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HomeMy WebLinkAbout0011 PEEP TOAD ROAD - Health -�' 11 Peep Toad Road Centerville P A = 173 057 No. 4210 1/3 ORA Pendaflexo 100 I 0 67 Commonwealth of Massachusetts A79 —10 Title 5 Official Inspection Form (� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r I 11 PeepToad Road ; Property Address J Mana Breton Owner Owner's Name information is required for every Centerville ✓ MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection ,f 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. \�pX0ItA I III 0Ff�up��i�' Important:When filling out forms A6-4- . Inspector Information �4- /39�� `� • ' G;. on the computer, 3�:' JA M E S p use only the tab James D.Sears key to move your Name of Inspector r„c cursor-do not Capewide Enterprises � �•.o o •� , use the return key. CompanyName 153 Commercial Street me Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes ..0 i 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7-1-19 spector'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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 11 PeepToad Road U- Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 1000 Gal. Tank D Box and two pits. Note: 30 Year old system.At time of inspection system is working. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is Centerville MA 02632 7-1-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Fis Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F!1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 21MOMs less than 6" below invert or available volume is less than '/2 day flow PJ- ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes 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? El 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)] t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: 1000 Gal. Tank D Box and two pits. Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2017-51,000 Gal g ( y g (gp ))' 2018-54,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: -Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <}Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: NA Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2' 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.): Pipeing is 4" PVC SCH -40. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form / Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 PeepToad Road �u Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 14" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 2-" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working Level. Tank at 14" below grade w/both covers at 4". In and outlet Baffles..No sign of leakage.. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Pee Toad Road Property Address Mana Breton Owner Owner's Name information is Centerville MA 02632 7-1-19 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ./ 11 PeepToad Road Property Address Mania Breton Owner Owner's Name information is Centerville MA 02632 7-1-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): D Box is 16"x16"-V below grade w/two line's out. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Pee Toad Road Property Address Mana Breton Owner Owner's Name information is MA 02632 7-1-19 Centerville page. required for every City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 2 ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 a Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two precast pit's. One pit full, not leaching, one pit leavel at 30" below inlet. Note: At time of inspection system is working . System is 30 years old. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I - c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 113 �29ck t o o o S- �s _3:3s -s= 019L � t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 PeepToad Road Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� Estimated depth to(k-igh ground water: 2 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.W.Per Town 20'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 PeepToad Road V� Property Address Mana Breton Owner Owner's Name information is required for every Centerville MA 02632 7-1-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i �+ G �O .O �i7— t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ' Commonwealth of Massachusetts Fj r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. C y e Enterprises ,sy Company Name 153 Commercial St. Company Address Mashpee Ma. 02649 City/rown State Zip Code 508-477-8877 SI 4522 Telephone Number 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 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 16.