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HomeMy WebLinkAbout50A PHEASANT WAY - Health 50A Pheasant way Fmrly: 61 pheasant way Centerville A=227 142 Ws 61 & 63 combined kv S M E A D No. H163OR f UPC 10259 smead.com • Made in USA Sq pZ t V l� d I The COMM. -Fire Department inspected-the-he construction located at # 61 or # 63 Pheasant ,Way Centerville. Because the road was not constructed in entirety, in this area and the abutters are .using an alternate access through a driveway easement, they (COMM.) requested address changes for 3-4. properties. I'll try to keep this simple. The permit (I believe ) was issued for Map. 227 Parcel 143, a.k.a. # 61 Pheasant Way. During construction, the owner had this parcel. deleted and the land was combined with Map 227. Parcel 142, a.k.a # 63 Pheasant Way. All the land with the old house and new house are now all on Map 227 Parcel 142. Under the. ordinance, when two or more buildings are on one parcel, they become unitized. The new addresses for these two homes arei # 50A for the new house" (formally #) �61) and #,50B for the. old house (formally #,63)on Map 227 Parcel. 142. The others that were changed afe,as follows: c Commonwealth of Massachusetts 1 q;li- Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 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. Inspector Information 6r-;F IL- '3� 5 on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return key. Company Name 350 Main St. tab Company Address W Yarmouth MA 02673 City/Town State Zip Code rermn 508-775-2825 SI-14423 Telephone Number License Number B. Certification 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 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails ,� � 8/10/2020 Inspector's Signatures 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. l5insp.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 •�' 50A PHEASANT WAY L:- Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name inormation is CENTERVILLE requiredforevery MA 02632 7/31/2020 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: SYSTEM IS IN WORKING CONDITION 4 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): t5inap.doc-rev.7/2612018 TIOe 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts -- , Title 5 Official Inspection Form .D' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 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. it. 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: l5insp.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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information isequired or e very CENTERVILLE MA 02632 7/31/2020 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 15insp.00c rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts _ , Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information isequired or every CENTERVILLE MA 02632 7/31/2020 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 cesspool is less than 6" below invert or available volume is less than %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 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 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. 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 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is CENTERVILLE required for every MA 02632 7/31/2020 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 Z ❑ 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)] 10 t5insp.doc•rev.7/26/2018 Titie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form III; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 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: Number of current residents: SEASONAL 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ®- Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): '19- GPD '18- Detail: GPD Sump pump? ❑ Yes ® No Last date of occupancy: Date I t5insp.doc-rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts x Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form-Not for Voluntary Assessments U° 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. Cityrrown 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: Source of information: 10/24/2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev,7/26/2018 Title 5 official Inspection Form;Subsurface Sewage Disposal System-Page 8 or 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e' V 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 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: 15-20 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2611 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 101+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5inap.