��emL: every page. CitY/Town State dip Code Date ofilnepeofion S. Certification (cunt.) 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. ❑ 9/1-*,- 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 ell. CO] 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 st•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.] ❑ Q/ The system is a cesspool serving a facility with a design flow of 2000gpd. 0,000gpd. ❑ The system falls. 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 9 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. tQln+ trio M$oina.i rnq»cdoo Pam:aubwrr .a«aW cup"syarm•Pop 6 of I? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 129 A f � ' Property Address / Owner owner's Name rrw — information Is required for state Zip Code Date of Ifispecion every page. cityrrown C. Checklist Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes o mping Information was provided by the owner, occupant, or Board of Health ❑ ere 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? �Q Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? �❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): tslne•1 f n0 TO 5 f)d W k Farm:MMUf s swap awow sywm•Pap.a d» � Commonwealth of Massachusetts 19 ol Title 5 Official Inspection Form / 9 F -,-- �" Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address � ✓R_ � — owner Owners Name I Information is 6ePAN i2✓vi �/¢ 0�6�� �" l°�' 3 required for CIIyRown -- State Zip Code Dete o neP ctlon every page. D. System Information Description: /0 00 (/r_l pn Q « aNli 1,fTi/ 6a �/fkl 'y Number of current residents: C v W14 H Does residence have a garbage grinder? f4ore' (� � 6 a 0 Is laundry on a separate sewage system?[if yes separate insp r 'as ['No Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: � --- � ❑ oYes N Sump pump? Last date of occupancy: Date CommercialAndustrial 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: tmm•t in o Title 5 OMcM mpecW Poem:subsudwe Swap Wow ay* PIP 7 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address .' 4 Owner owner's Name I Information Is cQh �erH � A4 3 required for state Zip Code Date of I speotion every page, ckyrr&M D. System Information (cunt.) Last date of occupancy/use: oate Other(describe below): General Infonnation Pumping Records, L 3 -0 t-V Source of information: Was system pumped as part of the inspection? ❑ Yes n— o if yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S m: 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): i81ne•11H0 TW*5 01FWM kapeWw fam:SUWxfbm$WMP MWW sriWM•Pepe 8 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A�7�na� G✓� Property Addressze Owner Owner's Name Information is a t✓{ �/� /required for CtlylToYVn State Zip Code Date of on every page. D. System Information (cunt.) Approximate age of all components, date installed(i known)and source information: / 9v 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): v 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 Materi 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) C3 Yes ❑ No S Dimensions: r Sludge depth: r&B maw Wspoctlon Pone:subweme swwp VAPOv sydwn•Pp"D a 17 tSiro 11/10 I Commonwealth of Massachusetts lugTitle 5 official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address Owner Owner's Name A4 _ �/ eln Information isrvi frequired for CNylTownstate — Zip Code Date o every page. 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 ut et endations, inlet ce outlet tee o bye condition, structural integrity, liquid levels as related to o ,QeV o ve 4, 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 roe 5 OftWj Impslon Form:Ubwrba BMW 04"8Y*M'F'P 10 or 17 qUq•11N0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / �T9 / rr Property Address �..t7 Owner owner's Name Information Is Cepi I„✓!// J/e , 0,43) l 1.7 required forT� / / /�1 a every pap. City/Town State Zip Code Date 91 Inspliction D. System Information (cunt.) 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 rs�. t to o Me 5 oeWw Imwftn Fam:Suboxtum Swap ChpoW symm-Prp 11 of 17 Commotnwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � y �A�,1� f r.✓'� Property AddreseOwn er Owners Name `(•, .2, Irlformetbn isA14 n /, ??