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0215 PINE STREET (HY - Health (3)
Ee Street was 03-002 El MEAD � Na.24NUR UPC IM .m..d�oan • wa.N wn s Page 1 of 1 Wadlington, Ellen From: Schlegel, Frank Sent: Friday, October 02, 2015 10:47 AM To: 'Grossman, Michael' -Cc: Barrows, Debi; Heath DeptMailbox n Subject: RE: 239 Pine Street Centerville ADDRESS CHANGE - It,�-W f rivLv�/ Hi Michael, Enclosed are the copies of the documents I will be sending to the owner. You may want to give a copy of the ordinance and common question statement to them for guidance. Let me know if you need more help with this. Frank Schlegel E911 Data Liaison Engineering Records Manager DPW/Technical Support 382 Falmouth Rd./Rte.28 Hyannis, MA. 02601 -----Original Message----- From: Grossman, Michael [mailto:mgrossman@commfiredistrict.com] Sent: Friday, October 02, 2015 8:55 AM To: Schlegel, Frank Subject: 239 Pine Street Centerville Importance: High Good morning Frank, I went back out to confirm access yesterday afternoon at 239 Pine St. in Centerville. The fence installed along the lot line of 241 does in fact block access from the paved area between 223 and 241 and therefore this cannot be used for access. So the only access that works is between 211 and 223 putting 239 out of sequence and requiring an address change. I spoke with the agent and the buyer and the closing is scheduled for next Friday. Thanks, Mike 10/5/2015 Parcel<Edit Page 1 of 1 171 <' 11.UTA5TAnf L� Logged In As: Friday,October 2 2015 Frank Schlegel Pa ree I Application Center Road System Reports Road System [T—�e�recard_h.as=b.een'upda�ed Parcel Detail Parcel ID; 248003002 Sewer Acct: I _ T/R F Update Devel Lot: LOT 2A Owner CHOY, JOLYNN W Co Owner: Street: 9230 3RD AVENUE City: SOUTH BLOOMINGTOf� State: MN I Zip: 55420 _� --------------- Location: 21 P1NE STREET'(HY,CENT)— Village: Centerville Road Index; 1258 ql Pri Frontage; 37 — To set road,you can also enter road index and tab out of field. Secondary Road: Sec Index: 0000 I Sec Frontage: _ Visions Location: 1239 PINE STREET(HY,CENT) Last Updated: 10/2/2015 10:31:24 Al --------------- No. Bldgs: 1 _ _) Account No: 328470 I Lot Size(acres): 0.41000918 State Class: 1010 Year Added: 1988 ` I Fire Dist: 3 — Deed Date: 3/3/2008 I Deed Ref: 2 7721/10 Land Value: 6980 _ Extra Features: 22200 _I Condo Complex: _ _ —I Building: Unit: Update_ l ttp://issgl2/intranet/Propdata/ParcelEdit.aspx?ID=l7927 10/2/2015 The Town of Barnstable Department of Public Works BARNSTABI,E MAS& 382 Falmouth Road,Hyannis,MA 02601 y_ MA89 Y r ,sav-zow `b 'aI A . ` www4own,barnstable. a,us 3T5 �Ep m��p Daniel W. Santos,P.E. Office: 508.790.6400 Director Fax: 508.790.6343 Jolynn W. Choy 9230 P. Avenue South Bloomington,MN. 55420 Date: October 2,2015 Re: Address Change for Map 248 Parcel 003.002,Formerly#239 Pine St.,Centerville Dear Ms. Choy, This office was notified by the Centerville-Osterville-Marstons Mills Fire Department that the address legally assigned by this office for your property identified above is out of sequence with other p our on buildings side of the road.The fire de artment indicated this is a direct result of Y the common driveway access being blocked and an alternate driveway access was provided in a different location. As indicated in the enclosed Town of Barnstable's Ordinance for Numbering of Buildings and the Common Address Questions statement provided by this department; when the conditions change on a property,a new address may be assigned to provide safe identification of buildings in the event of an emergency.This alternate access relocated the prime access to your property from after#223 &233 to a location on Pine Street that enters before#223. This requires an address change from#239 to a number lower than#223. It has been determined by this office that the new address of#215 Pine Street would be appropriate for identification of your building on Pine Street as a direct result of this alternate access. This number must be posted as defined in the enclosed ordinance at the entrance of your driveway on Pine Street and on the building so that it is visible from the driveway. Where this is a change of address for an existing building,you will need to contact me during regular business hours and be prepared to provide all active telephone line numbers at this location when the new numbers are posted so that you E911 telephone accounts can be updated with this new address. Please contact me if you require further assistance with this notice. Sincerely, Frank Schlegel E911 Data Liaison Engineering Records Manager DPW/Technical Support 382 Falmouth Rd./Rte.28 Hyannis,MA. 02601 (508)790-6400 x-4942 frank.schlegel@town.balmstable.ma.us 1Me' Town of Barnstable ' BAMSTABLE, Department of Public Works 382 Falmouth Road,Hyannis MA 02601 http://www.town.bamstable.ma.us Office: 508-790-6400 Daniel Santos,Director Fax: 508-790-6406 Roger Parsons,PE.Town Engineer SUBJECT:Numbering of Buildings Map No. a 4 8 Parcel No. 00 3. 00 D. Date: ©cT . Z0!S Dear Property Owner, Notice is hereby given in accordance with the General Ordinances of the Town of Barnstable, Chapter III,Article V, Numbering of Buildings, adopted March 3,1931,revised July 21,1994, public convenience and necessity requires the assignment of number a IS' for your property located on 'Pw w CCsA-M:P1 fJV�W STREET NAME VILLAGE This number should be affixed to your building so that it is visible from the street as outlined in Exhibit"E",Town of Barnstable Rules and Regulations for Numbering of Buildings. Please contact Mr. Frank Schlegel at the Engineering Division at(508) 790-6400 x-4942 and be prepared to provide all telephone numbers at this location so that your E-911 account records can be confirmed when the correct building number is posted. Roger Parsons, P.E. Town Engineer encl.: T.O.B. Rules&Regs. Common Questions ✓S`ite Map _ Assessors Change Form Town of Barnstable Department of Public Works Technical Support Division 382 Falmouth Road Hyannis, MA 02601 ¢ \ \ # x MAP-2 8 48 MAP 8 f+ MAP 228 4 $� >` 9 0: >: 0 4:1 01.4 01 4 r-- �, # . #238 - ''t I #8 # 186 --: AP 248 0, 40 01 — �'�: #211 - ' P 248 k Q48 Q-- MAP'248� 15-1 _ W MAP 22 i MAP 248 :`-� ` M 248 Oil zoo 2�}8 #259 # 41 L t 9 , MAP 2A MBA 248 ......... II( MAC 8 ---, I ...,� , a s: I `2 2 #30 I 1 basemapsAgn 1 0/2/201 5 1 0:35:07 AM Property 11nera i3i a ri on twe was are fvr assessing purposes Q and do sot represent actud. relationwwpo to.physicatbipew; BOO PAGE i�J •.� / — 7 V ' _ kA 1: 3 ;T \r FOR REGlS7RY USE ONLY LOCA770N ASP Access N PrNE STREET AREA83so� EA -11 S0. SEyENT qe �'` O/ 18484S7g4940� 54JyB30� 7400' 27,j/• 1 HEREBY CERTIFY THAT THE PROPERTY LINES SHOWN HEREON ARE THE LINES DIVIDING /t E)OSTWG OWNERSHIP'AND THE LINES OF THE D PARKING AREA SPRKE STREETS AND WAYS SHOWN ARE THOSE OF ( i`�..t/\, PUBLIC OR PRIVATEMBLIS STREETS OR WAYS ALREADY DIVISION OF AND THAT NO NEW LINES FOR DMSION aP ESHO N OWNERSHIP FOR NEW WAYS ARE SHOWN. 12 '12 f 2S�P- .p7 ,, .eaY 9 1987 i=�`-•�/C�� OATE PROFESSIONAL LAND SURVEYOR R,7 '� � �?/. O• 'NO � AR/Rf.R 0.1�Y00L.ENA i A osa¢R I Z O ` I CEf;7FY TRIG T1u3 PLAN C0.1iCeTw:.^..Tl+c 137G i RULES 8 REGULAT NS OF THE REGISTERS OF DEEDS. Al; DATE PROFESSIONAL LAND SURVEYOR io � a�`y�'a 1�6' 25's � —•-� /s- Av._=air �Z4� 3- � os9rs,- --• ,;sRr 3 � KZ ON ;u A O � ,; � W L 0 7 PLAN OF EASEMENT :� 3q °Iti P4715D 6'6-8� Gamrvue BARNSTABLE etas ` Ne`°" 'L /7s u• L O T 2q = _/=-,f , -aAu BARNSTABLE HOLDING CO E 1 — ee.Y.el� eaTC� '•. r( � .r—.