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0271 PINE STREET (HY - Health
271 PINE STREET, CENTERVILLE A = UPC 12534 No.2�QR HA$TING$. MN i aag -i L.q Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott 8t Marilda Frank Owner Owner's Name information is Centerville Ma 02632 2/22/2021 required for every state Zip Code Date of Inspection page Cityrrown Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the and of the form. Important:"'men A. Inspector Information filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2/22/2021 Inspector's Signat Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t6'utsp.doc•red.72612018 Tle 5 Official Inspection Form:subauface Sewage Disposal System•Page 1 of 18 i- 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is Centerville Ma 02632 2/22/2021 required for every Cityfrown State Zip Code Date of Inspection page. C. Inspection Summary Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 271 Pine St Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank& 1500 gallon septic tank, distribution box and 2 rows of 4 Infiltrators. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to b replaced or repaired.The system, upon completion of the replacement or repair, as approvedy the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Tide 5 official Inspection Form:subsurface Sewage Disposal systern•Page 2 of 18 l5insp.doc-rev.7J2812018 Commonwealth of Massachusetts F UTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is Ma 02632 2/22/2021 required for every Centerville page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board'of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed.pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): F 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: i • Title 5 Official Inspection Forth.Subsurface Sewage Disposal System•Page 3 of 18 t5irisp.doc rev.7@8f2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner owner's Name information is Centerville Ma 02632 2/22/2021 required for every CirytTown State Zip Code Date of Inspection page. C. Inspection Summary (cont.) ❑ Cesspool or privyy is within 50 feet of a surface water p ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water.suppiy or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5lnsp.doc•rev.72812016 Idle 5 ofridal Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is Centerville Ma 02632 2/22/2021 required for every cti Citylrrnan State Zip Code Date of Inspeon page- C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems:(cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 16.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No E ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ Elthe 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 Title 5 officiai inspection Fonre Subsurface Sewage Disposai system•Page 5 of 18 t5insp.doc•rev.7,Z52018 f Commonwealth of Massachusetts I MEMO Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is Ma 02632 2/22/2021 required for every Centerville Cityfrown State Zip Code Date of Inspection page. C. Inspection Summary (cont.) if you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The System owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ® this inspection? Were as built plans of the system obtained and examined?(If they were not ® El available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes'uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5'msp.doc•rev.7/16Q018 Tole 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 or 18 it Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is Centerville Ma 02632 2/22/2021 required for every Lynn state Zip Code Date of Inspection page. D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd Description: Dwelling consists of a 3 bedroom main house and a 1 bedroom apartment 3 Number of current residents: Does residence Have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date t5inap.doc-rev.7 26=8 Title 5 Official inspection Forth:Stbauftoe Sewage Disposal System•Page 7 of 78 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank — Owner owner's Name information is Ma 02632 2/22/2021 required for every Centerville state Zip Code Date of inspection page. CitylTown D. System Information (cont.) ' I Flow Conditions: 2. Commercial/Industrial Type of Establishment: i Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Title S official it spedion Fonn.Subwxface Sewage Disposal System'Page 8 of 18 t5insp.doc•rev.MM2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is Centerville Ma 02632 2/22/2021 required for every state Zip Code Date of Inspection page. city/Town D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy'of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5'and 3' Depth below grade: feet Material of construction: s ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): l Joints in good condition, no leakage,vented through roof. i Title 5 official brspe6on Form:subsurface sewage Disposal system•Page 9 of 18 t5insp.doc•rev.726/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owners Name information is Centerville Ma 02632 2/22/2021 required for every Citylfown State Zip Code Date of Inspection page. D. System Information (cont.) 6. Septic Tank(locate on site plan): see below Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) 1000 gallon septic tank 1'below grade. 1500 gallon septic tank 2.6' below grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000& 1500 gallons Dimensions: 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' 211 Scum thickness Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" Opened covers and took How were dimensions determined? 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.): Main 3 bedroom house has 1500 gallon septic tank,the 1 bedroom apartment has a 1000 gallon tank.Tanks do not need to be cleaned now but should be done soon and again every 2 years for proper maintenance.Water level was even with outlet, tanks were not leaking and were structurally sound. 1500 gallon tank has zabel filter on outlet tee. Covers are on risers 6" below grade t5in5p.doc•rev.7126r201 B Title 5 official Inspection Form:Subsurface Sewage Disposal System•page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owners Name information is Centerville Ma 02632 2/22/2021 required for every City/Town state Zip Code Date of Inspection page. D. System Information (cont.) 7. Grease trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle` Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5msp.doc-rev.7lZ6/2018 Tile 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's(dame information is Centerville Ma 02632 2/22/2021 required for every page• cityrrotnm stateZip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No. Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): H-20 distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup.Access cover is on a riser 6"below grade. 