�1 Ge�„-�-e✓yi Z required for Cart -- -- State Zip Code Date of e every page. own 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.): At S s GeAP6 4s Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note Condit pump Ion of chamber, condition of pumps and appurtenances, etc.): p Soil Absorption System(SAS)(locate on site plan, excavation not required): K SAS not located, explain why, T&a Of w bapsdM Form;Subnrha a";"a*"&A$"•P."12 d 17 IEba•11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systein Form•Not for Voluntary Assessments Property Address Z Ownerinformation is Owners Name _� 4of Z ��inform �yf-f V1-1/lamrequired for Cfty/Town " state Zip Code Dapectlon every page. D. System Information (cunt.) Ty:�/ Ieacnlng 19 90 214 Jf-k ze pits number: ❑ leaching chambers number: ❑ leaching galleries number: --�' ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number, ❑ innovativelalternative system Type/name of technology: --- Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): S �t�" o✓�d ✓J - l� - 7/yv-7 60 wI -A) W7 Li �a Si�I ©I 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 1�►a•t 111G TIN Omow kapaiion Form:subswfsa S& p DhpaW sy*m Page 13 of 17 Commonwealth of Massachusetts rh Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments o J- 4LI a h Property Address G Owner owner's Name f a Information Is ,Orrl�(/, / /J a1(3� � Al., required for Rown State Zip Code Date of on C every page, hY D. System Information (cont.) 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.): �� �� ugsaM,.prpr�4A i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System F rm•Not for Voluntary Assessments 0 . Property Address Owner owner's Name information is Ceyr 7C✓y/ O„2 6�pL p�• ,1, �, required for CitylTown l/ — State Zip Code bate of Ape" every page. D. System Information (cunt.) 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"ter supply enters the building. Check one of the boxes below: ❑ d-sketch in the area below drawing attached separately 16in.•11l10 mw 5 OI W Impodw Form:Sub wrboo Swaps AlepoaJ Sypom•F�1S d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address / L NG Owner Owner's Name Information Is �eh ✓Vr�lt �// D�G required for State lip Code Date of I ecdon every page. Clty/Town D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 2 S i h Estimated depth to h water: g g round 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 ❑ bserved site(abutting property/observation hole within 160 feet of SAS) Checked with local Board of Health-explain: -TCJ fio lP c ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must des ibe h w you established the hi h ground water elevation: � o�'/ o p Before filing this Inspection Report, please see Report Completeness Checklist on next page. tBMs•11110 TAN s oftW Wp-tw Form:6ubudoe 8WW 040W 8Y*M•PW 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address / owner Owners Name Infomlatlon is e required for City/Town 2 �yr ""--" " State Zip C� Date of Inspection every pa ge E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked D"I'n'spection Summary D (System Failure Criteria Applicable to All Systems)completed [Q�stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ���o TMN 5 WOW hopecWn Form:Suboafte SWMP ObPW SY*M•POP»Of t I ;Built a TOWN OF BARNSTABLE (�. LOCATION 1 ' SEWAGE# VILLAGE�•��"'t'enrt.��\l►�.. ASSESSOR'S MAP PARCEL 1z F INSTALLERS NAME&PHONE NO. {JL SEPTIC TANK CAPACITY LEACHING FACILITY:(type) eg.eC lh T"tti 5( � size) �raS S NO.OF BEDROOMS OWNER_QA is-t..� PERMIT DATE: COMPLIANCE DATE: ," Q C7 Separation Distance Between the: (�7 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility e" Fey( Private Water Supply Well and Leaching Facility(If any wells exist 0 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 —71 lei �u.^wS CC'��0'`.i`-` %©�o�•��� c�J� 1�1� s' Pi Cr 7 t Id ittp://tssq p p p as 12/intranet/ ro data/ rebuilt. x?mappar=193197&seq=1 1/28/2013 P r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y. . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 179 Patriot Way I _ Centerville,MA 02632 _1v 5 Owner's Name: Desouza,Alx-sanda Owner's Address: Date of Inspection: 10/25/07 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 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: asses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: r Date: / L 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. Notes and Comments c- 1~ C Ll ****This report only describes conditions at the time of inspection and under the conditions f 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. r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 179 Patriot Way Centerville Owner: Alx-sanda Desouza Date of Inspection: 10/25/07 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _Zl have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditio n#Pass" section need to be replaced or repaired.The system,upon completion of the replacement or repair, s approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for phe following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or tie septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration o�,,tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank�s 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: f Observation of sewage backup or break#t or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled 9Y uneven distribution box. System will pass inspection if(with approval of Board of