�� aeceeo eI,PAL AR.Y 0.1987 scat u� •tcVJ �) r •5905936-E• >16.96• ie se go 1 Romi I lflT.G➢AEOD L R8tY mwtm or. RU(-rAN / W� LANE aslems•taaasrnreaealttrn ruA.leae UM. ��� rtalaon•taeo seAmw 1276 ParcelEdit Page"1 of'I i�1911.. Logged In As: ��r C�I Friday,October 2 2015 Frank Schlegel Application Center Road System Reports Road System Parcel Detail Parcel ID: 248003002 _1 Sewer Acct: 1, TAR 5-6 Update Devel Lot: ILOT 2A _ _ _ ,____. Owner: CHOY, JOLYNN W Co Owner: Street: 19230 3RD AVENUE City: SOUTH BLODMIN73- State: MN Zip: 55420 _� Location: 239 I PINE STREET HY,CENT Village: Centerville Road Index: 1258 _ _J PH Frontage: 37 To set road,you can also enter road Index and tab out of field. Secondary Road; Sec Index: 0000 �I Sec Frontage: _ Visions Location: 1239 PINE STREET(HY,CENT)_ ! _ - _I Last Updated: --------------- No. Bldgs: 1 — Account No: 328470� —,I Lot Size(acres): 0�41000918 State Class: 11010 Year Added: 11988 —, Fire Dist: Deed Date: 3/3/2008T Deed Ref: 22721/10 Land Value: 69800 I Bldgs Value: 115900 _— I Extra Features: 22200 --------------- Condo Complex: _ --I Building: Unit: — ____ Update http://issgl2/intranet/propdata/pledit.aspk?ID=PL 17927 10/2/2015 M1 3 67 fro Z9 Sl AN`94 � tt tt QQ N�LD a {o � N1 2s• oo 'Pd l d°o�. ,��d�� 1.A s �i � D� � ' uo I' \� N 6-1 R. � 3 A zi 117'E'er p��rv,eeEn �dtivP NPIPES 63°07"25•E p��� ��� 0 7=ou"L, 1 om o Z A \�' ,a t. 0S96•�S °04 17793t ,S �Je•Y�. G \O(p' 'lam ti Q s S G QE < ti 009 47 ti-9 < o NOTE Ap - FO PE a/METE 25EE C//V2EC0 bED ,( PLAN Fo,l GUSTAV AV.ALL3E,er/ aY ,\,(� VN FILA A/OF LAND/A/ DAVID N•&REEniE DATED AUGUS /.961 �Q Y C E/V TE�21�/LL E n�A. 7N/5 nL11�/co�oHCrS AAvo AMA�-jr�/D5 v �P ,R/-^V S/GN�A L3Y P4J2NSTABz _ \' /� N TOW" OF BAe/v5TA,BL_E} PL4AFk//,VGBOA2D FEB.B,/982-I V GA I L A. DARSCI-1 APF'R0VAL jNor zE9U114E b DEEP eEFE.2EA/CES U/JL7E?e TA`/E: }SU80/V/S/pn! 8K.2G53 P6.E97 Be.3390 P6. / Co",neOL L�4W. A5s6S. MA)- 248 pcL. 3 dL12NSTABL FLq/.Iv/vG �OAEZ� 4-1 ZD 1-5 S Ui2 VE y CO 89 W/LLOW 57 eEET I CE,2T/FY 7-/-/1 7- TN/S PLAN /4,45 YARA4,ouTNrl0�a7", MA. L3EE// PeEPQ EA/NCOAIF02MlT`� Ir W/rH 'THE 2UL A/vo 2EGULA"0A1,5 I "T 'T Ctk (�ry OF7N�AEG/STS OF DEEDS Oy 731E GO'�M0,Vw&.4Ae-��� -/OFMAS5ACNUSETIS, O So loo /50 aArE zE .Lallo Su,evEyo e _s6 -d 2 - 9 Page-1 of 1 Schlegel, Frank From: Grossman, Michae commfiredistrict.com] Sent: Friday, October 02, 2015 8:55 AM To: Schlegel, Frank Subject: 239 Pine Street Centerville MN G Ply Importance: High Good morning Frank, I went back out to confirm access yesterday afternoon at 239 Pine St.in Centerville. The fence installed along the lot line of 241 does in fact block access from the paved area between 223 and 241 and therefore this cannot be used for access. So the only access that works is between 211 and 223 putting 239 out of sequence and requiring an address change. I spoke with the agent and the buyer and the closing is scheduled for next Friday. Thanks, Mike 10/2/2015 Commonwealth of Massachusetts Title 5 Official Ins e Form p ction F 4._ Subsurface Sewage Disposal System Form Not for VoluntaryAssessments' i7 Property AddressQ-(! l Ow ner �-Y 61 Aj W. H v Y _ information is Owner's Name P�5 required for every GEN'i'c�R.�r i L� Page. City/Town ML1 _� 2_l 1 - \Q � State Zip Code Date of Inspection - inspection results must be submitted on this form. Inspection forms may not be altered in any fillingo out forms way. Please see completeness checklist at the end of the form. �'� ut forrm'� A. General Information on the computer, use only the tab key to move your 1 Inspector. , nC� cursor-do not use the return key. Name of Inspector C,4S Company Name � �C- t'�� l rl 2 Company Address 9 GJi�Jt7t� lGy..( M A Cityfl-ow n State �� Zip Code Telephone Number ��c)•Z License Number B. Certification I certify that I have personally inspected the sewage disposal system at this ad information reported below is true, accurate and complete as of the time of the inspection. T was performed based on my training and experience in the proper function and and that the sewage disposal systems. I am a DEP a he inspection Title 5 (310 CMR 15.000). The system:approved system inspector pursuant to Sectionc15.340 of e of on e Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ""' inspector's Signature3t�—2QIQ Dae t The system inspector shall submit a copy of this inspection report to the Approving Authority of Health or DEP)within 30 days of completing this inspection. If the system is a shared system has a design flow of 10,000 (Board report to the a gpd or greater, the inspector and the system owner shall submit the or ppropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditi the same or different conditions of use. ons of use at that time. This inspection does not address how the system will perform in the future under fiile5pffiaN it's P-Xbc�iFxmn SuD,aur/fxleJcp. lbl U osal 6srem ro•P. t�,f 1 I 4 t I�• n a' Commonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewage Disposal System F� -Not tr V�,ojuntaOr�ry Assessments P�6- � F1'operty Address Cw ner Owner's Name Y informations required for everyj��ti J LLE M{q page. C4_frown ©� Z ( 2-(t - l 4- State Zip Code Date of tr�spection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/a/wayscomplete all of Section D A) System Passes: I have not found any information which indicates that any of the failure in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated desa rib ed indicated below. Comments: Oti t tv LeAO L,l C h,t_l.Y tJI& B) stem Conditionally Passes: ❑ or more system components as described in the"Conditional Pass"section need to MIDI ed or repaired. The system, upon completion of the replacement or repair, as appr be oved by the Bo d of Health, will pass. Check the box "yes", "no"or"not determined" determined,"pleas xplain. (Y N, ND) for the following statements. If"not The septic tank is metal d over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substanti infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank i eplaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspectio ' it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): ------------ 65rs•303 TitleSGifid,j IMPecfimFxrc Sub"are Se'•wgeDispc-A System Page 2of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form .Not for Voluntary Assessments z3 P�N S r- p►'operty Address Cw ner L'��cr✓ information is 1,"'ner's Narr>a I required for every c"4e- page CrtyyTow n •-1 r 0 Z l2—1\— \ F State Zip Code pate of Inspection B. Certification (cont.) A « Pump Chamber pumps/alarms not operational. System will pass with Board of mps/alarms are repaired. Health approval if B) Sy m Conditionally Passes(cont.): ❑ Observati of sewage backup or break out or high static water level in the distribution box due to broken or bstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspectio 'f(with approval of Board of Health): ❑ broken pipe are replaced ❑ Y El El NO(Explain below): ❑ obstruction is rem ed L. ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is level or replaced ❑ Y ❑ N ❑ NO lain Ex I. ( p below): E ❑ The system required pumping more than 4 times a year d to brok system will pass inspection if(with approval of the Board of alth)en or obstructed pipe(s). The ❑ broken pipe(s)are replaced ❑ Y ❑ N NO(Explain below): s ❑ obstruction is removed ❑ Y ❑ N ❑ N xplai n below): C) Further Evaluation Is Required by the Board of Health: ❑ itions exist which require further evaluation by the Board of Health in the sys . failing to protect public health, safety or the environment, order to determine if 1. System will pass u oard of Health determines In accordance with 310 CMR 15.303(1)(b) that the system is functioning in a mannerwhich will protect public safety and the environment: p c health, ❑ Cesspool or privy is within 50 feet of a surface wa ❑ Cesspool or privy is within 50 feet of a bordering 1+egetated wetlan t5ins•3113 mars h Title 5 Of firiai Ins pec tien Form.Su bsuf ace SwAog a Di sp osA S yste m•Pog e 3 of 17 A Commonwealth of Massachusetts Title 5 Official n y -- n s ec r tionF Subsurface Sewage Disposal System Form -Not for Voluntary Form Voluntary Assessments ST- 1013-ty Address Own information is �+ Owner's Narne required for everyL L� page. -.ty/Town A �Z� 3L ( 2 k Q— State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, de rmines that the system Is functioning In a manner that Protects the public health, safe and environment: ❑ The s tem has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a ace water supply or tributary to a surface water supply. ❑ The system h a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a sep tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system.has a septic tank and 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 a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammoni itrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are trigg d. 