15insp.doc•rev.7rz620t8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is Centerville Ma 02632 2/22/2021 required for every lente State Zip Code Date of Inspection page. Cityrrown D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):., If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number: ® leaching chambers number. 8 Infiltrators ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number ❑ innovative/altemative system Type/name of technology: t5insp.doc•rev.M2612018 Tide 5 Offxial Inspedion Form Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts Eaaii�F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner owner's Name information is Centerville Ma 02632 2/22/2021 required for every State Zip Code Date of Inspection page. cityrrow n D. System Information (cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): s.a.s.consists of 2 rows of 4 Infiltrators each. Both sides of leaching facility was video inspected from d-box and found with 2"standing water and no signs of past hydraulic overloading. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•rev 726/2018 Title 5 off w irspecUan form:Subsurface Sewage Disposal System•Page 14 of 18 c CommonweaKh of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is Centerville Ma 02632 2/22/2021 required for every State Zip Code Date of Inspection page CityFrown D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insP.doc•rev.72SI2018 Title 5 official Inspection Form:Subsisface Sewage Disposal system•Page 15 of 18 r Commonwealth of Massachusett Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is Centerville Ma 02632 2/22/2021 required for every Cii�rlTown State Tip Code Date of Inspection page. D. System Information (cons.) 14. Sketch of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ASmBUILT ATTACHED SEPARATELY N EXT PAGE t5lnsp.doc•rev.7P16r9A18 -Mb 5 offfew kmpecfw+Fonn.SLhaffraee Sewaga Disposal fie!^'PSe 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is C required for every enterville Ma 02632 2/22/2021 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) . 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar El Shallow wells 12,+ Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed Date it ❑ 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 was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5insp.doc-rev.7r26f2o18 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 V i V I V j l 3 a qu —419 ►� 1nouSe. � .�y,.tcy �I ® 4 A t 1 CIS c`t ^ �a �LI-a c, St{ '1Li L 1 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 271 Pine Street Property Address Scott&Marilda Frank Owner Owner's Name information is required for every Centerville Ma 02632 2/22/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5hV.doc•rev:712MO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE J LOCATION 7 1 n .c Lip} SEWAGE# VILLAGE C. Ak Vr kl-Q, ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SC.A�A 1;7rt,1\ SD C1y OO .'SEPTIC TANK CAPACITY t 0 ) CAL_ LEACHING FACILITY.(type) E � - `^c, (size) .�—� u , �,� 'r c +apt <, NO.OF BEDROOMS � ��" ��� Ox� An ° `< owNER cv F' r xad of PERMIT DATE: 20 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY t v C QX � rU%) (fo� \\ TOWN OFrBARNSTABLE I LOCATION `A SEWAGE# VILLAGE Ak"�� ASSESSOR'S MAP&PARCEL -�-�-1 INSTALLER'S NAME&PHONE NO. S LA)A V r-w`V L- S-O O SEPTIC TANK CAPACITY o O D C,c1-] LEACHING FACILITY: (type) �x�;�`nc, (size) 1 NO.OF BEDROOMS for GA\ OWNER CIO F -R �x"d r J PERMIT DATE: COMPLIANCE DATE: °f Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility . Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY d v C, ;r 0�) ev x i� 13 a � �6 a = m r\ e, s . � o F Town of Barnstable Building ' 'ld•ng - )Post This §" ° „ Street A roved Plans Mist be Retained onlob an,dthis�CardMust beKept ,Card SoThatit is Visible.From the pP. , _ t-tARiiSCABLE � ' • M" yet Posted=Until Final=lns ectlonHas:Been Made n >{w 4 q � * �'.�.�,,;,�'N�,�'.�: ,Fa�`.�,3�'�'^�``?� � :'. ^'%t� .�� ;:�?,.:. �':. ,:• ... a .°�.4.. � m ,r..� �:�. w;a . Permit hWhere�a Certificate�of.Oceu anc is Re. wired,such Building shall�#Not�be Occupied until a�Flnal Inspection��hasbeen�gma�de '�,�,y Permit NO. B-16-1190 Applicant Name: Conrad Remodeling Map/Lot: 228-149 Current Use: Zoning District: SPLIT Date Issued: 06/13/2016 p Permit Type: Amnesty with Construction Expiration Date: 12/13/2016 Contractor Name: Conrad Remodeling Location: 271PINE STREET(HY,CENT),CENTERVILLE Est Project Cost: $30,000.00 Contractor License: 124074 Owner on Record: FRANK,SCOTT M& MARILDA D Y, Permit Fee $228.00 Address: 271 PINE ST ry Fee'Paid $228.00 CENTERVILLE, MA 02632 Date 6/13/2016 Description: change of use from commercial to residential`aprartment for the amnesty affordable apatment program change windows, re-roof,re-side install new smoke detectors �• 4�7 Project Review Req Building Official This permit shall be deemed abandoned and invalid unless the work authorizedfby this permit is commencetl within six months after issuance. All work authorized by this permit shall conform to the approved application and the"approJed`consE�uction documents forzwhich,this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by lawsand codes. This permit shall be displayed in a location clearly visible-from access street or road a'nd shall be maintained open for pufhc inspection for the entire duration of the work until the completion of the same. c/--a-,6t-/� The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work , r ' 1.Foundation or Footing 2.Sheathing Inspection r -7- -G 3.All Fireplaces must be inspected at the throat level before firest flueilinmg is'mstalled: 4.Wiring&Plumbing Inspections to be completed priorto Frame Inspection k X 5.Priorto Covering Structural Members(Frame Inspection) s E'° 1��)t{C (C� AP 6.Insulation 7.Final Inspection before Occupancy � i`� r Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. C�(,(((,(/( "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 4s 1/ i f 3 (2 : PIZ l�P/vc 61 00 6'0...., ...... gip .. . .:� :... Ar A i Q .:y `.ice, � -:T+r.!-.�: Y• - 4 - .1 . •,•xu*c,e, taw: fiF > W o .�� � �:�__ .-�__ •-.;ate:._ .. ;�,� o-s yr a•� r '� M1r rT. A x6 r FF �+3�• 1 ; Y.. � �Fp as ,� a. F (• '� 1 Q .ry.V f �'': ! �. �'' _.,4 r .'.� '} Y -..: ,;H•a ,c tl y ��"s,�"�'y� '�` y ; ,�, hp' � r..h'p r -'4 ,�+`� ' � `3r. a f�?q �. a r r �`��'j��l��,,��i��e fi+,r�aa' �,.'�� J,� `��A S�, ��' �• ,ca.. �y,�� f' � �e��� �' a' 3 fL F-: L'1•��' ��,' .•,. y' Y' :��S�y9 -� a �+s+� X R � x v�,' ���' h h f��'n yak ' x"b�_tY•„'��. <'ttt�� 1 t:� e � � ,i�y:�Y( -� ",.,;�,Y.t ��r w .�'"'' , f '4�.: � 4y r ZF��:., � x.•s�t* e r � X�r�,���',.� c;; _is{ f.�e >s r :*'+ tax t �� .,c'�.'Y'So` r.^��q t Vic;5• ''3.*'S.t v'o''`k, � �x"5f �r'°��Y: -cr' i?P' �F., °j' y�� �� Y ,t .��n.,s,.µ �„ �s s e m Y• .a 'G �� ^' �. r{� r ." � r a!�y��.tt°y�d .:." � .3 =q�r• C � fr. �� � Sw :.4 F:;°7 M}t- � S 7� �` .- '' s ,'i�"iC s t"k �'tr �d -•t:.: YY. �4 r '�;.�` .- er ,s 4 .0 p. '� �,i r C e .d �'°'"*'`'�, ` t" F: 't'Y'a�Et i•�'^^,3K�S� r --X.lot.: � s x J j Y Y X r ti 1 Y4 .:• r. :-.i.:. d Town of Barnstable Received by Health 'THME y� Regulatory Services Department on Richard V.Scali,Director �7ARNRAA. Public Health Divisn®H 1639• Thomas McKean,Director 200 Mai.Street,Hyannis,MA 02601 .Office: 508-862-4644 Fax: 508-790-6304 ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE Property Address: assessor"s leap/Parcel Number: Z e/Liq Applicant(s) Name. Phone., s\ '��6 0`l E-Mail: t 0 M A Size of Lot: ®�s 2a. How many bedrooms exist at your property now? 3 2b.. How many bedroom are you planning to add as part of the.Accessory Affordable Apartment Program application? 2c, How many bedrooms total are proposed at this property(including the Accessory unit)? _ 2e. Is the proposed Accessory Apartment contained within:.. the main house; OR a detached structure 2f. Submit-floor plans for all buildings on the entire property. Show all*8xisting rooms in the dwelling and the proposed accessory apartments Label each room clearly. Label measured width of all open doorways. Use straight edge for hand drawn plans and be sure all labeling is legible. Signed: 6 ... Date: r Parcel Detail Page 2 of 4 Model 1commercial I Floor Pine/Soft Wood ' Rooms FU Full-1 Half -22 Grade Total Below Average lHyPe Radiant Rooms I`X Storiesri- I Heat EleCtrlC I Found-!Cons. Slab -I GRN Z' Fuel ation Gross [2IP BAS Area 1198 as __ Permit History Issue Date Purpose Permit# Amount Insp Date Comments 8/2/2006 Swimming Pool 20061857 $10,000 8/8/2007 12:00:00 AM 9/17/2003 Addition 71582 $150,000 11/10/2004 12:00:00 AM 11/1/1985 Remodel B28671 $30,000 CE REMOD' Visit History - ------------ --- - Date Who Purpose 2/11/2014 12:00:00 AM Geraldine Clark In Office Review 1/5/2010 12:00:00 AM Paul Talbot Drive by inspection only 3/27/2009 12:00-00 AM Nancy Finch In Office Review 10/17/2008 12:00:00 AM Nancy Finch In Office Review 8/22/2007 12:00:00 AM Jeff Rudziak Permit/Hold as NewGrth 11/10/2004 12:00:00 AM Martin Flynn Bldg Permit Completed 6/8/2004 12:00:00 AM Martin Flynn CALL BACK 3/7/2000 12:00:00 AM Gary Brennan Meas/Listed-Interior Access Sales History 1 Line Sale Date Owner Book/Page Sale Price 1 5/13/1999 FRANK, SCOTT M&MARILDA D 12265/213 $300,000 2 6/15/1985 HESLINGA, STEVEN GERALD&LYNN 4580/286 $75,000 3 9/12/1974 OBRIEN, MARY K 2095/135 $0 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2015 $232,000 $50,200 $48,400 $151,100 $481,700 2 2014 $232,000 $50,200 $49,400 $151,100 $482,700 3 2013 $257,500 $50,200 $50,500 $157,200 $515,400 4 2012 $263,900 $47,900 $32,900 $151,100 $495,800 5 2011 $293,100 $5,400 $21,500 $151,100 $471,100 6 2010 $289,800 $5,400 $22,500 $153,500 $471,200 7 2009 $263,200 $5,400 $13,100 $171,800 $453,500 8 2008 $307,600 $5,400 $12,900 $184,000 $509,900 10 2007 $255,000 $5,100 $600 $117,000 $377,700 .11 2006 $219,900 $5,100 $600 $117,000 $342,600 12 2005 $102,500 $0 $700 $105,000 $208,200 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=16115 10/13/2015 Parcel Detail Page 1 of 4 tiBAIL p° k Logged In As: Parcel Detail Tuesday,October 13 2015 Parcel Lookup Parcel Info er Parcel ID 228-149 I Develop LoY LOT 1 Location 271 PINE STREET(HY,CENT) I Pri Frontage F10 sec Road HEADWATERS ROAD I Front Sec age-313 Village CENTERVILLE Fire District C-O-MM Town sewer exists at this address No I Road Index 11258 I Asbuilt Septic Scan: 3�Y 228149_1 Interactive Map Nff 2281492 r 2281493 Owner Info Land Info Acres 0.75 use SSTORE/APTS-Large I zoning ISPLIT RD-1;RCJ Nghbd 0106 Topography Level .�. I Road Paved utilities Public Water,Gas,Septic _ I Location Construction Info Building 1 of 2 Year 1 660 I Roof Gable/Hip ) Ex Wood Shingle I Built Struct Walll Living[2362 Roof,Asph/F GIs/Cmp I ac None ' °P 1's Area Cover Type 'I8 . FUS Style Modern/Contemp Wall Drywall a I Rooms"" Bedrooms --j GAq 41 _, Model Residential Int Hardwood � 61 �� Bath 3 Full-0 Half I €u lMD Floor Rooms B $� $, 14 2 Grade Average Plus I Type Hot Air I Roomas" I `rtlS 8AS WDK, stories 2 Stories Heat ,Gas Found Poured Cone. I �"IT BM Fuel ation 12' s s Gross 149 88 Area Building 2 of 2 Year 1960 I Roof ,Gable/HipI Ext Wood on Sheath Built Struct Wall Living 504I Roof ,Asph/F GIs/Cmp AC None �I Area Cover Type Int Be Style Store I Wall"Drywall I Rooms�0 I Int Bath http://issgl2/intranet/propdata/PareelDetail.aspx?ID=16115 10/13/2015 Parcel Detail Page 4 of 4 :111I�����m�1111�� http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=16115 10/13/2015 I Parcel Detail Page 3 of 4 13 2004 $96,600 $0 $700 $105,000 $202,300 14 2003 $71,900 $0 $700 $140,000 $212,600 15 2002 $95,400 $0 $900 $140,000 $236,300 16 2001 $95,400 $0 $900 $140,000 $236,300 17 2000 $67,100 $0 $1,200 $48,300 $116,600 18 1999 $67,100 $0 $1,200 $48,300 $116,600 19 1998 $67,100 $0 $1,200 $48,300 $116,600 20 1997 $61,900 $0 $0 $35,100 $102,600 21 1996 $61,900 $0 $0 $35,100 $102,600 22 1995 $61,900 $0 $0 $35,100 $102,600 23 1994 $65,900 $0 $0 $39,500 $110,000 24 1993 $65,900 $0 $0 $39,500 $110,000 25 1992 $75,100 $0 $0 $43,900 $124,200 26 1991 $86,300 $0 $0 $83,400 $174,800 27 1990 $86,300 $0 $0 $83,400 $174,800 28 1989 $86,300 $0 $0 $83,400 $174,800 29 1988 $67,900 $0 $0 $43,500 $116,200 30 1987 $37,400 $0 $0 $43,500 $85,700 31 1 1986 1 $29,600 $0 $0 $43,500 $78,800 Photos 'I y' - age http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=16115 10/13/2015 TOWN OF BARNSTABLE l LOCATION SEWAGE# -' JVIT LAGE _ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. . -,�:by a qN CNA SEPTIC TANK CAPACITY Nn\/t Mmr Me%"P Vtri-Viv\ LEACHING FACILITY: (type) �n \t-t,\prj(size) NO. OF BEDROOMS OWNER PERMIT DATE: C\ (� '� COMPLIANCE DATE: Separation Distance Between the: Maximum'Adjusted Groundwater Table to the Bottom of Leaching Facility AM Feet Private Water Supply Well and Leaching Facility(If any wells exist on site"or within'200 feet of leaching facility) N�) Feet Edge of Wetland~arid Leaching Facility(If any wetlands exist ,` within 300 feet of lea hi ng facili ) N Feet FURNISHED BY ;r Gr(AA 03 a v o , f7 °�fl �� kt- ok �l No... 0 uvf Fee d THE COMMONWEALTH OF MAS:SACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for It.5poal �§pq;tem Con5tructton Verna Application for a Permit to Construct( ) Repair( t�Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. a� '� Owner's Name,Address,and Tel.No. Assessor's Map/parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder W y Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title _ Size of Septic Tank �`��c, Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Cl�/��. k O CSCAmvas Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date I ( Ito Application Approved by r Date I Application Disapproved by: Date for the following reasons r Permit No. I%LtS'— 7 Date Issued t'/ NO. 0s Fee THE COMMONWEALTH OF MASsACHUSETTS Entered in computer: Yes ✓" PUBLIC HEALTH DIVISION - TOWN OF BARNSTARLE, MASSACHUSETTS ZIppricatton for Migpogal �&pgtem Corrgtructfou. Permit ! Application for a Permit to Construct( ) Repair( 01"'Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Component'§ Location Address or Lot No. IX u - '( Owner's Name,Address,and Tel.No. c, -- Assessor's Map/Parcel a ( l/�Q 5 C.V\ 1� �� S�f Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. o� t� �? c �'t•tee 5-� . C,��Ic, <_c P < v e< < ��► Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder (N� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title `"Fw Size of Septic Tank `�`� C,` . Type of S.A.S. r, T C'-\Ty cS Description of Soil x J 5 Nature of epairsorAlterations(Answer when applicable) L� ecFJs(� (, �(Aj Vt- r { N Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe _ Date 14 I 0S Application Approved by q, ��r Date I r t,_t Application Disapproved by: Date for the following reasons Permit No.., GUS �^ 7 C-) Date Issued j l �2 / r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that theOn-site Sewage Disposal System Constructed ( ) Repaired ( `')� Upgraded ( ) Abandoned( )by .TIcr-, at 7 ( �� /� �,4 _ C-• �1 l �� has been constructed in accordance with the provisions of Title 5 a the for Disposal System Construction Permit No. ?uo� s7 g dated l ! 0 Installer �UYv 1� Designer > #bedrooms Approved design flow . 30 f gpd The issuance of this permit shall not be o�nstrue as a guarantee that the system wil,'fun t S esigned. Date 1 d'� �- Inspector ---------------------------- - ---------------- No. U0 5 .S/y Fee J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migpoml,�&pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ✓� Upgrade ( ) Abandon ( ) System located at Q 7 ( s e <<,JC C 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: Construction must be completed within three years of the date of Date I( tj 4, Approved by ACCESSORY AFFORDABLE APARTMENT. SEPTIC QUESTIONNAIRE FOR STAFF USE ONLY 1. Is the dwelling connected to Town sewer? ❑ Yes 01 No 2. Dwelling located ❑ INSIDE C�OUTSIDE the Saltwater Estuary Protection Zone 3. Dwelling located SIDE OUTSIDE public supply well Zone of Contribution 4. Dwelling is connected to ❑ ON-SITE WELL Cj�,VUBLIC WATER 5. Disposal works construction permit on file? Wes' ❑ No 6. If yes, how man bedrooms were allowed by-this permit:- bedrooms �c�c' 7. Were building permits obtained for additional bedrooms? ❑ Yes 5�_Ko 8, Engineered septic system plan: �� 4 a, On file at the Health Division? Yes ❑ No b. If proposed accessory unit is detached from principal dwelling, is that plan on file? ❑ Yes ❑ No 9. Existing septic system capacity is bedrooms For the accessory unit to receive approval from the Health Department the following action must occur: Ixisting system.accommodates proposed additional bedroom(s) Upgrade existing system to accommodate additional bedroom(s) ❑ Must remove a bedroom from the main house 17 Must connect detached structure to the existing septic system ❑ Must install septic system for the detached structure. ❑ Other GAD Pr Signed Date b N:D /?L71e 2 1 TOWN OF BARNSTABLE LOCATION SEWAGE# a— 7c "VILLAGE CZ1�1tisV\`1�C.� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. a �\4 SEPTIC TANK CAPACITY t ZO jc%,,y j O [A�hj p LEACHING FACILITY: (type) V 'Uri(size) NO.OF BEDROOMS OWNER PERMIT DATE: t\ 1Lj ���' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J\)'T Feet Private Water Supply Well and Leaching Facility(If any wells exist A'�, on site or within 200 feet of leaching facility) I Feet Edge of Wetland and Leaching Facility(If any wetlands exist / l` within 300 feet of lea hing fac-I- ) /�f'l Feet FURNISHED BY CFO �-t J -7 0 0 S-3 4 . vV I TOWN OF BARNSTABLE C MPLJANCE: CLASS: 1.Marine,Gas Stations,Repair BOARD OF HEALTH satisfactory 2.Printers 3.Auto Body Shops /--�/ unsatisfactory- 4.Manufacturers COMPANY T- �i�Yu see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS 2:Z/ o?�/L1� �5 Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN= indoors;OUT=outdoors) MAJOR MAT R Case lots Drums Above Tanks Underground Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: DISPOSAIJRECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply �/..i O Town Sewer Public *On-site OPrivate 3. Indoor Floor Drains YES__�/NO O Holding tank:MDC� 5W-1: �� c�a� f Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO 1� O ERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Na#me of Hauler Destination Waste Product YES NO 2. Person(s) Interviewed Inspector Date Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: 7"(\,Q— I�Aoll, t yC7:� BUSINESS LOCATION: 5A- Gy11'� ,j3 MAILINGADDRESS:_ Sc,�,�_ Mail To: TELEPHONE NUMBER: Board of Health Town of Barnstable CONTACT PERSON: Sc o�A n Cm k/L, P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: IU�1�S.cr Does your firm stor ny of the to r hardous materials listed below, either for sale or for you own use? YES NOThis form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners �p NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed,which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE (! � P LOCATION �`a �'fi SEWAGE # VU.,r,AGE ASSESSOR'S MAP & LOT I INSTALLER'S NAME&PHONE NO. 5( CIA SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS I)y\d BUILDER'OR OWNER 1 PERMIT DATE: COMPLIANCE DATE: . J 1.1-1,01qq Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility,(If any wells exist on site or within 200 feet of leaching facility) ", Feet Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by S1� No. '- 7 Fee-----y -----"-- BOARD OF HEALTH TOWN OF BARNSTABLE ZippCicat ion-*rVell Cootruction3permit plication is eby made for permit to Construct ( ), Alter ( ), or Repair ( )an ' dividual Well at: ------- --------- --- — 2 �-`- --—- --- ---- Loca' n — Address jssessors Map an Parcel ----Soy-` - ' =------ — - - - -- � L--s- ----- --- ---- - /y Owner/ Address ------- - --------------------------- ------- Installer — Driller /16 Type of Building Dwelling------ --------------------------------------------- Other - Type of Building------------------------- No. of Persons------------------- Type of Well �/'���-�-----�--------------- Capacity-----/K--- -- Purpose of Well / i ----------- ------ G-i¢ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until�aCertificate f C liance has been issued by the Board of Heal hSigned -------- - - - date Application Approved By —___—__________— ->y- date Application Disapproved for the following reasons: ---------------------------------------------- ----------- — - --- ------------- - -------------- date Permit No. W OO- 60'7 Issued------------ ------------------------------ ------- date ----------------- BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS ISTO CFRTIFF)�(,,That the Individual Well Constructed ( Altered ( ), or Repaired ( ) by----, - -CCl� o 2 ------ --- Installer — at_c471 t/ke __ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated----- ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------- —_- -- Inspector------------- -----------—— v Fee------ ----------- BOARD. OF HEALTH . . TOWN OF BARNSTABLE -Applicatiott'-*rWell Couttruct ion Permit A plication is, eby made fora permit to Construct ( ),:Alter ( ), r Repair ( )an ' dividual Well at: 7` -- ---------- ----- S --- -� ''� -- - ---2 -- --- --- -- `" Loca {n AddressZ ssessors Map an Parcel t. CS C -- Q- =--------- Owner Address f �2 - ------------------ - -- ---- ----- ------ a' Installer — Driller Address Type of Building Dwelling------ —---------------------------------------------- Other Type of Building- � No.-of,Persons---- r ` AW Type of Well- --- C_ -- -----__— Capacity-----. ---------------- -- Purpose of Well Agreement: The undersigned agrees4o install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable B-oard,of Health Private Well Protection Regulation - The,undersigned further agrees not to place the well in operation until�aCerrtific�fCliance has been issued byt the-Boardof'�/ahSigned-- -------------- - Application Approved By— . t — date Application Disapproved for"thetfollowing reasons: E A + ` 1 ------------ date Permit No. O o _ —_-_ Issued----- - ---- ---—------------- date E>i+.b9!3+i4w4uT.+iK !a!t^Ji�Y.iMiIiRLRS99NGtiRii!aN!1,�1,i4i4is4849!'9li.�ae9elN�AiTa-i!919M9o�69i19T6�bNMTa.siai�8..259946p9!KTB!9lifRd'litiiT6Ld,.:;S91ie4iWfRi.!iNi4al9w,y"T►ltiSi?9?w�; �( BOARD OF HEALTH TOWN OF BARNSTABLE Certificate 0f Compliance THIS IS TO C RTIFY, That the Individual Well Constructed ( 4- 'Altered ( ), or Repaired.( ) by----' .tG .C�� o/zLW -- Installer at O�7/ has been installed in accordance with the provisions of the'Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. do-Uo7_--Dated----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------- - =- Inspector--"`----- -- ----- ------- et4'a99?9?d4'iQMi4}?a:9�Y.Tae,��9QR9K?9�iE934iENfY494!siT9'!Ni�i9Ti�i,!9Mmi�.Wf<fib¢�/F4fi`Y�..i0i9+K09+iq."9'TiRilie99ti�!i4iFi'1s`::4�'4�ikiYi+.iYr4iGiild9i9Gtiti'NmiA!ir!'s4�Y^'��,i�w+r^.GTti"r4�. BOARD OF HEALTH TOWN OF BARNSTABLE Well Construct ion Permit No. U_ Fee .Permission is hereby granted <117 to Construct ( Alter ( ), or Repair ( ) an Individual Wellat: No. --s �� _L�-- — �� !-------- ------ -aStreet s shown on the application for a Well Construction Permit No._ 1.V Om .- ©�'T — -- Dated -- .`-f ----------- - - i� oard of Health DATE 'f No. — Fee ��� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migpoml *p6tem Construction Permit Application for a Permit to Construct( )Repair( 4pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel a �� I G ?I 1p' � C o"Al vi Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lo`Size j/0 Q sq. ft. Garbage Grinder Other Type of Building s SF Q Q&d 6 Persons Showers( ) Cafeteria Qt,1O) Other Fixtures Design Flow CC P V_gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ( Type of S.A.S. 7TLP V C�Ac—�. �5 Description of Soil MMac) C4 _'x<_ Is Nature of Repairs or Alterations(Answer when applicable) cZ C�ciS�s CQst�OU�S 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 iss, % �thi,Bo f Health. Signed d Date G �G Application Approved by Date „f'S 9 — Pet Application Disapproved for the fLoilowiWg reasons Permit No. 77 Date Issued �—r , _ No: V }'' - rr Fee 6-0 ' s �Entered in computer: THE-COMMONWEALTH OF MASSACHUSETTS �* p Yes PUBLIC HEALTH DIVISION - TOWN Of BAR`NSTABLES MASSACHUSETTS. Zlppr cation for Migpooar *p!5teM`Congtruction Permit Application for a Permit to Construct( )Repair( +upgrade( )Abandon( ) ❑Complete System 40 Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 3 �-�J1�s'�.C���� SGO� M�'�-r.�•�„[�C._ T'.IC�C,�?�f' 11-V ) Assessor'sMap/Parcel 1 0)?► �t r,.e_ i.kcs�� Installer's Name,Address,and Tel.No. Designer's Name'-`Address and Tel.Na. E Type of Building:Dwelling No.of Bedrooms I 1 Lot�Size31oa sq.ft. Garbage Grinder(N9 Other Type of Building S,� (� �14 persons Showers(e' ) Cafeteria QW) Other Fixtures Design Flow—s 3 Q (_� (Do,,% gallons per day. Calculated daily flow `�ffl gallons. „ Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Ma J C bI..Cser_ f -o ) � �G•� C �Sit CSS 0 U\S WNature of Repairs or Alterations(Answer when applicable Gc.\ / o 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 issd by thij BoaHealth. Signed Date c s Application Approved by "._ Date - Application Disapproved for the following reasons t Permit No. 7 C/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ) Repaired(1/ )Upgraded( ) Abandoned( )b <;cq SA r'1 V_ '1�\U,_�e.C- 1 at 1 V\11-Z S_� has been constructed in accordance with the provisions of Title 5 the for Disposal System Construction Permit No.�' 79 dated Installer �� (1 Ott^� Designer Q. n The issuance of this pe t n t/b/"� ued as a guarantee that the sys ern trfunction as d� ned. Date / 7 Inspector �/ � 1' / 61' ---------------------------------------- No. 7.9 Fee- = THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Migozat *patent on!9truction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at I 1 pl^t S-� C 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:Construction must be completed within three years of the date of this permit. Date: 5' —9 -W Approved by 1 , V TOWN OF BARNSTABLE LOCATION SEWAGE # VELLAGE ASSESSOR'S MAP & LOT- —Z Y 5INSTALLER'S NAME&PHONE NO. 3 - ,A SEPTIC TANK CAPACITY Ck) LEACHING FACILITY: (type) :e �c -�.k-b% -s (size) 3 � r NO. OF BEDROOMS d 5�C- ""t� BUILDER OR OW PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Al1r.�'`� 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 s 9 S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rop"Address: 271 Pine St . , Centerville OWf1er: Lynn He s 1 inga Date of Inspection: ✓r S`I NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) D ermined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 I J = COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE N INTER STREET. BOSTON MA 0210S (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Conunissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:271 Pine St . , Centerville Name ofOwnerLynn Heslinga cog Address of Owner: S aM p Date of Inspection: Name of Inspector:(Please Print)Wm- E . R ob ins on S r . I am a D mappred s�st�rriin peon rsua to S on 15.340 of Title 5(310 CMR 15.000) Company Name: KoD SO peptic ervise Mailing Address: F 0 13OX en ervl e , MA Telephone Number: 77 5—8 7 7 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se�rage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: ��e Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS TOWN Of BMNSSABIP �;, HEpl1►►DFYL � St, revised 9/2/98 Pagel of11 N i• Pr^ted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) "rop"Address: 271 Pine St . , Centerville Jwner: Lynn Hi§t3 1 inga Date of Inspection: INSPECTION SUMMARY: Check 09 C, or D: A. SYSTEM PASSES: I���✓✓✓/ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. ENTS: t B. SYS M CONDITIONALLY PASSES: O e or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon co pletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, n , or not determined (Y, N, or ND). Describe basis of determination in all instances. If."not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 271 Pine St . , Centerville Owner: Lynn Jj es 1 inga Date of Inspection: 5--j?