Health): �oken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pump" more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 179 Patriot Way Centerville Owner: Alx-sancta Desouza Date of Inspection: 10/25/07 C. Further Evaluation is Requi/en e Board of Healt Conditions exist which reqer evaluation b the Board of Health in order to determine if the system is failing to protect public health, the enviro nt. 1. System will pass unless Bealth termines in accordance with 310 CMR 15.303(1)(b)that the system is not functioningner ch will protect public health,safety and the environment: Cesspool or privy is wof a surface water Cesspool or privy is weet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier4f any)determines that the system is functioning in a manner that protects the public health,safety and e�fvironment: _The system has a septic tank and soil absorption system(SAS)and/ffie SAS is within 100 feet of a surface water supply or tributary to a surface water supply. r' _The system has a septic tank and SAS and the SAS is withi5VA Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is wj in 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS i less than 100 feet but 50 feet or more from a private water supply well**. Method used to determin distance **This system passes if the well water analysis,pe Aimed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that a well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitroge is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis ust be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 179 Patriot Way Centerville Owner: Alx-sanda Desouza Date of Inspection: 10/25/07 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 and overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow �d 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 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 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'erve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to eac of the following: (The following criteria apply to large syste in the to the criteria above) yes no the system is within 400 fee of a surface drinking water supply the system is within 200 t of a tributary to a surface drinking water supply the system is located�' a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public 'ter 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 a large system has failed. The owner or operator of any large system considered a significant threat under ection E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system o er should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 179 Patriot Way Centerville Owner: Alx-sands Desouza Date of Inspection: 10/25/07 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? vim_ 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? _Z_ 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? _/T_ Was the facility owner(and occupants if different than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No _ Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CNM 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 179 Patriot Way Centerville Owner: Alx-sanda Desouza Date of Inspection: 10/25/07 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): "3 Number of bedrooms(actual): _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 23<!3 Gr o. V., Number of current residents:"_ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): ._ Seasonal use: (yes or no):_A;jc,'-> e `? L 0 Water meter readings,if available(last 2 years usage(gpd)): Qc=gno C - i ti C n Sump Pump(yes or no): Last date of occupancy: Cv,r a-',!; COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15 03): and Basis of design flow(seats/perso sq.ft. etc.): Grease trap present(yes or no _ Industrial waste holding present(yes or no):— Non-sanitary waste disch ged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupan /use: OTHER(describ. : GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or 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: �� - ~ors'1� : 0,, Q V,+ �.,. tY Were sewage odors detected when arriving at the site(yes or no):�a p Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 179 Patriot Way Centerville Owner: Alx-sanda Desouza Date of Inspection: 10/25/07 BUILDING SEWER(locate on site plan) Depth below grade: 'Q�`° Materials of construction:_cast iron " 40 PVC other(explain): Distance from private water supply well or suction line: 1z Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: locate on site plan) Depth below grade: 41 Material of construction: concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: `h' �/`-, 'k- Sludge depth: =r Distance from the top of sludge to bottom of outlet tee or baffle: Scum thickness: H �( t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: / e` How were dimensions determined: ,, [Y�'tz ',,e--a,„ ., S�;g,• , Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakagytc.): f:....,�. Q—' � 'e.1' �-�G ®`tom ;..