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/18/2011 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:;"systgV or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall suflmit We report to the appropriate regional office of the DEP. The original should be sent to the syste"-, ner 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 co itio0j, of use at that time.This inspection does not address how the system will perform in t d futll under the same or different conditions of use. t5ins•11'110 Title 5 Official Inspection Form:ad ' go Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..'c 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 11 Peep Toad is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 Teach pits. The inspection results in a conditional pass because the distribution box was found to be rotted and needs to be replaced. 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-11/10 Title 5 Official Inspection Farts:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 't 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ - obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins-11/10 We 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Jy� 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. [Sins•11110 ride 5 official Inspection Form:Subsurface sewage Disposal system-Page 5 of 17 Commonwealth of Massachusetts Maya Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Peep Toad Rd. Property Address Robert Fraser Owner Owners Name information is required for every Centerville Ma 02632 8/18/2011 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•1 1 n o Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Aim Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name Information is required for every Centerville Ma 02632 8/18/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original system installed 1977 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof 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 certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness 2" 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 10" How were dimensions determined? opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank Should be cleaned now and again every 2 years as maintenance, water level was at bottom of outlet invert,tank was not leaking and was structurally sound, outlet baffle was in place and in good condition. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): D-box was rotted and need to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): Leach pits were inspected with video camera from the d-box and were found to have approx. 1.5'of standing water. 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 11 Peep Toad Rd. Property Address Robert Fraser Owner Owners Name information is required for every Centerville Ma 02632 8/18/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M "< 11 Peep Toad Rd. Property Address Robert Fraser Owner owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below drawing attached separately ❑ 9 P Y T/�N✓ 2 ° � ' 13-r A'?- 27` a-Z 36' 3 3 Y4,jl &_5 (>Co P`TS A-Y Z5' 21 ' t5ins•11/10 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • .. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Peep Toad Rd. Property Address Robert Fraser Owner Owner's Name information is required for every Centerville Ma 02632 8/18/2011 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I No. �/ / Fee o 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliLation for Disposal *pstpm Construction Permit Application for a Permit to Construct( ) Repair(" ) Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot No. I I ; �� Q Owner's Name,Address,and Tel.No. ""�1 Assessor's Map/Parcel 1 �3 os7 G�� �F-Co. (,\L� Installer's Name Addf' ss,and Tel No Designer's Name,Address,and Tel.No. Cpe-w aQ__ l r�"��*Pr/n'�� g Wz Type of Building: Dwelling No.of Bedrooms Lot Size 6-35 &%gs Wit. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea Signe Date _ Application Approved by Date Application Disapproved by Date for the following reasons Permit No. -0 Date Issued 't,.-�-... 'v.. .-,n-�».:r.�t.-. -.w -.M:-...-__'.•. n.^'II�M 4 'art.. r.n}'�..+.wnw ._.....-w .w+«w�,._.. ...... r 'T...�..:Y'.,.-. :�...�.-... V„.