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 16 I Commonwealth of Massachusetts 4 I? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 15"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON 11 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 211 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. t5insp.doc-rev.7/26/2018 Title 6 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 i Commonwealth of Massachusetts ,p Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name required for is y CENTERVILLE required for ever MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,`i� Title 5 Official Inspection Form J. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c, 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 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 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp.doc•rev.7/2612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts -- IP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "1 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner information is Owner's Name required for every CENTERVILLE MA 02632 7/31/2020 page. 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 Ise conditional pass.. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 6- INFILTRATORS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts . y - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments !% 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information equir for is every CENTERVILLE required for eve MA 02632 7/31/2020 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.): &INFILTRATORS WITH STONE FOUND DRY DURING INSPECTION WITH NO EVIDENT STAINING. 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.): 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every very CENTERVILLE MA 02632 7/31/2020 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.): 15insp.doc-rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts 193 -= Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is y CENTERVILLE required for ever MA 02632 7/31/2020 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 t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official In pection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` V 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name required for is every CENTERVILLE _ required for eve MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +15' 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: HAND AUGER TO 15'WITH NO WATER ENCOUNTERED. BOTTOM OF LEACH IS 4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc,rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 50A PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 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 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 A � M1 ',itY w m�' v�S'3�...r � -r>az aR.�a t �` �r:Fr"� r+,. ��sk t A r •^+ L r 72!ieE „T,ul ; n -� - ""ttih w 5px- ...fr '> �"a+.roW liirt'tiA K r v?Gf•w! +e h"f P , tYx` ��'�;ia"r �• ri "t✓'�a�'r � � �`� �s� r.y a ��e w � 2.r.�r, ay�gL� .�ui �'YaYrt€ „,r* r r ,• • Fir _j � � ,,y�- +� 'a��f' a r� 1 >v �^�' S' ;:y ; r L` yra �t���� 6°' ., g x ytef«e ,errs� ^� f, r ri'i �,;r•n,"4+L�...{' •`n ':'�, +"' S '.' �r 1v^1 P-ek:. r.«are flr� r. 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'4+'�t � ' •, p r 1 w '�tu �A•{ r �++���ar�rwf aS'- �tx € - a. - • • i a " .'""^s"- r'r 91.;"7."i eY' i ram. 3y.,r"is^ tYi r1k aU +�'C'r'�d fr{F+q'„7 4` •� x +� p a r +t/' a+�y''' ✓t :,r x ! k nra-v a r-. s. x OWN .,.t �.IY r.., y# �' .„,� n err �rdr Y ,+ a�� r '„ r•T k4a ,�r� y qy,.'•o .f€� �s s r S Ty Y .t � ���� f .E L r"sr '`+4ny xF-;•• ''.�""^,f?1's�r�e r_.Yrj >r sa h.,r�,ef v- T < Way ,:,t t .: ^ TOWN OF BARNSTABLE (/P6/ �� I "� LOCAI ION 1'nent 6467 to'av SEWAGE # V1LLAGE—(--' 0--t ASSESSOR'S MAP & LO . 27 OT INSTALLER'S NAME&PHONE NO. 7,31IV SEPTIC TANK CAPACITY • LEACJ7ING FACILITY:,(type) ( ) / r -/f- IJ T rf�l/�T�; size /V.Z ,X `7 NO.OF BEDROOMS 13UILDER OR OWNER PERMTTDATE: j -���/�l� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 'a• Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of le ng facility Feet Edge of Wetlan chin acility(If wetlands exist /_ within 3 feet c g Me Tel(�:? Feet Furnished b l r 1�A.A - ---- -- ,�' J No. o+-L--�-� (0 "��0�'�t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplication for Mt5po5al 9pp5tem Cowgtructto'n Vermtt �. Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. W/ Pha5an L 10az� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel aa7 / eV`; Installer's Name,Address,and Tel.No. 'T K,7 kdedy Designer's Name,Address and Tel.No. l,16- 6U4 Type of Building:Dwelling No.of Bedrooms 3 Lot Size- Z70, G 0® . sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons 9- 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 qP 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 ea ne Date 4 �4 !J 41 Application Approve by Date o:& Application Disapproved by: Date for the following reasons Permit No. (D —05 Date Issued /�-ds Fee k• k a y $` Entered in computer: THE COMMONWEALTH:::OF MASACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplicationjor Dizpaa[6p.5tern Conotruction Permit Application for a Permit to Construct O Repair O Upgrade`-(._�) Abandon O ❑ Complete System ❑Individual Components ,. Location Address or Lot No. �� p �S�`nt t 106V Owner's Name,Address,and Tel.No. I r ? 1:11e �� ��b � � PGr //oCk— Assessor's Map/parcel // JJ Installer's Name,Address,and Tel.No. 7M) K7 AV 66V r Designer's Name,Address and Tel.No. &,4; Goff eon,-fir. Type of Building: Dwelling No.of Bedrooms Lot Size 2Zy, 000 sq.ft. Garbage Grinder ( ) Other Type ofBuilding No.of Persons Z Showers( ) Cafeteria( ) Other Fixtures � Design Flow(min.required) gpd Design flow provided -_;,7 -3© gpd Plan Date Number of sheets Revision Date Title r , Size of Septic Tank �5 69&o 15-oo Type of S.A.S. Description of Soil qPd / e Nature of Repairs or Alte ations(Answer when applicable) / s Date last inspected: f , Agreement: The undersigned agrees to ensure the construction and mai ntenance of the afore"'descnbed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and of tto ptaceAhe system in operation until a Certificate of Compliance has been issued by his -o£H.,ealth. { ". / �'gfiea _ ,tee~ Date /�� Application Approvedlby * ) Date o��p Application Disapproved by: Date for the following reasons `. Permit No. �O -mod Date Issued �!b --- ------- -------------------- T E COMMONWEALTH OF MASSACHUSETTS 10I�O BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded Abandoned b ( ) Y at (u `Aa& \,J4 NA Cpn f�►� as been constructed in accordance with the provis��`i�s..,�o.ff�Title 5 and-the for Disposal Syste Cm onstruction Permit No. 6900 (0 _0`� 1 dated Installer ,rj Designer �I L, #bedrooms C/ Approved designs flow ,. 3 3 d gpd The issuance of this permit shall not �e o4ir6ed as a guarantee that the syst m will functiio<aA—figedDate / �� Inspector-, �------------------------------------- No. DCO l0 -0_ Fee �50 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 'i5ponl J�p!ftem Con5truction Permit Permission is hereby granted pW Construct —Repair ( ) Upgrade ( ) Abandon ( ) System located at W r 'lo 1 and as described in the above A_ pplication for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the da e of:th:is�pZit. Date_ Approved by Bk 210 659 PS 51 =29£� 01-17-2006 12 2 4 8p DEED RESTRICTION . r WHEREAS, Christopher Bullock Trustee Rill-lack Ro,i f- of (owners name) T-' 61 PhPa_aant (tira3rr �'anf-4„ i.11e TrUSt l�nA (address) is the owner of 61 Pheasant Way, Centerville located (address) at MA(hereinafter referred to as the "Propety" and being shown on a plan entitled "Subdivision of Land in CentPrv; 1 j P, MA, Property of et al, duty recorded in Barnstable County Registry Of Deeds in Plan Book 298 ., Page 88 ; Or on Land Court Plan Number WHEREAS, Christopher Bullock, Truateeas the owner of said lot has (owners name) agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the.pgreemortt for the,restriction on the number of bedrooms in any house constivdted on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, dw& ,. , Bk 20659 Pg 52 #2988 NOW,THEREFORE,Christopher Bullock does hereby place the (owners name) T us ee B lock ea t Trust following restriction on us atboJe-re` erenced�an iKaccordance with his agreement with geTD.V=of ,inhieh-reg#i tw run with the-land and be binding upon all.successors in title: • _6.1 Phoasant Way, M-ntPrvi 1 1 P may have constructed (address) upon the lot a house containing no more than 3 _( ) bedrooms. Chri etnpjar Rill 1 nrk Trns;t.ggrees that this shall be-pennanentdeed } (o MWS name) restriction affecting located on MA, and . being shown on the plan recorded in Plan Booker, Paged Or on Land Court Plan 88 Christopher Bullock, Trustee Fortitle of Bullock Realty see the following deed: Book _, Page r�1 Or Land Court Certificate of Title Number Executed as a sealed instrument jr 'day ofr,, r 1�-� '�"`` 410 Owner's signature �U,i U� , Owner's signature a`�l Owner's signature COMMONWEALTH OF MASSACHUSETTS as . 20 Then personally appeared the above-named known to me to be the person who executed the foregoing Instrument and acknowledged the same to be _ 17,-1 free act and deed efor e, Notary Public v. LANWOi 1:R c�ry Public IF MAS �86rT! Octala>K mtulon Exalres QCtgk;w 22, 2010 BARNSTABLE REGISTRY OF DEEDS FROM :down cape engineering inc FAX NO. :15083629880 Nov. 06 2006 01:51PM P2 Y LOTS 1 & 2 �SOO �. 5.1 ACRESt TOTAL JN 12 \ LOT 18 \` LCP 32290E LOT 1 \ o EXIST. 1500 GAL. LOT 17 SEPTIC TANK LCP 32290E tig;P sas: 6 HIGHcaPaclTY INRL. WITH 2' STONE AT SIDES AND 1.5' AT ENDS m of ° LOT 16 150,Qp 10' LCP 32290E JOB # 96-319 SEPTIC AS-"BUILT FOR THE PURPOSE_OF OBTAINING A SUILOING PERMIT ONLY LOCATION OFF PHEASANT WAY CENTERVILLE, MA PREPARED FOR: SCALE : 1" = 60' DATE : Oct. 13, 2006 REFERENCE : ASSESSOR'S MAP 227 PARCEL 143 C'HRIS. LLOCK PB 309 PC 99 0 OF MAS`T9 c� ARNE ntf H. lei 3a6 361-96Ba OJALA y down capeteinse'noRg. inc. �' 34 v c1 Z ? CIVIL ENGINEERS LAND SURVEYORIS DATE ,r REG. UR EYOR 939 moin at. Yarmouth, ma 02675 FROM :down cape engineering inc FAX NO. :15083629880 Oct. 17 2006 07:06AM P1 Town of Barnstable Regulatory Services Thomas F. Geiler,Director KAW l Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: l o l_ o Sewage Permit# G -02 Assessor's Map\Pareel 2 2'7 143 Designer: mow- Installer: Address: 3`l A Address: On l �� k�v� was issued a permit to install a (date (installer) I \V` 'L \\-4- septic system at 41 al�based on a design drawn by (address) dated o 3 v 5 ( signer) I certify that the septic system referenced above was installed substantially, according to the design, which may include minor approved changes such as lateral ref catioicof th.e; distribution box and/or septic tank. 0 h 2 � I certify that the septic system referenced above was installed with m r chants (i.-' greater than 10' lateral relocation of the SAS or any vertical relocation. Y con?Pon& of the septic system) but in accordance with State & Local Regulations. Ian reion�r certified as-built by designer to follow. to CSC - � o o r o „ - OF S e ' ARfVE H. G4tall; ' ` ig afar o UJALA �+ CIVIL y No. 30792 )<.,Xko esi n ae) (Affix mp Here) 'LEASE RETURN TO BARNSTABLE PUBLIC HFALTH DIVISION CERTIFICATE OF COMPLIANCF, WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND As-BUILT CARD AR" RECEIVED BY THE BARNs'I'A.BLE PUBLIC HEALTH DIVISION THANK YOU. Q:11ea1th/Sertic/Dcsigncr Certification Form 3-26-04.doc FROM :down cape engineering inc FAX NO. :15083629880 Oct. 17 2006 07:06AM P2 LOTS 1 2 s�soo 5.1 ACRES± TOTAL *4),' LOT 18 LCP 32290E LOT 1 1 b O EXIST. 1500 GAL. LOT 17 1 `•; SEPTIC TANK : 6 HIGH CAPACITY LCP' 32280E '��. `4 INFIL. WITH 2' STONE AT SIDES AND 1.5' AT ENDS Io v7 e LOT 16 t 5a,_ 10' LCP 32290E JOB # 96-319 SEPTIC AS—BUILT FOR THE PURPOSOF OBTAINING A BUILDiNG PERMIT ONLY LOCATION : OFF PHEASANT WAY CENTERVILLE, MA PREPARED FOR: SCALE : 1 " = 60' DATE : Oct. 1.3, 2006 REFERENCE : ASSESSOR'S MAP 227 PARCEL 143 CHRIS. LLOCK PB 309 PC 99 ARNE o H. off 900-362-4541 QALA m fax We 36Y-9880 down cape erVineering, inc. �. (� CIVIL ENGINEERS `- —J1� ——— — — — 3tlR V LAND SURVEYORS DATE ' REG. UR EYOR 939 moan st. yarmouth, ma 02675 - S m gvoeo�S�eVs d d a Ace o'sF mr an �m sf �m aH {N J J � J � y X� Qy d _ d r c I .� m m I I Prop top of foundwtion B" : 0 m I for^G"sixc eilceo door Q � r � _ D"m x 4'-O•/nonot°bcm/a yfootm I '�a I poured concrckc deck footings. - I 1 ;'- - ,, - - C �. L ----- -----------------------------------------------up } C I I 1 I O 9=PeVred aoncrctc slwb j I O v �/ J v O � I w/Pfbcrmcsfto wnd to F(il. I � � 1 I poly owpor bwrricr. I 1 I I t v � � I 1 � option peurad concrcta retwininq 1 I � � 1 wall w/footing,If r+qulred. 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I I — I I � I I I j 7iC �1 • • e e�d�,'- t �g ag� L 4. r f+.r Iv' I � �vr n 7 PLANS BY o$ - I I L'1 PLr i I ld VOI ATIONS 1. c ° "xl ornvtar mIG+"e.L. ;1 j,,'e l.f PI II IW:E.F.Y FINES u. • �,;,,,I aml.vm� p- o{ TO sroo.1100 PFROFFENSE I p D M1L1�e°• CALL Ti F CESIG?IER TO ° J C'TP,IN LFi:AL COPIES •���✓/,`� OF T'I. .Plli1J �` D I,JL -I." -14 DRAWING TYPE: . `V\���"'�L�:y,�T bra}Floor FrAma Plan hatond Floor Frnma Ft— haof Frnms Plan SHEET NUMBER: G F—OOF FF—ArlE PLAN A I O I L ` Iv11P 1 "REPRODUMICIN`e �•%^.� m o OF TH ' . 7H 1i"L AN PY$ Z Gon}Inuaus ridq¢vent - P.HYDEPPAISA IMJLA I?(N Qoa$ ) f;Y FEDEP;\L LW VIOL/:TIODiS tt,I/ Makit¢c+urai asphalt shingl¢s l/)1 °" F,;;E PC6;:IN^. LF-E.i'I'li�'ES UP'"�•• I Z•f¢I} -� ° jE+� A:1ER`Citt IItlGT!TU ° f�� i 1/2"APA rated sheet __N ..Carry UIILUING CY�IGN l! TO S10G,000 PER OFFENSE 2 x I O P-af+era® 1 lo"o.a S„1•°°° C/ALL TI;E DESIGHER'r0 O KAW LEGAL COPIES •° /yam Y `1 '�' i • •OF THIS PLAN 1 2 F.G.Insula}ion %B 0"H.O.Insula+fon Z C. 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