�-� �, ��"r'' C�a-_..a' ts� ��:`�,.�✓"�°� �2_' ,,;,e >t'S �arv"'Jw r �' GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal berglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet t or baffle: Distance from bottom of scum to bottom outlet tee or baffle: Date of last pumping: Comments(on pumping recommenda • ns,inlet and outlet tee or bale condition,structural integrity,liquid levels as related to outlet invert,evidence o leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 179 Patriot Way Centerville Owner: Alx-sanda Desouza Date of Inspection: 10/25/07 TIGHT or HOLDING TANK: (tank must be�p�mped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_me fiberglass_polyethylene_other(explain): Dimensions: Capacity: gallo Design Flow: g ns/day Alarm present(yes or no): Alarm level: Alarm in orking order(yes or no): Date of last pumping: Comments(condition of al and float switches,etc.): DISTRIBUTION BOX:�if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ��"I Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): �1e;J�,: '�vJ rear.,J• 4''�-a�' .tom'. ca,1-- 6=�..2 ..�:V•.. �o'� CIP_ -5 1-14cA , PUMP CHAMBER: (locate on site,plan) Pumps in working order(yes or no): Alarms in working order(yes or no)- Comments(note condition of pum chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 Patriot Way Centerville Owner: Alx-sanda Desouza Date of Inspection: 10/25/07 SOIL ABSORPTION SYSTEM(SAS): vr ocate on site plan,excavation not required) If SAS not located explain why: Typeleachingpits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): iWl';*T v, '_'��ati +tit r0 (.'• -•lalA,�V a"'E�a GGJL�J... �j,fr" cuf w+-�w 'P'� � cn' �C;\��r„a,� �.r'•4s�4�r..�a•� l�`v.�''�!� CESSPOOLS: (cesspool must be pumped as of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: f Dimensions of cesspool: Materials of construction: Indication of groundwater inflow s or no): Comments(note condition of soi 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 by failure,level of ponding,condition of vegetation,etc.): r r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 179 Patriot Way Centerville Owner: Alx-sanda Desouza Date of Inspection: 10/25/07 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. ram,-'•�'_J} ! i.�'a•\�i�avj I! act 5` - 3 CQ yLA 1 . I Page l l of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 179 Patriot Way Centerville Owner: Alx-sands Desouza Date of Inspection: 10/25/07 SITE EXAM Slope j-D-2) Surface water,,,_00 Check cellar C Shallow wells.,.:7ko Estimated depth to ground water >_t- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the 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: U <.s._sr vc 2c) W t^ Town of Barnstable OF 1HE Tp� Regulatory Services rsrnB Thomas F. Geiler, Director BARcbMASS `0� Public Health ,Division AlFp�,�A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. Commonwealth of Massachusetts Title 5 Official Inspection Form ' Not for Voluntary Assessments `=• :` FA,BIL Subsurface Sewage Disposal System Form x; e''' '-' F i 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 -- 4 Important: When filling out 1. Property Information: forms on the computer,use 179 Patriot Way only the tab key to move your Jane Marie Holden cursor-do not Owner's Name ' use the return key. Same Owner's Address Centerville MA 02632 Citylrown State Zip Code Date of Inspection: August 28, 2005Date 2. Inspector: Patrick M. O'connell Name of Inspector Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508.428.1779 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 in ction was performed based on my training and experience in the proper function and maintena t0" n i e sewage disposal systems. I am a DEP approved system inspector pursuant to S Title 5(310 CMR 15.000). The system: �` ••'" • '• .s'- ® Z •• •�ti Passes ❑ Conditionally Passes ❑ Fail_s' AT m .M_ ds Further Ev �tionby the al Approving Authority � :• *. 8/28/05 �% �•' �Q' Q� ��` Inspector's Signature Date y�NSPE``N,��� 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. 05-258 Holden.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments y Subsurface Sewage Disposal System Form A. Certification (cont.) 179 Patriot Way Property Address Centerville MA 02632 Citylrown State Zip Code Jane Marie Holden August 28, 2005 Owner's Name Date of Inspection 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: Overflow pit has 12-14"effective leaching, tank was pumped as part of inspection. 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: 05-258 Holden.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 179 Patriot Way Property Address Centerville MA 02632 Cityrrown State Zip Code Jane Marie Holden August 28, 2005 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 05-258 Holden.