-�_._. r ^No. / ` Fee 1/0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC.HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ,r application for Misposal Opstetu Construction J)ermit Application for a Permit to Construct_( ) Repair(v) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components i Location Address or Lot No. ( �Qe .j �4. �� - Owner's Name,Address,and Tel.No. 562 7 ".21 t9 Assessor's Map/Parcel 1 13 657 Cbr vH- Fc� 11 siv.Y Pew -1- �l Installer's Name,Address,and Tel.,No., $d�-c+Z7-$$ Designer's,Name,Address,and Tel.No. # Type of Building: , Dwelling No.of Bedrooms Lot Size 6 35 &o- sq-#. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9-tom, <- - LW Date last inspected: Agreement: it The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental`Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date Application Approved by ;Date 'S Application Disapproved by Date for the following reasons Permit No. n�( c�`-Zs Date Issued THE COMMONWEALTH OF MASSACHUSETTS Y BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V ) Upgraded( ) Abandoned( )by at 1 (��x p }c�o�` (� C A, -V v A\P has been constructed in accordance ) with the provisions of Title 5 and the for Disposal System Construction Permit Not9C11�&q dated Installer C`�P�W rdQ- ���� �('t LLe Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system ill fun i n signed. Date- I / A Inspector - _--- No. �O � �'_`�•�(.'-•-._�.,_, �:...t,..-:_,._,.__._._,._-----,--------------___�____._____----------------Fee'-=/ 1 THE COMMONWEALTH OF MASSACHUSETTS' PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal &pstem Construction 3permit Permission is hereby granted to Construct( ) Repair V l Upgrade(• ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mus be co�letedwithin three years of the date of this permit. Date %�� Approved bye COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P F�T!y�' RECEIVED SEP 1 7 Z003 TOWN O OF DEPTABLE TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAR 1 Property Address: I Peep Toad Road PARCEL ' i�S� l Centerville, MA 02632 - -`— Owner's Name: Bonita Dipesa LOT Owner's Address: Date of Inspection: August 31, 2003 Name of Inspector: (Please Print)Gordon Bumpus Company Name: Gordon Bumpus Mailing Address: 215 Osterville/West Barnstable Osterville,MA 02655 Telephone Number: (508) 776-2345 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: e (,vJ Date: September 4, 2003 OF 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 ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 11 Peep Toad Road Centerville, MA Owner: Bonita Dipesa Date of Inspection: Au.2ust 31, 2003 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: 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: 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 11 Peep Toad Road Centerville, MA Owner: Bonita Dipesa Date of Inspection: August 31, 2003 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 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 11 Peep Toad Road Centerville, MA Owner: Bonita Dipesa Date of Inspection: August 31, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"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.] No (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. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 Peep Toad Road Centerville, MA Owner: Bonita Dipesa Date of Inspection: Au.-ust 31, 2003 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. I 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 Peep Toad Road Centerville, MA Owner: Bonita Dipesa Date of Inspection: August 31, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped on 7125/97 Was system pumped as part of the inspection(yes or no): 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: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11 Peep Toad Road Centerville, M4 Owner: Bonita Dipesa Date of Inspection: August 31, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" 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: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert Recommend pumping every three years for maintenance GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11 Peep Toad Road Centerville, MA Owner: Bonita Dipesa Date of Inspection: August 31, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: 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: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11 Peep Toad Road Centerville, MA Owner: Bonita Dipesa Date of Inspection: August 31, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6' 1000 gal, 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.): Leach pit #4 had 2'of water on the bottom. Leach pit#S had 4'of water on the bottom There appears to be no sign of failure. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (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.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION (continued) Property Address: I Peep Toad Road Centerville, MA Owner: Bonita Dipesa Date of Inspection: August 31, 2003 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. 13 /6 AQ. 3S 0 Qa- a 3� 0 3 10 J Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11 Peep Toad Road Centerville, MA Owner: Bonita Dipesa Date of Inspection: August 31, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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 local Board of Health-explain: Checked with local excavators, installers-(attach documentation) ✓ Accessed USGS database-explain: topographic and water contours maps You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 30'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 LOiCAT ION �/ �y /Jp SE/yW/�� A/ (/�," E �, R M I T N0.. VILLAGE Hsi= I N S T A LLER'S N ME & ADDRESS B WIDE R 0 OWNER DATE PERMIT ISSUED ,_ ��` A DATE COMPLIANCE ISSUED -- ' R - Ir in*k No............' Vie.. .- � F1cs........ THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH ..................�............OF........... - .. Appliration for Dispas al Wark,5 Tonstrnrtion Prratit 100- Application is hereby made for a Permit to Construct ( ) or Repair (i�-<an Individual Sewage Disposal System at* ocation-Aa�ress f t - .• - or Lot No. W Owner, Address Installer Address � Type of Building ize Lot...........................S q. feet Dwelling—No. of Bedrooms............. --------------------------Expansion Attic ( Garbage Grinder (;I(-) �a Other—Type e of Building yp g ............................ No. of persons..... Showers ( ) — Cafeteria ( ) d Other fixtures -•---------------•--------------------------------- W Design Flow....... ...�. -_-__gallons per person per day. Total daily flow.......�30.......................gallons. 94 Septic Tank—Liquid capacity,,l/&.t-__gallons Length................ Width................ Diameter---------------- Depth................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching arez� .........sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet---_..._. ...... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank IC -l a -7 7 Percolation Test Results Performed by..... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit................_... Dept to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ --------- •---- --------------- Description of Soil - - `�. 6-- A-- ..-- --1 ............. U ......................16a•_V ---------------------------------•----- ------------------•----•---...._ W UNature 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'HTL U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee sued y the board of heal ned t � ele Date Application Approved By.... .. . .. .. ......7............... Date Application Disapproved for the following reasons-.............................................---................................................................ --------------------------------------------------------------•...-•---------------•---•-----------••• ---------•----•--- Date PermitNo......................................................... Issued....................................................... Date t S c n hit. Ir ' r 1 1 b � f• V �S li .. P ,� ��'. iV t I ri �� ,II✓II.� ! �• I 1� f t ,� I S � 7 +� �. I , I � gg iy � 7 � f/ail ,� I L. k i' r S � 1' :f•?�' , .,f I �'�'� t �) 1 { �I %r y � '� t� 1 �,F f , r 56 I �11 � r •' f.' - 1 / � p{ �.`, tf '! _ !I r 4y Ili Yr,4, �,, f :'� � I ? Yi S 790 p /7,!SCl SIB •{ 11 x, 14 ' I r _ I ' • 1 , I 1 ;lj I 1, /�l/l J ,. T 4 .; I '� } 'Iti • ,. .. � t • r e = „r SH OF�y4 ROBER P T P.o BUNIMIS i -1L3 No.22162 n +j i � Nam' 9o�sGf TE�� t S'ONAL EN/ _ CERTIFIED PLOT PLAID. NEW CONSTRUCTION ONLY = C�Iv 7- 'SOP OF FOUNDATION13 ,z FEET IN y l AEgOVE LOW POINT,.OF, ADJACENT � ,� �� �ASL ROAD sC LE: �� DATE �/z3 /?7 d DREDGE ENGINEERING CO.oN CLIENT I CERTIFY THAT THE �nv��y�t7foN SHOWN ON THIS PLAN 13 LOCATED E®IDS t"RED REGISTERED . 7 �1< � CIVIL` I LAND ;10® ?