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 al! inspections: Yes No [] Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 50 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 ❑ VIA, Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz day flow Firs•3113 Title 5 Official Vs;ectiw Form Subsuiace Se•:ega disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official _ I Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �3� NG Roperty Address Cw ner information is C+rvners Na required for every C-C—:r�Te a f page, CitY/1awn 2 State B- Certification (cont.) Zlp Code Cate of�spection 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. ❑ u tri y Porno a surface water suof cesspool or p is thin 100 feet of a surface water su I PP Y. PP Y or ❑ v� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ All Any Portion of a cesspool or privy is within 50 feet of a private water supply E] PP Y 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 laboratory, for fecal coliform bacteria Indicates absent and system passes if the well water analyst% performed at a DEP certifled 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 co and chain of custody must be attached to this form.] copy of the analysis The s P g y ❑ ���� 10 000g d is a cesspool serving a facility with a design How of 2000gpd- I � 9P ❑ j The system fails. I have determined that one or more of the above failure T" 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 i necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a Ign flow of 10,000 gpd to 15,000 gpd. facility with a For large stems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in tion D. Yes No ❑ ❑ the system i ithin 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen nsiti%area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a lic water supply well If you have answered"yes"to any question in Section E the system is or answered "yes"in Section D above the large system has failed. The owne eyed a significant threat, system considered a significant threat under Section E or failed under Section D speratp ra any large system in accordance with 310 CMR 15.304. The system owner should contact the appPgraateethe regional office of the Department. 65ns-3113 Ti Ile 5 0f ficial tr S PW 110n For in:Su bstrf ace SO Neg e Di sposal S yMem-PNe 5 of 17 C Commonwealth of Massachusetts __- Title 5 Official InspectionForm .y • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments RopertyAddress ON nor information is ow ner's Name required for every c c Q page. City/Town d26 3Q tz-ti State Zip Code Date of Inspection C. Checklist _ Check if the fbIlowing have been done. You must indicate"yes"or"no°as to each of the full owi ng; Yes No ❑ [ l Pumping information was provided by the owner, occupant, p , or Board of Health ❑ Were any of the system components pumped out in the previous two wee❑ ® ks? 7. Has the system.received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduc this inspection?: ed to the system recently or as part of �l ❑ 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 sewa e g 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? (�tJ ❑ 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 Absor tion System (SAS) on the site has been determined based onAo $ve c.-e(s�� v�p r- aA) ❑ Existing information: For example, a plan at the Board of Health. p�J ❑ 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)] ®. System Information fr 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): t a t5rs•3/13 T tle 5 Dffiaal Inspection Forrrc Subsu7ace Sewage Disposal System'Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspect'1On Form Subsurface Sewage Disposal System Form .Not Voluntary Assessments FToperty Address Qv ner information is CW ner s Name required for every page. Clty mown �� b?z—32 State ZipZip Code Date of hspection D. System Information Description: T-. fl 63-3 Z Y¢Y y X�v Trzr-�cc�-Ls Number of current residents: —� Does residence have a garbage grinder? Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) ❑ Yes 12 No Laundry system inspected? El Yes l§ No"IA, Seasonal use? El Yes Ud No Water meter readings, if available(last 2 years usage (gpd)): Detail: 5oo -I- -r 4 ooa ; t u �v . C2o�z� C2o t3) --�. '7 30 = l t3l d Sump pump? �. Last date of occupancy: El Yes No 14- N� Commercial/Industrial Flow Conditions: Date Type of Es ishment: Design flow(based on 3 R 15.203): Gallons per day(gpd� Basis of design flow(seats/persons/sq, ., Grease trap present? Industrial waste holding tank present? El Yes ❑ No ❑ Yes El No Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: Yes ❑ No 15ns•30 3 7i1e5INfiGal Irspec mFcrm Subsisf,xe cp,n�eDispos�S7s'em•Page 7017 z Commonwealth of Massachusetts Title 5 Official Inspection _ Subsurface Sewage Disposal System Form -Not brVoluntary Assessments Z"3� FLA W- S-'-- RopertyAddress Ow ner Owner's Name G Y information is required for every %--t_r. page. CitylI UW n NIA d�ZG 3_2 1 Z- State Zip Code Date of Inspection D. System Information (corn.) X14 Last date of occupancy/use: Other(descrl e Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, wlume pumped: "IA- How was quantity pumped determined? • � Reason for pumping: 741/K OUSA Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ 0\ertiow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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): 15ns-3113 7iiJ"'DffiOal IM(OC60n Forrrr SubSirlxe SO%'Age Di�prszg S,Vem-Page 8 of 17 Commonwealth of Massachusetts - - _- Title 5 Official Inspection F Subsurface Sewage Disposal System Form -Not III' Voluntary Assessments FYoperty Address Ow net information is Ow ner s femme ��.��� required for every (�/it page. City�Town State Zip Code Date of Inspection D. System Information (corn.) Approximate age of all components, date installed (if known)and source of information: dszcP lo—3�/ Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: Z feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 4-e�7L i2�/IcC" 4ee Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: feet Az concrete ❑ metal fiberglass g ❑ polyethylene ❑ other(explain) If tank is metal, list age: of// years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: � Sludge depth: t5ns•3113 Tine 5 Official Ins pec tlm t=orm Sul"Siat3oe SOVaga Disposal System•pale 9 of 17 Commonwealth of Massachusetts � - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow ner Ow ner's Name / information is required for every CtWT-c-R-✓t L C&- MA- Dz-4�-Sf lTow page. Cityn LZ-tl- l 4 State Zip Code Date of inspection D. System Information (coat.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness �S 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? �op—kg tr16jd-e Comments on u a -I-ecoss�Y �Z� ( p r+�ipi g recommenoo►y�(inlet aroutlet te)or baffle condition, �#ruWa "'tegtity liq ' levels as r lated t o t invert, ED. a of I ka 11 v!r aY 2<<'� ge, etc.): Y) C1U!/QvS Uo ,�—P�l DOC► l�mcS�u wJ �'l�v( C /DISC /I�/ Gr _ase Trap (locate on site plan): Depth bel o de: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass 9 ❑ polyethylene El 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: ns•3113 Date Title 5 offid<'l ins POOM Fxm Subsufacs Se wage 0i5posal System Page 10417 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not forVoluntar y Assessments RopertyAddress Z39 ` l Af 6- �(- Ow ner Cw ner's Name information is required for every C'-EAJ 7 E� f t LL C „,t page• City/TVW n S'v'A- oily D. System Information (coat.) TV cod Date of Inspection N/.4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition liqui as related to outlet invert, evidence of leakage, etc.). structural integrity, old Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Dept low grade: Material of con uction: ❑ concrete etal ❑ fiber lass g ❑ Polyethylene ❑ other(explain): Dimensions: Capacity: Design Flow: galons gallons per day Alarm present: Yes ❑ No Alarm level: Alarm I 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 5ris•.Yt J FiMe5Offiidal;mpecdor)Form SubsirfIr.,e S"eDisposal System.PNe 11 or 17 Commonwealth of Massachusetts v1--- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not forVoluntary Assessments Z� t��rJ� Sr —perty Address Cw ner Owner's Name G information is required for every I<l_C OZ fo'JZ page• GtylIOwn State Tip code Date of inspection D. System Information (corn.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert �� Comments (note if box is level a&d distr(bution to�tfe"t&/�equal, any v dienc�of solids ce�hd r�c�l, akage into or out of box, etc.): carryover, any aclP11 wi dZ rL✓S flci►"c Co✓e r/ 4 Chamber(locate on site plan): Pumps in workin er. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, con ' " n of pumps and appurtenances, etc.): ------------- * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): '/SAS RVIocated, 15 rs-3113 Ti Ile 5Offiaal Ifs Fec bon Fffm.Subsuye SeymeDisposal System•P;r9e 12of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments Property Address Sir C�v Ow ner Cw ner's Name Y information is required for every �'Uj'(rr� uc L�[_4�i7 l� 7- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/na of technology: �n1 Comments (note con�n�Nsoil, signs fdruJjl failure, I v�l ouf cQ dinrdAP.,0 v etation, etc.): P� g, l, condition of 0Y Ala� Gt7 64,41 41t/Q J4✓p �2 1Cd X Z 34 N/ C spools (cesspool must be pumped as part of inspection) (locate on site plan): Number and c ration Depth—top of liquid to inlet i Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ns•313 7iUe5OfridI InspecticnFrrm Subsurface SevsagaDispc3al 3Y5Wm•Page 13d 17 I . Commonwealth of Massachusetts _ V Title 5 Official Inspection Form s� Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments esssm ents Property Address Ow ner Gf40Y information is Q^'ner s Name required for every GEPu'wIZ✓l l L - 1L(A page. Qty/To v n O Z!h 3Z State Zip Code Date of tnspection D. System Information (corn.) N� Com nts (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ri 'vy(locate on site plan): Materia onstruction: Dimensions Depth of solids Comments (note condition of soil, signs of by r failure, level of ponding, condition of vegetation, etc.): i t5(is•3113 Title50fficial Iris pecucnForm Sutsirface Sevageoispc�A System page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Asssees'sments - 5 Roperty Address ow ner Cw �f�Y information is Hers Name required for every irT kz_U' LLG- �(� Ou3z page. CitylTown State Zip Code Date of hspection D. System Information (coat.) Sketch Of Sewage Disposal System: PrmAde 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 r5z0 T w e Vv Z3 seYvtc� i 4c.)v5 �x t5ins•3r13 Tine 5offinallrLS.MChionForm� NaceSe'rageDisposal%stem•Paps 15d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Z 3 nJ c 5T Property Address Coo Y Cw ner ON ner's Name information is required for every 6F�T-E-C-V1 LL-AE Ar OZ,61 32 I z_ t 1 _l4- page_ Crty/Town State Zip Code Date of Inspection D. System Information (coat.) Site Exam: e Check Slope I C�4 Surface water �IA Check cellar Shallow wells -Okrn t-12"k 19V S'-av Estimated depth to high ground water. 7 l O feet Please indicate all methods used to determine the high ground water elevation: ( ] Obtained from system design plans on record On �t 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: Cl Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: hd4e Yt►, CI ♦ •d u r s j e d J 0 0�r 2 / r--t .d ✓' O�O O �s -�, Zd /l o �� ,C(,x Before filing this Inspection Report, please see Report Completeness Checklist on next page. tins•3(1 s Tide 50ffici�Ins pec ban Form%bsurfxe Sevege0isposal System Page ti of 17 . Commonweal th of Massachusetts _ = Title 5 Official Inspection F ? Subsurface Sewage Disposal System F� -Not for Voluntary Form _ ry Assessments ST- R'opertyAddress ON ner information is Owner's Name required for every TIFF— page. Cdgfrbwn E. Report Completeness CheckliTta—stte Tip e gate°'blspection P1 Inspection Summary: A, B, C, D. or E checked [ 1 Inspection Summary D(System Failure Criteria Applicable to All Systems) completed l '1 System Information—Estimated depth to high groundwater �l Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ris•2/13 Title 5 CfficirJ Ins Pec oat Fcrrrt SuGSrrfxe Sej%oge DiSPOSA SySrem.p3ge 17 Of 17 J - Commonwealth Of Massachusetts Executive Office Of Environmental Affairs Department Of Environmental Protection TITLE 5 Official Inspection Form -Not For Voluntary Assessments Subsurface Sewage Disposal System Form Part A Certification Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma.02601 Date of Inspection: 1/12/2008 Name of Inspector(please print)Sean M.Jones#SI4522 Company Name: S.M.Jones Title V Septic Inspection rri Mailing Address: 74 Beldan Ln. ' Centerville Ma. 02632 Telephone Number: 508-778-4597 MI � CERTIFICATION STATEMENT r -` I certify that I have personally inspected the sewage disposal system at this address and that the inforr iation reported;j2 below is true,accurate and complete as of the time of the inspection. The inspection was performed bE sed on my' r; 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: X Passes Conditionally Passes Needs further evaluation by the Local Approving Authority Fails Inspectors Signature Date: ( 1 `3�O'C" 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. Page 1 f f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cownqum) Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma.02601 Date of Inspection: 1/12/2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.System Conditionally Passes: N/A 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 the 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 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: i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(coNnNuED) Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma.02601 Date of Inspection: 1/12/2008 C.Further Evaluation is required by the Board of Health:N/A 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 310CMR 15.303(1)(b)that the System functioning in a manner that protects the public health,safety and the environment- - The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a Surface water supplyor 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 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: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(coN DaiED) Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma.02601 Date of Inspection: 1/12/2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of cesspool or privy is within Zone 1 of a public well. X Any portion of cesspool or privy is within 50 feet of a private water supply well. X Any portion of 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 pp,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X (Yes/No)The system fails.I have determined that one or more of the above criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large systems:N/A 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: 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 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 CM15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma.02601 Date of Inspection: 1/12/2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following_ Yes No _X Pumping information was provided by the owner,occupant,or Board of Health X_ Were any of system components pumped out in the previous two weeks? X_ Has the system received normal flows in the previous two week period? X_ _Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding SAS,located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X — 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 X_ _ Existing information.For example,a plan at the Board of Health. _X_ _ 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)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma. 02601 Date of Inspection: 1/12/2008 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 0 Does residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no):—no [if yes separate report required] Laundry system inspected(yes or no):_n/a Seasonal use:(yes or no) no Water meter readings,if available(last 2 years usage(gpd):2006=65000 2007=38000 Sump pump(yes or no): no Last date of occupancy/use:_9/2007_ COMMERCIAL/INDUSTRIAL:N/A Type of establishment: Design flow(based on 310 CMR 15.203): and Basis of design flow(seats/persons/sgtetc.): 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: Was system pumped as part of the inspection(yes or no): no If yes,volume pumped: gallons--How was this quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be Obtained from the 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: new S.A.S. in 2001 Were sewerage odors detected when arriving at the site(yes or no): No OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma.02601 Date of Inspection: 1/12/2008 BUILDING SEWER(locate on site plan) Depth below grade: 18=/-" Materials of construction: cast iron_X_40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): Joints were in good condition,no sign of leakage. SEPTIC TANK:_X_(locate on site plan) Depth below grade:_8" Material of construction:_X_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) Dim «_ . Dimensions: 8 6 XS 6 X4 10 —1000 Gallons Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: 3.5` Scum thickness: trace 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: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.): Inlet and outlet tees intact and in good condition.Tank structurally sound.Tank does not need to be cleaned at this time but should be cleaned every 2 years to maintain the useful lifespan of the Ustem. GREASE TRAP: N/A (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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma.02601 Date of Inspection: 1/12/2008 TIGHT or HOLDING TANK: N/A (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: X (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 structurally sound.No solids carryover. PUMP CHAMBER: N/A (locate on site plan) Pumps in working der es or no P g order( :) Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma. 02601 Date of Inspection: 1/12/2008 SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type Leaching pits.Number: Leaching chambers,number: Leaching galleries,number: X Leaching trenches,number,length:_ 2-3x4x30 leaching fields,number,dimensions: overflow cesspool,number: innovative/alternitave system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Soil was dry and vegetation was normal.No signs of past hydraulic failure Trench is 60 feet long split in the middle by the d-box. Trench was probed in various locations with no indication of being saturated CESSPOOLS: N/A (cesspools 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: N/A (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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma.02601 Date of Inspection: 1/12/2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 5+_feet Please indicate(check)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- You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing the Town of Barnstable Groundwater Contour Map. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:239 Pine St Centerville Ma.02632 Owners Name:Michael Shipman Owners Address: 142 Bacon Rd Hyannis Ma.02601 Date of Inspection: 1/12/2008 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandm arks or Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building REAR OF HOUSE A B 0 0 2 1 3 TANK G-BOX A-1=2W -3=27'8" B-1=18Yi B-3=27V A-2=24 B-2=227" Town of Barnstable Of THE Regulatory Services BARNSTABLE, * Thomas F. Geiler, Director Arf16.19.�A Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE .v LOCHPION J 9' ? � -L S T SEWAGE # Z009 1" 3c?Z- VILLAGE CL*'L- ) a ASSESSOR'S MAP & LOT ZVD'003-00Z_ INSTALLER'S NAME&PHONE NO. J?0A o *,J o.. � 7 -1 '7 ,1 SEPTIC TANK CAPACITY k fad t LEACHING FACILITY: (type)l P (size) le Zl 1; a NO. OF BEDROOMS / J BUILDER OR OWNER. 9 A k PERMIT DATE: COMPLIANCE DATE: Z Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 dN, • ;'Ci.I y.: v� OF BARNSTABLE [i , LOCATION " 3 SEWAGE # �CJ� — 30 VILLAGE C'4_ > a ASSESSOR'S MAP & LOT � INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY k cr - g J � LEACHING )=ACILITY: (type) X�)�1. Zj jC. (size)c �' Z� Y 6 0. NO. OF BEDROOMS ;��_ 77- . , .. ,.. PERIvIITDATEc r-2 2 — 0 1 COMPLIANCE DATE:. O Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) F eer Edge;of Wetland and Leaching Facility(If:any wetlands'exist within 300.feet ofleaching facility) Feet ` F by urnished " - _ — b J \ COMMONWEALTH OF MASSACHUSETTS Ch EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVE® TITLE 5 JUN 13 2001 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ST1N��a�E SUBSURFACE SEWAGE DISPOSAL SYSTE KEPT. PART A CERTIFICATION Property Address: 239 Pine St. Centerville Owner's Name: Carol Randlett Owner's Address: Date of Inspection: ° 7— G I Name of Inspector: (please print) Wi 1 1 i am _ Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5 0 8) 7 7 5-8 7 7 6 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: Date: ' -- The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health',or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing 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 i. . Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 239 Pine St. Centerville Owner: Randlett Date of Inspection: 4 7—0 1 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. SysPasses: ✓ 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: � I 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 exp``lain. I 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 inAicating that the tank is less than 20 years old is available. explain- Observation of sewage backup or break out or high static water level in the distribution box due to-broken or ob cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with ap oval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND xplain: The system required pumping more than 4 tines a year due to broken or obstructed pipe(s).The system will pass ' spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 'Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 239 Pine St. Centerville Owner: Randlett Date of Inspection: 6,-2—O f 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 fail g 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 sy em 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 front 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. Other: 2 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 239 Pine St. Centerville Owner: Randlett Date of Inspection: 6, 7—e> i D System Failure Criteria applicable to all systems: Y1 must indicate"yes"or"no"to each of the following for all inspections: Ye� No _VV ackup 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 V 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. t/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. �ny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To a considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You ust indicate either"yes"or"no"to each of the following: (The ollowing 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 u have answered"yes"to any question in Serhan 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 airy large system considered a sign ficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.3 4.The system owner should contact the appropriate regional office of the Department. 4 P. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 239 Pine St. Centerville Owner: Ran satt Date of Inspection: �"CU 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) .,L/ Was the facility or dwelling inspected for signs of sewage back up? —4z�zWas 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? _V_ 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 239 Pine St. Centerville Owner: Randlett Date of Inspection; G --1—6 1 FLOW CONDITIONS RESIDENTIAL 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): Number of current residents:-2--- Does residence have a garbage grinder(yes or no):h 0 Is laundry on a separate sewage system(yes or no)A,LQ [if yes separate inspection required] Laundry system inspected(yes or no):iL d Seasonal use:(yes or no):AYO Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 0 58,00 0 gal. Sump pump(yes or no): A.0 1999 167 , 000 gal. Last date of occupancy:L� C MMERCIAL/INDUSTRIAL T e of establishment: De ign flow(based on 310 CMR 15.203): gpd Bass of design flow(seats/persons/sqft,etc.): Gre a trap present(yes or no):_ Ind strial waste holding tank present(yes or no):_ No,-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: La t date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records _ Source of information: y ay Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: /fie t allons--How was quantity pumped determined? Reason for pumping: .= TYP OF SYSTEM eptic 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: Were sewage odors detected when arriving at the site(yes or no):A.,O 6 Page 7 of I I • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 239 Pine St. Centerville Owner: Randlett Date of Inspection: 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: , 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) , t Dimensions: T Sludge depth: Ci Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: t Distance from top of scum to top of outlet tee or baffle: ' Distance from bottom of scum to bottom of outlet tee orbaffle: /j f ►1 How were dimensions determined: 0 j� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): ' r., 1446 RlerY tr GR ASE TRAP:_(locate on site plan) Depth b low grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum/,,hickness: Distahce 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: C mments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels a elated to outlet invert,evidence of leakage,etc.): 7 Page8ofll ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued.) Property Address: 239 Pine St. Centerville b., . ;:1 Owner: Randlett Date of'Inspection: -G TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth be�ow grade: Material oaf construction: concrete metal fiberglass_polyethylene other(explain). Dimensions: Capacity: I 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: Z(ifsent must be o ened locate on site lan P )( plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUP CHAMBER: locate on site plan) ( Pumps to working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 -Page 9 of 11 a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 239 Pine St. Centerville Owner: Randlett Date of Inspection: 6—1--o/ SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: ✓ leaching trenches,number,length: 66 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.): cate on site plan) CESSPOOLS: (cesspool must be pumped as part of tnspection)(lo p ) 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.): PR! (locate on site plan) Ma serials of construction: Di ensions: D pth of solids: C i mments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 239 Pine St. _ en erville Owner: Ran- 1 Ptt Date of Inspection: 6•—'7° 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. i .........___,....... s .._�....o .... _ 1 C. (5 -Z 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 239 Pine St. Centerville Owner: Randlett Date of Inspection: —f—U z SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 0 feet Please indicate(check)all methods used to determine the high ground water elevation: O'�tained 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: You must describe how you established the high ground water elevation: d y , 5 11 No. ! r 1' ,� 50 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Ztppltratton for Migogaf bpotem Congtructtou Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessors' 1GI Paz e1St. , Centerville Carol Randlett Z _CO3-00Z- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Install a D—box and leach trench 4' X 2 X 60, 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 Certifi- cate of Compliance has been issued by thi Boar He Signed v Date Application Approved by Date Application Disapproved for the following reasons Permit No. 'Z.�y i- 0 Date Issued �— L 2.—0 / s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ` PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01pplication for �Biopogaf 6p$tem Conttruction permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 239 Pike St. , Centerville Carol Randlett Assessor's Map arcel zyF-(D3-002- Installer's Name,Address,and Tel.No. L_ Designer's Name;Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons !'+ �Showers C ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of'S.A.S. Description of Soil Sand /) p Nature of Repairs�orAlterations(Answer when applicable Install a D—box and le ch trench 4' X 2 X 60' Date last inspected: o-, ^ 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 Certifi- cate of Compliance has been issued by this Boar Hea f Signed ✓' Date Application Approved by Date Application Disapproved for the following reasons t Permit No. _ZAW I- 0 Z rr Date Issued s— Z Z —O 1 i1 M1' f -------------------------------- -------- THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS Randlett Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( ) \Abandoned( )by Wm. E. Robinson Septic Service j\at 239 Pine St. , Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.?&Q /- 3 d Z dated--!;-- Z Z— O ) Installer Wm. E. Robinson Sr. Designer The issuance of this permit 1-7401 all of be construed as a guarantee that the syste 11 functions desi ed Date to Inspector s --------------------------------------- NO. W� �d --- Fee 5 0 THE 884MONVVEA'LTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Randlett liopooaf *potem Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) Systemlocatedat 239 Pine St. , Centerville and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructi n must be completed within three years of the date of this t. Date: Y / Approved by U NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND AYYLICATiON FOR A DISPOSAL WORKS CONSTRUMON Pic"A T(WITHOUT DES S[GNKD PLANS) William E. Robinson.Shy certify that the application f,r disposal works construction permit signed by we dazed �'"��" . concerning the property located at 239 Pine St. , Centerville meets A of the Mowing criteria: • The failed system is emTadwelling only. 'there are no commercial or�siness uses associated with the • The soil is classified he parootatimt rate is izss than or equal to 5 minutes per inch There are no wetlands within or the proposed septic atistem There arc no private wefeet of the proposed septic s)stem There is no increase in in use dosed There are no varianceseeded • The bottom!vvifl f leecdgng facility will"t be located�than five feet.above the ma�rimttm table elevation[Adjust the groundwater table using the FrMptor method whlirarle • If the S.A� be with 250 feet of any vgpated wetlands.the bottom of the proposed leaching facility will Mt be located lcss than fourteen(14)feet above the nwdai m adjusted groundwater table elevation, Please co ut>plete the follawin g-- A) Top of Grwmd Sndace E (using GIS itift mation) S' B t r.W.Elevation +the MAX thigh G.W. Adjustatent DIFFERENCE BETWEEN A and B — SIG : �i `// v DATE: ��r, "'aISIGNED f V [Sketch proposed plats of system on back]. . tF heath fotdu:ten . I •� r. j �, � Hazardous Materials Inventory Sheet Checklist .21a ate d Physical Street Address.Check- to ensure it.exists Working Phone Number Actual Amounts.-( ie. gas being used.to'fuel machines, thinner to /clean brushes.all.countas hazardous materials-no blanks) ✓ Storage Information:,location of storage, how long is:storage for? If none'-note that. isposal information where and who? If none;:note that `Applicant Signature-understand what is listed and noted /Staff Initial l-.any.questions; know who to.ask V Vehicle.Washing/Rinsing?. -:give a vehic.le:washing.policy and expiam it.. .. Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Mein St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL, 367 Main St., Hyannis, NAA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: © 9019 Fill in plea 1-.. L 0NO EA Q� ,e_ APPLICANT'S YOUR NAME/S ati BUST ESS YOU H ME ADRESS: i TELEPHONE # Home Telephone Number - - NAME OF CORPORATION " NAME DF NEW BUSINESS TYPE OF BUSINESS IS'THIS A HOME OCCUPA O ES NO µ k ADDRESS OF BUSINESS ;t i, y /P.i_ MAP PARCEL NUMBER: "/ ..tQ3:e (Assessing)„ When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining.the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO ISSIO ERT OF G E ! MUST COMPLY WITH HOME OCCUPATION This indivi ual h s e infof d any er it re uirements that'pertain to this type of business. RULES AND REGULATIONS. FAILURE TO Auth ; g tupe COMPLY MAY RESULT IN FINES. 01 IPQMJC) 21 T 2. BOARD OF HEALTH This individual ha be f ,rr� of the permit requirements that pertain to this type of business. `' MUST DAMPLY WITH ALL RVARDOUS MATERIALS REGUI_AT!nrtic Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS(LIC SI G AUTHORITY) 6. This individual ha en i or ed o t e li n ' re nts hat pertain to this type of business. Authorized Signature COMMENTS: L. Date:0.2/0�l SO/d` TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: egal MI-A61 !5 BUSINESS LOCATION: i INVENTORY MAILING ADDRESS: TOTAL AMOUNT- TELEPHONE NUMBER: - - CONTACT PERSON:y5, EMERGENCY CONTACT TELEPHONE N MBER: oe- 3 o©- 2 T2 9QMSDS ON SITE? TYPE OF BUSINESS: C, f, (v C INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum 1 Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive C.NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ® NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) 2 NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS 4Apc2an�Vs Signature Staff's Initial d v Q X BORTOLOTTI CONSTRUCTION, INC. SUBSURFACES SEWAGE DISPOSAL QDISPOSAL SYSTEM INSPECTION FORM Address Of Property 3 / i%2 — v W� e_ Owner's Name _(� �e �. Date Of Inspection PART A CHECKLIST Check if the following have been done: t" Pumping information was requested of the owner, occupant, and Board of Health. _Z None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large columes of water have not been introduced into the system recently or as part of this inspection. I,-- As-Built plans have been obtained and examined. Note if they are not avail- able with N/A. � . The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. G All system components, excluding the SAS, have been located on the site. L The septic..tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, / dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the SAS on the site has been determined based on exist- ing information or approximated by non-intrusive methods. _ The .facility owner (and occupants, if different from owner) were provided with .information on,.the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms VGcCO/I/number of current residents garbage grinder, yes or no Vs laundry.connected to system, yes or no iva seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: 2 Last date of occupancy GENERAL INFORMATION Pumping re ords and source of information: i System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: system Type off 1/ 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) other (explain) Approximate age of all components. Date installed, if known. Source of informatio Yr, - s 4x 6 Sewa e odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION CONTINUED SEPTIC TANK: (locate on site plan) depth below grade: Cl �� material of construction: _ L,,,fdoncrete metal _ FRP other(explain dimensions: 9,S ' ( 5 6/A,6�y sludge depth ---- ------- �3S distance from top of sludge to bottom of outlet tee or baffle scum thickness 3/ distance from top of scum to top of outlet tee or baffle 1 Z distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) ,tit a Cie AS /6'' --- 3// S / P DISTRIBUTION Box: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendatio faro repairs, etc. ) PUMP CHAMBER: /U —- (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) � I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. B SYSTEM INFORMATION CONTINUED SOIL ABSORPTION SYSTEM (SAS) :_I (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type J leaching pits and number z A) GaIld2� ��r�4 leaching chambers and number Q/ — leaching galleries and number _— leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number — Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) a� CESSPOOLS (Locate on site plan) :/�Q 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 (cesspool must be pumped as part of inspection) conuients: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) PRIVY: 1A Q (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, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM: INFORMATION OONTINUED SKETCH OF SEWAGE DISPOSAL SYSTEM; include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 191, O 7 DEPTH TO GROUNDWATER 6 depth to groundwater method of determination or approximation: n��rf-ep SUBSURFACE .SEWAGE,DISPOSAL.SYSTFM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. Backup .of sewage into facility? T Discharge or ponding of effluent to the surface of the ground or surface waters? Al Static liquid level in the districution box above outlet invert? NIA Liquid depth in cesspool, 6" below invert or available volume, 112 day flow? ARequired pumping 4 times or more in the last year? number of. times pumped /Y Septic tank is metal? cracked? structurally unsound? substantial infiltration? .substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy, below the high groundwater elevation? N Within 50 feet of a surface water? Within.100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, net the SAS)? Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed. to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, amonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector: Company Name : A(Val it &S8 ruC4oy), C , Company Address : k laa(-sues g2,AT Certification Statement I certify that I have personally inspected the sewage disposal system at this address and .that the information reported is true, accurate and complete as. of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site:sewage disposal systems. Check One: V I .have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 31.0 C MR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determinimation is provided in the FAILURE CRITERIA section of this .form. Inspector's Signature Date Original to. System Owner Copies to: Buyer (If applicable) Approving authority I • y THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA H .-----....OF.... ..........Ck. Appliratinn for Disposal Works Tonstrnrtinn Frrmit Application is hereby made for a P rmit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst -a� -------------------- /��/�� .Location-Address �^ / V-., r No.J // or Lot/ ......•----•-. -.C.Z........ ....:. ... 1.__�r.- .�.-.----.� Oy�iy r Addres -, Installer Address dype of Building Size Lot...........................Sq. feet V Dwelling—No. of Bedrooms.............. .__..Expansion Attic (�/ Garbage Grinder ( ) aa Other—T e of Building � '%� Other—Type g _:._ _ ___._____.. No. of persons._..�-------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ----. '!' f' ------------•--------------------------------------------------------------•-------------------- w Design Flow...... 0.....................:. ....gallons per person pp5 day. Total daily flow......43_Q.........................gall,Qns. WSeptic Tank—Liquid capacity. allons Length.... Width.......-1_..... Diameter________________ Depth............. Disposal Trench—No..................... Width.................... Total Length_._.....-__ ....... Total leaching area.._.. ----s . ft. x � g q Seepage Pit No..........f'...... Diameter....1......... Depth below inlet.................... Total leaching area....�k� .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..........._ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil.--•--------:'._. :.�7- .----• � U ......... zek-&rx.... .gam •---•--•4611-1611C.- ------------------------- w -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------------•--•------------------•-----------------•--•--------•-..............----•----------...----------------------•---------...--------------------------------...•----------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certi to Compliance has b sue by the board of h lth. r' ---� Signed--- -- �.,.�,�..,-•------ -��_.. Date Application Approved By............. ._. ' ........................................ Date Application Disapproved for the following reasons-------------------•----•---••-----•-----•--•------•-----•----------•-•-------•-•-----•-•-•-------._....-------- .....................................................--•-•--------------•••--•-------......-----------•...._-•----------•-------------.---------......_---------•-----------••--•---•-••-.-----••------- Date Permit No.-•----._..7....L-14-e----------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD �HEA H ...........................................OF.......... N.�C:.. . AVVfiratiun for Dhipmal Works Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S st at... ,� � Location-/Address / or Lot No O er / /^ Addre lit C CJ / .. ,1 ------••--- Installer Address dType of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms..............�_..........................Expansion Attic $ Garbage Grinder ( ) _______________-...._..... No. of persons - _-_-__________•___-___ Showers — Cafeteria Other—Type of Building � U��' p .,3 ( ) ( ) Q' Other fixtures ...f!:!r✓ ................................................................ d W Design Flow...... v.............................gallons per person day., Total daily flow------ .G..........................galWns. 9 Septic Tank—Liquid capacity_/4 allons Length....•-•.../___ Width__.... ..... Diameter................ Depth_..' ......... Disposal Trench—No..................... Width......._------------ Total Length........ __ Total leaching area.....&'....sq. ft. Seepage Pit No----------/-_....... Diameter....l4c.......... Depth below inlet.................... Total leaching area...... ._� r✓..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date___---_..____________ Test Pit No. l. Z_..__minutes per inch Depth of Test Pit.................... Depth to ground water.__' 4.. .'fr} (T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil------------ Z -----------•-------_--- v ---------•-•-------------------------------------/_�v.........�h.c�,�-..%A.M.------8-G-----------•----•----r<''�-^-a---------0.�-I�'_.cif_................................. W ..................................... ••••-••••••••••---••-•--------•---------------------•-•-•••••--•--•--••••---------••------...--•-•----------•-•••••••••-•---••••••••••••-••-•--••-•-•----•----••-- VNature 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 TITL% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Cert•- t/o o�f Compliance has ben • su by the board ofl alth. gned.. ----•-•• t Date Application Approved By........ �..�„ .. ._...---•------•---....---•--- Date Application Disapproved for the following reasons:.....................------------------------------------------------------- ----•-•----•-----•---•--••-•-•--•----•••...--•--------------•-----•---•--------••-----........----------•--••••----•--••--•••-•-•-•••--••-•-•••••-•----------------•-•. •....••-----•-•-••-•••-••••---- Date PermitNo.------ r = t —---------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH . / icJs�/.................OF........ . if1/ .! .J ,................................ Tnrtifirativ of Toutplionrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (><) or Repaired ( ) by................ '. ...... ....................................... ........ ------•--------•-•--------•----•-•-•----•------...._..---------•--....---•--...------- ? ,Q j� Installer at••----.....�'Q-j ..Z;• -f ....-•t•••-R.<ta cL... n � ` ----------•--•----•--- has been installegd-in-accordance with the provisions of TI r j of The State Sanitary Code as described in the application for Disposal.Works,Construction Permit No.....�_Z�_!�_n__�_........... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................I G =.. ..^...57 ---•----•---..... Inspector....................:...... ---- . .-------•--.. ....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD /OF HEA TH CyI ✓�..................OF...��./ :C.0 ... �.........---•--•-•--...---•-• No..!S_�_..�..0�> FEE..2�...- DiupuuaI ViaThs Tunu r iun �eruti#Permission is hereby granted------.._ r� lo ••--.0 . 2A••••••-•••-•--•-••--••---••--•---•-•------•-••••••-••••--••..............•........_.... to Construct ( k4J or Repair ( ) an Individual Sewage Disposal System atNo -.._....... - -------------- Street as shown on the application for Disposal Works Construction Permi "Dated------------___............................ Board of Health DATE........ `"- -------•-•----•-----•--••-•-----•-# FORM 1255/HOBBS i& WARREN, INC.. PUBLISHERS •3. `�'4. f` f�! � 7 TOWN OF BARNSTABLE WCATION L. 07,R A +' /,U e 5-r SEWAGE VILLAGE �'e^J7R Ul/1f� ASSESSOR'S MAP & LOT,;?'/& ' "INSTALLER'S NAME NAME & PHONE NO. 0�7 ( �(a 7 `®� C) SEPTIC TANK CAPACITY LEACHING FACILITY:(type)�� W�� (size) NO. OF BEDROOMS -3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER -/tT��_' DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: 2)c2 / VARIANCE GRANTED: Yes No / `l��A � �� ,��� I20 FT. MIN. ADM OF FOUND. "SOIL, 7EST'10 FT M IN. OF -te DATE SOI 4sw'L TEST CONCRETE WITNESSED BY _T COVERS 4 SCH. 40 P,VC PIPE CLEAN SANDI., PERCOLATION RATE Milt/ INCH MIN. PITCH 1/8 . PER F OBS-OBSERVATION `-"HOLE I ' ERVATION HOLE '�"2:CONCIRM � OF LEV 4 CAST IRQN PIPE 12 COVERS' 2 LAYER ' E .............. 1LEV.(OR EQUAL M IN. V ._WASHED,',',PITCH 1/4 PER FT To;> I:STON E,FLOW LINE -S;A w 1>:met)IN ELr W1 6RAVSLI MIN. EL EL = LEVEL E L,= EL.DIST IEL.-w WATER AT'--'I BOX ,-. .WATER AT 3/4" 2 GALLON WASHED STONE. U- 00-0 00' DESIGN �CALCULATIONS ' ,,�,'.;L."�"".,.:`NU .:BEDRO0 SEPTIC TANK � I . I : -. % , I MS'PRECAST LEAC ING MBER 'OF'GARBAGE DISPOSAL U141TI BASIN OR EQUIV. t,�'IOTAL ESTIMATED. FLOW_'.__'t 6 DIAM.,77 DAY SEWAGE DISPOSAL SYSTEM P OAL. DAY,ROFILE R.) GAL-SEPTI NOT TO SCALE REQUIRED., C,TANK CAPACITY�',?,'IIACT UAL SIZE 'OF SE TMK I DbO` `6AL`REQUIREMENTS�'R'LEACHING'�A FEA E. S T BOTTOM OF TEST PROBABLE WATtR :TABLE' EL. WALL :ARE ATER TABLE ( :- 1/ -' SIDE A ,OTTOM t7 IGAL. SLF"'B 'C PACI (BOTTOM SIDE WA'LO q'D-LEACHING' TY + A CAPACITY' LEACHING GAL:DEXISTING SPOT,ELEVATION O'EXISTING C N*600'"IFINAL SPOT ELEVA 16 N ............T 'NOT LOT P ES:FINAL CONTOUR, 1. �ALL..'WORKMANSHIP,'ANI) SHALL ,CONFORM TO'DLE.G.E.,UTILITY POL TITLE 5_ AND THE TOWN RULES `AND SOIL TEST LOCATION ,E REGULATIONS -FOR THE SUBSURFACE OISPOSAL;,OF,SEWAGE;-TOWN .,WATER 7—W—��=-�w AL L' COVERS TO MARY UN ITS SHALL BE 13RWGHT SNCATCH BASIN WITHIN --OF fINIS ED 'GRA E 6 12 L RE IN ESSENTIAMY' 'THE SAW.EXISTING'AND,FINAL ibk4cid Sk m4 tNO TA I3 ' 4. ALL`,COMP0 NTS OF THE 'SANI AY,.SYSTEM sHALL.OE �CAOA E . 'UNDER OR IC) OF THSTA ING;' O',LOAD I" 0 -ARE NO H N UNLESS THEY T,OF"DRIVE SO WITHIN10 F 0ARKING�,AREAS.R 20 C> SHALL`,B -'.'UNDER 'OR WitHIN)OF-TOF DRIVES-OR PARKING'!��.�MIN. FRONT SETBACK E',USED M IR REAR UNITS-,USED 0 RING; VERS�j(ANY ,�MASONARY�- T CID IMK 'SIDE �SETBACK',,: ,co ETERMINA ION 14AS Etw,oiAb 4 6 C, iO*NEA/A PL Is" T, i",;,DEEDE �OR`20N EG IIN SU H DE R'to TE�",AUTHOR ITy OPRIA IIH AL ROVED- - '70 F ip P' "T IIIDATE II �,7 PROJECT LOCXrION1 IC IAPPLICANT,.-` I_N T LoT 3 P tOD 1AIC ELDREDGE ,a Eli W4 64 IER �OC S 0 4 Is,P4 r- ENGINEERS LANDSCAPEARCHITECT LANKRS LAND SURVEYORS' CENTERVILLE A 02632 L C. " 889 WEST MAIN'STREE tir I_PA u C'o P I4v, 4r JON MD.LOCATION : MAR" SHEET OF ING A 0 tE 7 II