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 179 Patriot Way Property Address Centerville MA 02632 City/Town State Zip Code Jane Marie Holden August 28, 2005 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: 05-258 Holden.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 179 Patriot Way Property Address Centerville MA 02632 Cityrrown State ZipCode Jane Marie Holden August 28, 2005 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 05-258 Holden.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form A. Certification (cont.) 179 Patriot Way Property Address Centerville MA 02632 Cityrrown State Zip Code Jane Marie Holden August 28, 2005 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 If 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. 05-258 Holden.doc 1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 179 Patriot Way Property Address Centerville MA 02632 City/Town State Zip Code Jane Marie Holden August 28, 2005 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)) 05-258 Holden.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 179 Patriot Way Property Address Centerville MA 02632 Cityrrown State Zip Code Jane Marie Holden August 28, 2005 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: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 221 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied 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): I 05-258 Holden.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 179 Patriot Way Property Address Centerville MA 02632 Cityrrown State Zip Code Jane Marie Holden August 28, 2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2500 gallons How was quantity pumped determined? Glass on pumper truck Reason for pumping: Excessive solids in tank and first leaching pit 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: 1979, overflow installed late 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No 05-258 Holden.doc-W2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for VoluntaryAssessments ents Subsurface Sewage Disposal System Form C. System Information (cont.) 179 Patriot Way Property Address Centerville MA 02632 CitylTown State Zip Code Jane Marie Holden August 28, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 25 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 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: 8.5' long x 5.2'wide- 1000 gal. 9„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 21" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 8" How were dimensions determined? Measured 05-258 Holden.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) 179 Patriot Way Property Address Centerville MA 02632 City/Town State Zip Code Jane Marie Holden August 28, 2005 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): 05-258 Holden.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 11 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 179 Patriot Way Property Address Centerville MA 02632 Cityrrown State Zip Code Jane Marie Holden August 28, 2005 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 0" 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.): Some solids, no high stains Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 05-258 Holden.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 179 Patriot Way Property Address Centerville MA 02632 Cityrrown State Zip Code Jane Marie Holden August 28, 2005 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: Two in series ❑ 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.): Liquid level in first pit at bottom of outlet pipe, overflow pit has 12-14" effective leaching. 05-258 Holden.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) 179 Patriot Way Property Address Centerville MA 02632 Cityrrown State Zip Code Jane Marie Holden August 28, 2005 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.): 05-258 Holden.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form C. System Information (cont.) 179 Patriot Way Property Address Centerville MA 02632 City/rown State Zip Code Jane Marie Holden August 28, 2005 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. Patriot Way Water service Driveway #179 Porch 26 46 12 51 79 05-258 Holden.doc 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) 179 Patriot Way Property Address Centerville MA 02632 Cityrrown State Zip Code Jane Marie Holden August 28, 2005 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: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 40 and topo map shows property At el. 80 05-258 Holden.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE ASSESSOR'S'MAP\&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY ��C j LEACHING FACILITY. (type) L-e%44:t ,Nsize) ` A(e NO.OF BEDROOMS OWNERlie�-�ws2� � PERMIT DATE: COMPLIANCE DATE: !!gzoo,�g Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > ET Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY .� � R��►�.]'' ,.� 1 a �.,I'LL = a a S� No...t... Fm3............................_ R3 THE COMMONWEALTH OF MASSACHUSETTS, 1 BOAR® OF HEALTH � l TOWN OF BARNSTABLE D lAtipfiration for Uh4voti al Works Cnunitrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair (/�an Individual Sewage Disposal System at: .............� `�._... ... ..... - - .................. ------------- Loc tion-Address Lot No. O er Address Installer Address d feet Type of Building Size Lot...........................S q. U Dwelling—No. of Bedrooms..--- ................................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P 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........................ fZ4 Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth to ground water........................ P4 --- ------------- O Description of Soil 2 `r ------------...................`2..,- n. Ep"i .m SL?�o x •------•.._....-•---•-- x --------•-•----------•--------•----------••-••-----••-•----•---•-•---•---••-••-------------------------------------•----••••--....-------------•-------------•---..•---••--••••---------••-••-••-....... U Nature of Repairs or Alterations—Answer when applicable._1 7( ... 't�.�D..___:_..poe: .... ...l.F9o©-------- ........... 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 issued by the board of health. Dare Application Approved BY ........... _ ............... -----(�J�/J� �1�.�..-----.. to Application Disapproved for the following reasons: .....................................................------------------------------------------- ---------------- ------ t Dare .��Permit No. ........ L .. Issued Date THE COMMONWEALTH OF MASSACHUSETTS � 1 93 l BOARD OF HEALTH TOWN OF BARNSTABLE �Appliration for Bispaoul Works Tuns#rnr#iun 1jamit Application is hereby made for a Permit to Construct ( ) or Repair ( -..�y� Individual Sewage Disposal System at: ------------- Location-Address or Lot No. ( h :b ...=.=................................... ..... .w__1_.. v.�: .................................................. V Owner Address r Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms-__ ----------- -------••___•___Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) A4Other fixtures -----•--•-••--• ••----------------------•-••-------------•-••----------------•--......-•--••----••-•---•-----•-=•-•---•------------•---•--....------ W Design F ... ..................gallons per person per day. Total daily flow___-----__�__------f-----____----------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......;A............ Diameter..._\._%`?(...... Depth below inlet......tn(........ 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........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil_._.___d:�- ___.._S� `�_ ,� C'LEN rYr9 5 .4 x = U -•---------•-•--•••----•-••--------•-.................................................................................................................................................................. �VW� ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------- ' Nature of Repairs or Alterations—Answer when a�plicable..`, ___�. ++_F���_ __. .Sa ._`_. c4 S V AA r . ' ?M `"'" j " Sr-$� s -�........................... - ` = = - --- - ,_.. _ i --------------------------------- --•--------.--------- ------•--- 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 issued by the board of health. Date Application Approved By -- ------ . ................... ---.................. ......._---------------- to Application Disapproved for the following reasons: ..................................................................... .--..... -- ----..---.-----.......--- --- ...................................... --`........... ............................---- ---------- ----....-. t Date PermitNo. ........ ................. f Issued ..----------------------------------------------- oate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Graylianre i cte'd THIS IS TO'.CERTIFY'That he^Individual Sewage Disposal System constructed g p y ( ) or Repaired by.... ... �c�L. `t. %9 •4 ! � �.� `c�k.................................... -............................. ---- -- ---- --------- -------- Installer at�7 - A `m ..t 4si� c.4�: .e..4" � tLr 4`--- /�t r�; _•........................................................... ................. ,Kas 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. ----.-�-------�--.,-- dated -'.�.-- . -��91�---.-.-------- --: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU -1J AS A GUAR N4N E THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �1 -'`r DATE------� 2 /..