�0. ON THE GROUND 'A3 IP9DICATCo®. AEd® }I �_ ;�, CONFORMS TO THE ZOO UIG LAWS ENQi�IEER SURVEYOR DR. BY _�_ OF BARNS 1- , &SASS., 3;, �O. MAIN ST 712"'MAIN ST. CH. ICY c� tr ? �SO''YARMOU.TH, MASS. HYANNIS, MASS. SHEET' OF / DATE RE®. LAND SURV11YOR . yi L. - - COA*G�fLIDTE.' CL EAA/ /�D., y - /,iN P/TCN Al Mows co 'Pao.0- COMCR--rc _ S - �_ =• . :a �IJKICA OF4'�E*l4 P's s�jq� �+ -per q e�` D/ST, o o e o . o 0 o e o " IeAASHED S7?7NE O 6 0 0 O o o s 0 0 0 BOX o e o ov � o- o o6aa - ve - :�� a ,.. _ :: .. . ,.,:. _ .. o �. r e o D�PTN o 0 0 • �_ o , _ �SNEQ_STO/f/E _ . . 0 f vQ u a c o 0 0 0 0 o p o y PRECAST SEEPAGE" 1MVC97 E'LEdi. 7'1DNS ff o n e o el b o ® o e e e ' a °o . R17 OR EQU/V_ �1( /IVVER7- s9T:BU/LD/NG `��. D/AM. •e� INCE? •WP'r/C"T.4M/C 9 6 S FT _l1�_ FT 91,4 w. i C(S--ETyiBULATJ0A 0094ET S&PT'%C 7-A VbC ?-k6 =r /IV�T.P157RIA5UT/®N BOX 96, �T. - GRDUNO MI�ATEF� TABLE P yJ - OIITLE�YD/.iTR/®f�+�'!ON BOX 9 6,3 � ' SECS/O/V OF _ J /A/LETSEE6 GE !—/T 9 S. fT a5'E• /ACa� ®/o$i� i� SYST�/� SCALE �4 _ /�- O" Dl/►9E/V3!O V A 3 F'T. o/MEWS/0 ts-�—FT.: -J�u�dBa�i� 6F�ERoo/►�s D/t�YENS/ON C. _`7 N,��� Y'OTAL..�ST/i 'T'EA_ FL.Os' / n�G.tbL.�DAY- o &' A* �'e-'T AluMBER 0-P sE,0'A4',5Z AVrs 7 �; 4&ACNIW40 ApeAt P/r' !88 PT. .S®O� L®G = OA OF SO/L.T�ST. 78 �T- TEST P/T: etaV TEST P/T�2 RESt1LTS by/T/VESSE® �orTan9 t,�ca/A/G P���/r - 7'O,YAL GEAC'H1W<r AReA � 6 S4X FT ELEYAT/ON 1�ERCCLAT/OA/ /q.a97�.., Jej/M�/A/GJ�' _SQ. FT 0/1 Pi-l-C- �i'1T,�,� 3.t3�n/sr.4?�S �8GA2t� HErA 7�+' VA OF by{SS 90 moo? ROBERT. 1-OT 3 PP EA ?'©A p ::c P. - C�NT.E/2ilLLE { o. BUNIKIS R p No.22162 O Q E `+ 0 AlE�6\ = T/.2 MA/N Sr . MASS:' SO:'ITsO /?itg_ N _ 77 0. n-8 _ . THE COMMONWEALTH OF MASSACHUSETTS BOARD QF7 HEALTH Appliration for Utipus al Works Tonotrur#tun Vamit Application is hereby made for a Permit to Construct.. ( ) or Repair ( an Individual Sewage Disposal Sy s. �...pgc- c5r�, - - q+ __ tn "�t x - $--............................................................... ocatio Address or Lot No. ow ne Address a .......................... ... ....-....04�. ��' ......._._.._._...---------------.._.... ........................................... Installer Address Type of Building ize Lot____________________ _____Sq. feet .—I Dwelling No. of Bedrooms____. __ .:°.._Expansion_Attic ' Garbage Grinder (ho a Other—Type of Building .............................. ._____ __ 2No of persons. ._________________ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------•-----------------------•--•.....«-- W besign Flow....... gallons per person per day. Total daily flow..____...!r1 ......................gallons. WSeptic Tank—Liquid:capacity gallons Length................ Width................ Diameter______ ______ Depth................ xDisposal Trench—No..................... Width.:................... Total Length.................... Total leaching area ----------sq. ft. Seepage Pit No Diameter' Depth below iplet. Total lea ing area._ _: ......sq. ft. z Other Distribution box Dosing tank F . Percolation Test Results Performed by �tL ___..__.__ '` _.: Date__ __________________________________ Test Pit-No. 1 ::: :::.._._minutes.per,inch;.- Depth of Test Pit____________________ Dept to ground water........................ Test Pit No. 2.............. _minufes per inch> Depth of ,Test Pit____________________ Depth to ground water........................ O Description So .� " _ ��`'1t " 7+ _ *'__ _*- •._r_ d1 lr�- /' A! V ..................... •. ---------------.....----•-••--•-•-•-------------- ____------------- -----------•------------------------ - ......._.. W UNature of Repairs or Alterations .;Answer when applicable.________ ______________________________________________ ;____.._.__.....__.._._._____.. y . ... --.----•--•-•---------•-•-----•------•-•....... •-• -•-_•-••• . Agreement The.undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT :I�` 5 of the State Sanitary Code— The undersigned further agrees not to place.the-system in operation until a Certificate of Compliance has bee •ssued y the board of heap . gned 40 ­V s .. _ _ . ._ Dat Application Approved BY_ ... .. - 5 -D7�7...----•-•. ate Application Disapproved for the following reasons---------------------------------------------------------------•----------------------------•---•---------••-••-- ------------------------------•••------••-------------•••-----•-•----•---•----•-------._....••-----------•-----------.;....-----••--------•-----•-•---••------------- ................................ r. Date Permit No.................... Issued----------------------' .. - ......._.. - _ Daze ----- .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H . ' .... QF:.'..ePiw✓ .................................. Tatifiratr of f ompliatta THIS 0 CE TIF t the Individual Sewage Disposal System constructed or Repaired ----------- ----&,t at---•------- ------ -- ------------- ----- has been installed in accordance with the provisions of ` f he State Sanitary Cod/a des ribed in the application for Disposal Works Construction Permit No. ' , ....._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FU TI N SATISFACTORY. DATE............ .......... .... . Inspector ' .. _THE COMMONWEALTH OF MASSACHUSETTS it -...- BQARD F HE . H �. No..........x�..__.._.. FEE..-,/ Fbtuirk/�, nr pn Permission is hereby granted__._ � __... .___ �ermt# z: .. . to Constr ct ) oj Rep • (V) an Indi du Sewage Dis osal stem * { at No.... oe4 --•--- __-- Street as shown on the application for Disposal Works Construction Per m' /_`�_ ed____ _� _1�.__.�...._. ...... 4 ` .mow Board of Health' ' DATE-= .. •----••--•....... • ' .. FORM 1255 HOBBS & WARREN INC PUBLISHERS �,. .a�. ..+�o.,::�,.. .:s. �'.-,...:- .f'"3.yuo-lww•a r,.+,;.;y�.,S "{�r�^;y.eaL'sx�i'�a't��n+'sy;�n No......... ,_ ....................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH --------- --------- - -------------OF.......................................-- .......................................... Appliration for Uhipvii of Works Tomitratrtivat Urrutit Application is hereby made for a Permit to Construct ( ) or Repair ( jo<an Individual Sewage Disposal System at: £y....... .... .... .. ------------- ---- .................................... Location-Address or Lot No. `------------------------------------------------------ ---. -----------.._............_..........-••--------------...........__......... Owner Address ..........1*iS:k :`T•.----.---•-------•----•-------------•--•-•- . ..... .......................................•... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms___ ..!?Ya-..... ................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria aOther fixtures ....................................................................................... 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......................... fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------.............. a ---------------------------------------------------------------••-•-•---•-------•---•--•-----•--......-•--•-•-----.....--------............-•••--•-•-------•- ODescription of Soil----- °'hodd_....................................................................................................... x U •••--•-•----•••••-•-•-••-••--•-----•----......-•••••....••-•---•-•----------••-•--•••._._......-•---•----•-........................................................................................... ---•-------•-------•-•---------- ---------------------•-------•----••------•---•••-•--•----•-••••-•---•-•-••••------------------•-••-•-----••-•--••-••-••-•-•-•••----•---••......--•---•••••.......---- U Nature of Repairs or Alterations—Answer when applicable---j_�I:TIL..--------_-1000....... L 2 ts)....__ Q - 1- tc1� eIT..................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI 11 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 boa of health. Si ned--•----•K .-.._W...._._.s.. ...... ............ ....1. / Dat Application Approved By.... �._.��-----' �� •.•••. �... �............. .. ........................•----•-- Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------•-•--- ..........................•--------•-••.......-••••••••------••-•••---•--•-••-•-----•---•-••-••..........-•-----•----•--------•--•--•-••---•••--••----•••-••----•---••••------•-----••-•-•••------•-•--- . e Date PermitNo......................................................... Issued....................................................... Date J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................ . ....._.....OF.................... Appliration for Disposal Works Tonstrnrtion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( V an Individual Sewage Disposal System at: ... �.4 "c" 1...... zl.e...... TOM)------.-OA-)�------------- -- -���►-r��,���..�.C, ------------ ......... ........ Location-Address or Lot No. W Owner Address ......g£-U_4.0j•--.......Ii CKVIV------------------•------------•--------•--- -----1AM.S .wa ......................................................... Installer Address UType of Building Size Lot.................... .....Sq. feet a Dwelling—No. of Bedrooms....2..�0.4 .....................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures -----•-------------•---------------: ..................... 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........................ fr4 Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ ---------------------------------- •........ -.......... •--------- --.-... --•------------ --•------•-------.-------------........... •-------- ••••-- D Description of Soil..... -- V ..............................................--•---•--••-•••------- " --•-----•-•---------••--•---•••---•--------------•••-----------•----••-•----•-•--••........................................... ---------------------------- ------------------------------------------= ---------------•-------------------------------------------------...................................................... U Nature of Repairs or Alterations—Answer when applicable....t.!�%T ..........N0100...... ....--SP&IA------Q- -------•--------------•-•------------•--•--------•---........-----------•----------------------------------••-------•--------------------------------....---•-------• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 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. ; Si ned--•••--•-K f3 - ----A.-------- '!✓� `.� V14.6 IDtj Application Approved By.... :.._/Q<_...-W '�' ;1��� ........ Date Application Disapproved for the following reasons:•--------------------------•----•-------------------------------------------•-•---•---...-- •----•............. -•----------------•--------------....-•-•••---•-----•--•-----......------...•••------••----•-••--------•-•-------•---••-••----•---•--------••--•------•-••-•---------••--------•-•-•----•-••--•--....._. Date PermitNo......................................................... Issued------••-------•--------------•-•-••--••--......-••-... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF Orrtifiratr of Tompliattrr THIS ISeTO CERTIFtY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( - by...........f a.St.&Axv.......�Xul,&8.e-......................................--•--••••-•-----•-•-•-•-•--•---•----.............-----...••••••...---.....--•••-- C Inst ller has been installed in accordance with the provisions of TITLE E ?5 o The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... " _ dr. ......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................. .E ....... Inspector------------------ a-,F t�• +--........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.... FEE........................ Disposal Works Toct�t,,�s#r ion permit Permission is hereby granted--...•--- ---------------------------------------------•-------•--------..............-•-•--. to Construct ) or Repair ( an In ividual Se age Disp 'A S -stem Street as shown on the application for•Disposal Works Construction Permit No..................... Dated.......................................... ..-:T-.............__-_•_Y_.J......................P•___ ............................................ DATE_ ------••-•---••---....-•----•---•-•-•--•-••-•................................. Board f Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS P TOWN OF BARNSTABLE LOCATION �O 7 0A F-�. SEWAGE # VILLAGE ex, rya It- ASSESSOR'S MAP&LOT 73 07 INSTALLER'S NAME&PHONE NO. oT- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) v�" �X (size) � 7 NO.OF.BEDROOMS BUII.DER OR O WNER 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 B c 9 . %3 !6 Aa- 3s C3a-.a3` 6 01 0 3 'C3 3� ► ,J i r t` LOCATION J l ?tv e -Viaoa SEWAGE Vr,-I'AGc 2���� _ ASSESSOR'S Ivl..° R LOT_ ._ D STALLER'S NA:NE&PHONE NO. SEPTIC TANK L'APACM. ' Sim LE,kC1ING FACIT-=: (hype) a, IV�S isi'•e) --- — NO. 01-BEDROOMS BUILDER OR OWNER DATE: l COMPUMNCE DATE: Separation.Distance Between the: a� Maximum Adjusted Groundwater Table t��...r,.•.,.m^{} ^^•.���•�^;•;;;rr, ._ _.._ Private Water Supply Well and Lcaclung Facility (if any wells ecist on site or witl`jn 200 feet of leaching facility) Edge of Wetiar.d and Leaching Facility iIf any wetlands ms... ,A•idiin 300 fee;of leaching facility) _ F= It 170 Af- IS `� B1 I-Tit U �- aq SZ. % D k3^ y,D 63'aLl D 1%, 3 41_ ��� 9y "31 O It,olV's' �^ 35 .e LOCATION SEWAGE PERMIT NO. VILLAGE /-_°ry/s_/_ I N S T A LLER'S NAME i "ADDRESS i U IL D E-R OR O`WItER- /,- e c DATE -�P`-GE' R'M-1T ISSUED D-AT E COMPLIANCE ISSUED � /' -- .. i .� a �,� 6 � 4 ���