--4 �)i C. RTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the ublic health, safety and the environment. 1) S STEM 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SY TEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FU CTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for colifo►m bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) 0 HER revised 9/2/98 Page 3'of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 271 Pine St . , Centerville'!, Owner: Lynn He.s l inga Date of Inspection f g-$ -q D. SYSTEM FAILS: You mus'l indicate either"Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N Backup of sewage into facility.or system component due to an 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LAR E SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: e following criteria apply to large systems in addition to the criteria above: T e system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public he Ith and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office o~ a Department for further information. e4of11 Pa revised 9/2/98 g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST f . Property Address:271 Pine St . , Centerville Owner: Lynn He s 1 inga Date of Inspection:P p J O' Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving"mmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. , _ As built plans have been obtained and examined. Note if they are not available with N/A. e _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. (J Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] The facility owner(and occupants,if different from owner) were provided with information on the propermaintenaaca-0f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: �71 Pine St . , Centerville Owner Lynn He s 1 inga Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms(design):: Number of bedrooms (actual): Total DESIGN flow 3 C b Number of current residents: Garbage grinder(yes or no): L Laundry(separate system) (yes or no):Z d; If yes, separate.inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):A,6 Water meter readings, if available (last two year's usage (gpd): 1998 4, 000-dal Sump Pump(yes or no):%L t) 1997 58 , 000 gal. Last date of occupancy:: 1996 78, 000 gal. COMMERCIAL/INDUSTRIAL: ,,// Type of establishment: 1 0•g 1 5 ) 5C10 r) Design flow: 36 0 qpd I Based on 15.203) Basis of design flow Grease trap present: (yes or no)A,0 Industrial Waste Holding Tank present: (yes or no)�. v Non-sanitary waste discharged to the Title 5 system: (yes or no),6 O Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: y�h System 156m ped as part of inspection: (yes or no)A, ® If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system _Single cesspool Overflow cesspool Privy Shared system (Yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other t APPROXIMATE AGE of all components, date installed(if known)and source of information: ;1�0 .�,�3 P. r t to v i�S •� Sewage odors detected when arriving at the site: (yes or no)A/ 6 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyA Tess: 271 Pine St . , Centerville Owner: ynn Heslinga Date of Inspection: BUI ING SEWER: (LOcat on site plan) Depth low grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance rom private water supply well or suction line Diameter Comments (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TA K:_ (locate on si a plan) Depth below grade:_ Material of c nstruction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is m al,list age_ Wage confirmed by Certificate of Compliance_ (Yes/No) Dimensions Sludge de h: Distance om top of sludge to bottom of outlet tee or baffle: Scum th' kness: Distant from top of scum to top of outlet tee or baffle: Distance rom bottom of scum to bottom of outlet tee or baffle: How dime sions were determined: comments: (recommenda ion for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of le�kage, etc.) GREASE TRAP: (locate on site Ian) Depth below gr de:_ Material of con truction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickne s: Distance fro top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: Date of las pumping: ' Comments: (recommenda "on for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of le kage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) AropertYAddress: 271 Pine St . , Centerville Owner: Lynn He s l inga Date of Inspection: .S TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate o site plan) Depth bel w grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm presen Alarm level: Alarm in working order:Yes_ No_ Date of previo s pumping: Comments: (condition of i let tee, condition of alarm and float switches, etc.) DISTRIBUTIO BOX:_ (locate on si plan) Depth of li uid level above outlet invert: Comments: (note if level nd distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - PUMP CHAMB (locate on site pl n) Pumps in working order: (Yes or No) Alarms in workinc order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8oftt 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 271 Pine St . , Centerville Owner: Lynn H e s 1 inga Date of Inspection: g 9 c� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:. leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: Inote condition of soil, signs of hydraulic failuure, level of ponding, damp soil, condition of vegetation, etc.) /7 3A6�-- 2 CESSPOOLS: (locate on site plan) Number and configuration:_ Depth-top of liquid to inlet invert: 0 Depth of solids layer: )epth of scum layer: Dimensions of cesspool: C'$ Materials of construction: / O/16/c Indication of groundwater: ,{,6 _ inflow (cesspool must be pumped as part of inspection) s Co ants: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI _ (loca a on site plan) Mat rials of construction: Dimensions: Dep h of solids: Co ments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98. Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) ''rop"Address:271 Pine St . , Centerville )wner: Lynn He s l inga Jate of lnspe . on, f g SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) XAJ { revised 9/2/98 Page 10of11 Lt' CAT ON SEWAGE PERMIT NO. ;;�% fir— l o Z- VI: LA I N S T A LLER'S NAME a ADDRESS tJ •:J- Z);C/,5(f o tL s/UILDE R OR OWNER DATE PERMIT ISSUED 7 j DATE COMPLIANCE ISSUED - j 4zil tiE�o L0CAT ON SEWAGE PERMIT NO. 31- LA AA INSTALLER'S NAME i ADDRESS BUILDER OR OWNER �5 &/"'i&A Z-6 DATE PERMIT ISSUED OAT E COMPLIANCE ISSUED/ 4� /uEk1 s: Fxs....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH W.N ..OF NS� gt_c_ , pphration, for Uiiivniitt1 Works Tonstrur#iun ramit Application is hereby made for a Permit to Construct ( ) or Repair (V� an Individual Sewage Disposal System at: ) #� P/ S� .. ,....._...---•-••....................:......•-...._�.......�...�`...U�:�C.. ----...---•-•--•----•--...-•- �--_�--__-_.------------.._..----�-- •C-------......-...----M-- !G YEn� fi Ci7AV ca ion..A( l`���/v ...... . J .__. 'f �... Lot No:`��LbJ � ................ ...... ./ ---.. Owner Address •---------------------------•-----.....-----.._..-••--...-•••----.....-•--•---...-•-•.�---.... . .................................................................................................. Installer Address U Type of BuildingGau1��7L. Sly Size Lot__° �=1_°� q. feet ------------5 0-4 Dwelling—No. of Bedroom ___ ________________-___.___..______:._._Expansi, t' ( ) Garbage Grinder ( ) 4 Other—Type of Building apmz � o. of Persons_r ---==---------- Showers Cafeteria ( ) a Oth Design Flow______:_. _ urea. 0_._..____gallons per person per day. Total -y flow_____________ r______....__.__.___.gallons. WSeptic Tank—Liquid capacity Length................ Width.__ _. __.__.. Diameter................ Depth______.:.. x Disposal Trench—No_____________________ Width................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter... Kk2.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by.........................................._............................... Date........................................ aTest Pit No. I________________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........................ a ......................................................... ------------- •-------- •------------ •------- -------------- •---------------- •----------- •--- •---------- 0 Description of Soil.........................................................................................................................--------------------...-•-••--.......__...•--- W V --••-••---------•••---•••••-••-------•--------------------•----••••••-•---•--•------.........••-•----•--•--------•----...--•••••...-•-•-----•---•--••••-•••-•--------....---•------•••--••--------•--•-- W ----••-----•-------•--•--•-•••----•-••••---------•-•-----•----•---•-----••••-••-•-•-------------••----•-••-•----- q r UNature of Re rs It ations—Answer when applicable_______= .__._____ `_1_.u.l...:..:... .../ ............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAITL U 5 of the State Sanitary ode The unde signed urther agrees not to place the system in opera 'o until a rtI to of Compli has be n ' by the lb and o altR. / f J. App 'cation Approved BY__......... --•--...�Q ��� l -•f- . /� --------- Date Application Disapproved for the following reasons:................................................................................................................ .....-•..................•-----------••---.._.__._...----._......._..........------------------•----••----------••--•-....-•-.__..••---•-.............................................................. Date Permit No....... S�T- 0 2 0 Issued. - --- ----••----- Date 1 O Fims"p� ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...:"`^1.T�.w..N.............oF....................... N � g ........................---•-- Appliratiun for Uiopuoal Works Tunotrurtion "amit Application is hereby made for a Permit to Construct ( ) or Repair (V/ an Individual, Sewage Disposal System,4a : .......................... -- -----.....--•.......... ...'• ................................ .ter / ,,f ...... ---•----- JV'��j ion..A...r s_.!g-7f ...................... �✓�y /�J S F— t No. q��/�� 4 •/ '`1 ....................... .(.•�d•V ►6K1f/s,J Owner Address W Installer Address UType of Building P �. Size Lot...`..}, _t__._!__�_j.,,.y..._Sq. feet ,.. Dwelling—No. of Bedroom ......................;___._._______.___.._Expansi txi� ( ) Garbage Grinder ( ) aOther—Type of Building mi_�-�_�� o. of persons__..____.,___4_`.'__._..._.. Showers ( ) Cafeteria ( ) P4 Oth re -•----•-------•-------- .-•-•---•-----•-•----------------•---------------------- - -- Design Flow......__ . ..�d.__ __.gallons per person per day. Total flow......._ :[...................... lons. W l0W Septic Tank—Liquid capacity gallons Length.............:.. Width... ...... Diameter..'.-,............ Depth... ------ Disposal Trench—No. .................... Wi h..._.. ............ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------........... Diameter-_— .... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date......................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth-to ground water...._.._............._.. Lt, Test Pit No. 2................minutes per inch Depth of Test Pit..........:.:....... Depth to ground water........................ ---------------------------------------------------------------------------- -.. , ....._....._........................................................ 0 Description of Soil...................................................................-----------...-•-------------------'-------------•-----------•---•---•------------------•---•-••-•••. x c, W V Nature of.Re s It ations—Answer when applicable 0 .._ �� !.............................' � f� •----------------- kr1l ...........................,.,,........................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System_in accordance with the provisions of TITLE: 5 of.the State Sanitary Aode—.The unde signed urther agrees not to place the system in opera ' until a rti- to of Compli has be ' by thel. rd of alth"". igned.............................................•-• -•--'--- ............-••...-'-- l-`-� ................. �/f /Date App ation Approved BY =- 'x"r p v-� ......--•-----------•--' " �• /°.,c Date Application Disapproved for the following reasons:............................................................................................................... -----•...............................•--•---•---------------....----.....--•----•----•--•-----•------------•"'---..._..............-•••-•-••--••••-•------•••-------••-----------•-•--••-•--'-•-'--.--- Date PermitNo.•-• ..�- -ram............... Issued....................................................... ti Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............�I..: .cn.�1111........OF........... .1U a?A$4..q ............................ Qlatifiratr of Toutplittnrr THIS IS TO CER IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (✓f r—by................. l.:J ---oll.-----•--....-•----------------------•. .....-�.. :::... N•- y Instal ' at-------------71 + 9-•---.... ..... ................ .--------............._.......------------._...........-----------•------------.------------ has been installed in accordance with the provisions of TI T LF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... dated.......(./��`t_1. .................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F � SATISFACTORY. DATE.............. ........................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......T�M..............OF......... ` .1.. I.-�:......................... No. ~� ?? � FEE...tea.............. Oiopoottl Workii Tunotrurttion "prrmit Permission is hereby at -��....�_..: .t. �s-x l--•................................ to Construct ( �ar Repai>i,-, �n Individual Sewage isposal System �,../ ... Street as shown on the,application for Disposal Works Construction Permit No� f .....' Dated_._.__. % ' ; -------------------- Board of Health DATE......_..._ ... f_....s !.ts.. FORM J255 A. M. ULKIN. INC., BOSTON h� { a ^s$" xC^ nai CL --!�7h z m �g3a� St�s� FM EL s W V �00 a o00 } A- A FONT ELEYF•TION _- �amova door.nd r L ' hcale, 1'/4"- 1'-O'• P.tch+o ma+ch. -6 1, '}' C �1 R r..o o"x�'-o• � � '� of -(1 N � s � z W Clsc+ric panel - � d • P P P P P x ! - v - R m o o< ,x. ® a...' LL U - ��� 1•1 �A�FIST FLOOD PLAIN m o� wl+h $' Th plan wa dignad in accordams d +h t#area+ 1 PKldsn#ial Gods 2 009 '. edf}'wn and+hs 1&0 GMT - ( ' """ Walls}o bs rsmavad axis+inq walls o`o,�°, �r • p LEFT ELEVATION w o wp c m Windo ra+ac+ion#o onfor wi+h All M—ursmsn+�/0imsnsinnc bs cl+a—if—I� by 4ansral OS h:naks ps+sc#or�syuirad - mm�is"6 E N.J DRAWING TYPE: ' Firs•F Floor Plan • Eleva}ions ,.r� SHEET NUMBER: 2 0 0 /4 0� �Fsr LONG P ND sr� pI E TREE M N ocu 1 �0 C �0 m ' J Q L. 000S MAP PINS' STD I 10 09 • S/DEWALK 1 � I � SHELL OR/YE/pgRi'/ TAN/{L of4 PEAS-0Al NG 1 64 t I I -�� NUBS 16.8•t ERY/SHOP �O � 1j• W � o J N W W 00 �I b O 20 B EX/ST/ NG ti0 33 * /O• OWEL � L/NG 30• O 17.7 O on Ov PROPOSE 3p.4•t DO/T/0N_ ..c. 30.8 * \O h � Z W •M y LOT l _$ 3I020 + S.F. N 68/0 92. ha 35.00. 1a 013 N 49 40 K • ' THE DWELLING DEPICTED ON THIS PLAN WAS LOCATED ON THE GROUND BY SURVEY ON JUNE 24. /999 AND PLOT P L A N UPDA TED ON JUNE 26. 2003 AND EXISTS AS SHOWN. 27/ P / NE S TREET. MAP 228 . PARCEL / 49 �3 A R/vs rA B L E . <CE/V TER V/ L L E � THIS PLAN IS FOR PLOT PLAN A4A � PURPOSES ONLY, AND NOT FOR PREPARED FOR RECORDING. DEED DESCRIPTIONS OR ESTABLISHING PROPERTY LINES. S C O T T F-R A /V K SCAL E : / " - 40 NO VEMBER 9 . 2005 EAGLE SURVEYING , INC 923 Route 6A Yormouthport , MA . 02675 /A ZJ (508) 362—S 132 (508) 432-5333 0 20 40 80 JOB NO: 99-038 FIELD: CFW/EEK FCALC: SAH/CFW CHECK: CFW DRN: SAH S COVERS MUST BE:WITHIN MINIMUM. V / O S DES [GN CR 1 TER 1 A . AGES 9 M INVERT EL E A T N , 6- OF FINISH GRADE 3 MAXIMUM COVER l00.7 INVERT AT BUILDING. DESIGN 'FLOW, ,95 FIRST 2 TO �'' INVERT IN SEPTIC TANK: 3 BEDROOMS AT 110 G.P,D. PER BEDROOM V a BE LEVEL MIN 2 OF PEA STONE r INVERT OUT SEPTIC TANK: EQUALS 330 O.P.P. PLUS 500 S.F. RETAIL �1 fII�•+ �9.25 ,� INVERT IN DIST. BOX: 98,77 • 200 G.P.D. MIN EQUALS 530 G.P.D. TOTAL - Tf� 4• DIAH PIPE 3/4`, - I l/2' D lA. �' • e �'T INVERT OUT DI ST. BOX: _ 0 2 - WASHED STONE s/n ® ROUND DRAIN NO GARBAGE GRINDER �/Oo' / T s .25 • l 0 fie ( E►rAc,r* GA .v •o_L 9 _ INVERT IN LEACH CHAMBER: 98.5 99.5 BAFFLE T9• BOTTOM OF LEACH CHAMBER: 97.67 8 HIGH CAPACITY INFILTRATOR 1 40•�r> SEPTIC TANK REQUIRED: 3 `OUTLET _ � ao� N/A CHAMBERS` W/3.5 t STONE AROUND PAR FENCE p 39��8''�--�� �`"---.� 1 ADJUSTED GROUND WATER: 530 G.P.D. X'200-V - 1060 GAL. `D-BOX ,' OBSERVED GROUND WATER: N/A I500 GAL 2 14 r X 32 I X l0 d �. 1- B _ SEPTIC TANK PROVIDED: .1SOO GAL, MIN. - SEPTIC`TANK 6• CRUSHED STONE BASE -/ '-, �1 p / �`'`�-��-�� _BOTTOM OF TEST HOLE +1. 90.2 -=.... .,„---�. SOIL ABSORPTION SYSTEM REQUIRED: POST d RA/ :- "., p r / m� \ DESIGN PERC RATE ( 5 M1N/INCH P R OF I L C • NOT TO SCALE f �` - SOIL TEXTURAL CLASS - 'J L 1 LAWN srex oosT4 ® EFFLUENT LOADING RATE - 0,74 GPD/SF 99.9 /� s oo 530 GPD / 0.74 GPD/SF - 716 S.F. REQUIRED LOT I o PROVIDED: '8 HIGH CAPACITY INFILTRATOR / ED IN f CHAMBERS W/3.5'1 STONE AROUND. A-780 S.F. GENERAL NOTES : 31020 _ S.F. 780 S.F. x 0.74 - 577'GPD I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION � SHELL DRIVEiPARKINe OF THE SEWAGE DISPOSAL SYSTEM ONLY. , S O.I,L TEST PIT DA T A RA/( "FOR BENCH MARKS P£AstoNf �oc °A INDICATES l ND I CA TES 2, VERTICAL DATUM IS ASSUMED. tl ••-- COBeIE _ PERCOLATION ---- OBSERVED SEL. SEE SITE PLAN, 10. P PONE Epa TEST = GROUNDWATER PfA9TOH£/AR90R LANTE;q Ilya 3 ALL CONSTRUCTION METHODS AND MATERIALS AND - Kalt eox TP #1 MAINTENANCE_ OF THE SEPTIC SYSTE6. SHALL Ial�1 '`�'-- HOP CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL \� ' HORIZON TEXTURE COLOR �\ � 0' 100.2 / LOAMY IOYR 'BOARD OF HEALTH REGULATIONS... 4 � � A SAND !p• 99.4 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER AS SUBJECT To VEHICULAR TRAFFIC OR GREATER �, SEPT SAL I� \ ARE sEPri,c TANK SANDLOAMY 4/6R THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- D-Box,; +101.3 �H,yousfi � � STANDING H-20 WHEEL LOADS 24 ......................................... 96.2 02. �-��FNcE 4 v Ug C I MED-COARSE IOYR .. F 3�. 5, ALL SEWER PIPE SHALL BE SCHEDULE 40 OR V SAND S/8 APPROVED EQUAL. O h ti `dp E�/ sTiHa 6. SEPTIC TANK'AND D'-BOX ,SHALL BE REINFORCED h e HIaH CAPACITY 4 I �, I � �FE eErRO„, �� . AV l s INFILTRATOR CHAMSERB 48 t- PRECAST CONCRETE AND WATERTIGHT. ` ti W/s.s's STONE AROUND BM CORNER BH �-IO2.93 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE'. -- 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. �\ FOR LOCATION OF UNDERGROUND UTILITIES. l 02.3 [,� NO WATER 102.E 120' 90,2 9. EXISTING CESSPOOL TO BE PUMPED DRY AND sy� o CKF ED ''` b DATE: MAY 18. 7999 BA ILL /� \ SOP o TEST BY: STEPHEN HAAS c, WITNESSED BY: DONNA MIORANDI PERC RATE: l 2 MIN/INCH JHED \ �.. .. ^ \ DOGWOOD TREE CHERRY Jrlk apt r, z/ ice" /t2`7 Atk J • :oy S E-P T C S Y �S T EM DE /CRAB APPLE 1 :o 1 ' 12•�oAK 2 ,71 f? / /VE S TRE'E" T MAP 228 . PARCEL / 49 ,• I a g i I 1 CHERRr f ou i SA R N T, L l CE/V T E-R 1•' l L L E > 1 10. OAK ,K \\ '� , r PRERAR2FD FOR LONG P F TWO PURPLE PLUMS I PI E TR !.:• 1 APPLE TREE a- ,/ ' y SCALE / 20 A UG(JS T 6 1999 \ ••., /1 +AT APPLE TREE 1 � • �` OCU •y � .9 , o , .... ........I................. ACL__ E SUFRVEY I NG I NC a auY WIRE : .......... A .• � � SHRUBS �0 r 923 R o u-t Q 6 A S,Op. �� HrD SPINDLE R =, Y co r rno u t h p'o r t MA . 02675 t 2 N 79.4q^ -'�- 5 0 8 3 6 2--8' 1 3 2 ( 508 ) 4 32---5333- .: 0 : 10 0 40 - =DRN. LOCUS MAP 2 JOB NO. 99 38FIELD, CFW/EEK CALC, SAH/CFW CHECK CFW SAH