--9 .......... Inspector -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 02 TOWN OF BARNSTABLE �� No.. .:.............�.. FEE.........._........... Disposal- orks,%11notr iIDi /Virmit Permission is hereby granted.............IC�L° `1:4._4 'E )t--."'roKb . -----------------••----•-----...---•-------•---....-- to Construct ( ) or Repair (-� an Individual Sewage Disposal Systemlr _ at No......:'•-��`i7r___:__�t��c,= `"��'`� "=�-4: �,�''� :���U.l����-... � � ` - Street p� G as shown on the application for Disposal Works Construction Permit No._-`_��_ _ _ _ Dated..._._ /- CP- --------•--------------------------•• " ----•-•---•----- DATE-------.. .......................................................... Board of Health FORM 36508 HOBBS h WARREN.INC..PUBLISHERS, TOWN OF BARNSTABLE LOCATION ?I--1-tr;a1- SEWAGE # q- ;^ C 0 VILLAGE rU� ASSESSOR'S MAP & LOT r 3 �9 ` 'S NAME&PHONE SEPTIC TANK CAPACITY lCOO LEACHING FACILITY: (type) 5 (size) i Ck"I oC Z o- NO. OF BEDROOMS T n_ BUILDER O OWNE �1 af- PERMITDATE: C CE 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 r p S ss TOWN OF BARNSTABLE LOCATION 171 10-�rio�S Ccl�►� SEWAGE # VILLAGE �'���riy;�Ie ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO._;gJK,�, ro,i c,4 Ca 77 I- /1 29 SEPTIC TANK CAPACITY /DOU a,l LEACHING FACILITYAtype) pf c Cosh (size) /4©d NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER hR0/C��rit DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No u v-C-k 3g l7' 17 `LO CAT ION tot 9 %u/ SE AGE PERMIT NO. � �Q , 9 la Lit VILLAGE /1 ' V/Ile I N S T A LLER'S NAME & ADDRESS BUILDER OR OWNER Z1 DATE PERMIT ISSUED A-4 DATE COMPLIANCE ISSUED �`� �, ..� ( ' vCIS z ������ � �� � �� (� �S `� / S� 07� No ---......_....... Fizz.............................. THE COMMONWEALTH OF MASSACHUSETTS �- BOARD OF HEALTH .............TOWn.................OF..... arnstable ..............................................•---•••...............•.... Appliration for Uhipao al Works Tom.itrurtiaan thrmit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: ---•-Lot # 25 Patriot -- - • Centerville MA 0263 -Wy •..._..-•- ) - Location-Address or Lot No. ......................fflk Realty Trust P.O. Box 308 Centerville, MA 02632 ........ ...._..-----•-----•---- --------•-•-------•-----••---....•.................................................. Owner Address W Kevin Hic Owner .........Carriage-Lane Barnstable 02630 Installer Address e of Building Size Lot....... ........ � Type g A � � � :t......Sq. feet U Dwelling—No. of Bedrooms___..._.three .Expansion Attic (n9 Garbage. Grinder (n9 aOther—Type of.Building .....ranch No. of persons......3................... Showers ( 2y —, Cafeteria (ng � Other fixtures .............................................................................................. W Design Flow.....110 gallons per person per day. Total daily flow........_330: gallons. WSeptic Tank—Liquid capacityl QQQ.gallons Length................ Width................ Diameter..._.................. Depth ............. x Disposal Trench—No. . ................ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.................... Diameter...-...".S _____ Depth below inlet....... ........ Total leaching area..�2.4�....I..sq. ft. Z Other Distribution box (t) Dosing tank ( ) '-' Percolation Test Res is Performed by__..`AWSMw..C:t.�seax�o........ ............... Date........................................ Test Pit No. 1. ?....._._.minutes per inch Depth of Test Pit........144". Depth to ground water.......UQnP........ rZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------•------------------------------------------------•-•------........--•----•-•---•-•------.............------••--------...-•••--•--•--•-•---•••-•-...-- 0 Description of Soil..............................0" - 30" loam and subs-oll................................................................ ................ .• ......•-- - v 30�'...- 84��•-----sand__and• ravel W 84" - 144" med. sand 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 TITLE 5 of the State Sanitary Code—,The undersigned further agrees not to.place the system in operation until a Certificate of Compliance has been issued by the board of health. Si 3 -• .��'? --•------- - ..../1/7 9 Date Application Approved By --•--------------•----------•------•---- r Date Application Disapproved for the following reasons----------------•----------------------------------------------•----------------•------------••-•-••--•........- .........-•••---••-••-•......-•-••-••••-•.........--••••-•--...---•••-••--••--••--••----••••-•-----•••-•-•••••••••..._.......•-•--•-•••-••-••---•--•••••------•-•••••••••-•-•••-••--•-•••-••.....-.....- Date PermitNo......................................................... Issued_ 7 Date No................ .... r o Fps....".S .. THE COMMONWEALTH OF MASSACHUSETTS f BOARD OF HEALTH To.......................oF.....8arnstable App irativat for Di-sposal Works Tonstrur#ion Vamit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: -Lot # 25 Patriot Way.._. ... Centerville, MA 02632 ......... ..... ......... - - --.....---........--......----............ ..........._....... ....... ocati Addr s or Lo No ......................fflk Real t.7t'rus� P.O. Box 308 benterville, MA 02632 _...... -------- •-•-••.............••-••--..................--------••----.........._................. a KeY Owner Address .................................. .......................................................... .........Carriage._Lane----Barnstable.........02630 Installer Address Type of Building Size Lot..... ...�._ 2.....Sq. feet ...... Dwelling—No. of Bedrooms........three.....................Expansion Attic (ng Garbage Grinder (ng — C n Other—T e ou a Other—Type Building ra g _ riCh No. of persons._._•_�............:...... Showers ( 2) Cafeteria ( g d Other fixtures . W Design Flow.....110..............................gallons per person per day. Total daily flow..........330_.------------- ..........gallons. WSeptic Tank—Liquid capacity1000.gallons Length................ Width................ Diameter.--............. Depth................ x Disposal Trench—No..................... Width.................... Total Length........ Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter....... .......Depth below inlet......4........ Total leaching area...;Z0 ..1..sq. ft. Z Other Distribution box (1) Dosing tank ( ) aPercolation Test Res is Performed by......RO.N.AhO...<n.t-f.60A_0...................... Date........................................ a Test Pit No. 143........minutes per inch Depth of Test Pit........1.4. ". Depth to ground water......XI gn-a--_--- f� Test Pit No. 2................minutes per inch.;_ Depth of Test Pit.................._. Depth to ground wafer........................ _-:--•-------------------•......_... '...---------------•------.-----------... ----------•---- --- ................... ...-•------•---=------------------- D Description of Soil-----...... 0#1 . 301.-•---1Q m•-and_-subs©• 1. .... x ------••-----•---•---- v :..............................................sand...and. aye1 •----•----------.............................................84."... .1.441.1.-----med_.._._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'TTL, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar of health. ^f , . • ......... .... ... ., 3/1_/7 9.....- Date Application Approved By-• .. ..•---. - Date Application Disapproved for the following reasons:................................................................................................................ .............................................. •••----•-••------••--....----••--•-•-•-----••-•--•--•••••-•-....-••----•----•••-------•••••-••••-••--••••------•••-•--•-••-----•-•----•--•••-••-•---..... Date PermitNo.......................................................... Issued-....................................................... Date Sr THE 'COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............Town.................oF.......Knatable.......... .................................... C9rdifirate of TiantpliFaatrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O':or Repaired ( ) by---------------Kevin.-.HiCkay---------..----------------------------••----- -----------------•----.-----•-----------------•---•-----------------•--•----•----..---.---------•-- at...._.....Lot_# 25 Patriot Way Centerville has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the ------------••.... dated-_... ... ..! t application for Disposal Works Construction Permit No.... ___._..�..�- '° -- -----------•-•••••- THE ISSUANCE OF THIS CERTIFICATE SHAL NOT BE CONSYRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... f =............................ Inspector__..!_./.... ...... ..................................................... THE COMMONWEALTH OF MASSACHUSETTS H. BOARD OF HEALTH Town Barnstable No � 1/ ...............................oF......................................,.............................................. 1... ..... FEE.... 14upus al Works Tonotra ivat rrnti# Permission is Hereby granted_.. Kevin Hickey•.............•--•-••-•-•--•-•-••••-••••-•-•-.....••-••-•-••••-•-••-•-•-••---•-----....................•--...... to Construct (X) or Repair (( ) an Individual Sewage D}s osal System at No..._._....L6t...# 25 Pa£rlot Way Centerville x ..... --••-••---•............ . .........----...-•---••. ............... Street ... as shown on the application for Disposal Works Construction P it o... .. ........... Dated...:_-�.._-."...._-........ .......... V .. .. oa�Healt ' ................ DATE----3-...... .. .... ................................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS