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Home My WebLink About0252 PRINCE HINCKLEY ROAD - Health 252 PRINCE HINCKLEY RD., CENTERVILLE Commonwealth of Massachusetts /-7/ -/ �- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessmentsy 252 Prince Hinckley Road 1M .I Property Address h*,i Harvey Rubinovitz _;� Owner Owner's Name »�+ information is Centerville Ma 02632 10-17-17 required for every � page. City/Town State Zip Code Date of Inspection 0 .,0 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information c$�.# /a(oS? on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation rQ Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI 13747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-17-17 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 approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �jj a V s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cwM 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old`` or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cM 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Prince Hinckley Road M Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. CityTTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No 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 ears usage d See below 9 ( Y 9 (gp ))� Detail: 2016-77,000gallons 2015-58,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: September Date Commercial/industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. CityfT'own State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Second d-box and SAS added in 1998 to existing d-box and tank Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 6 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): I Septic Tank(locate on site plan): Depth below grade: 1'6" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallons Sludge depth: 4 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is Centerville Ma 02632 10-17-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 /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.).- System has 2 d-boxes in place. The first d-box was not removed when the new SAS was added in 1998. Both are in working order at this time with liquid levels equal to outlet inverts. 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.): NA * 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): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M10 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: rs ® leaching trenches number, length: g'x Infiltratoltrato ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. The leach field was dry and did not show any signs of past back up. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privylocate on site plan): ( p ) Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is Centerville Ma 02632 10-17-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i REAR A B Al-24' 131-48'6" A2-30' 132-43' A3-33' 133-39' A4-35' 134-40' 4 9'X31'x2' t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ar ® Shallow wells Estimated depth to high ground water: >18'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: 9-4-98 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 252 Prince Hinckley Road Property Address Harvey Rubinovitz Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. CityTrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Zg. TOWN OF BARNSTABLE Y� LOCATION SEWAGE # y 5'Y76 VILLAGE A SESSOR'S MAP &LOT 17 f -/q 7 INSTALLER'S NAME&PHONE NO.- " SEPTIC TANK CAPACITY Z �� LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER �— PERMITDATE: Qf c7� COMPLIANCE PATE: 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 A � within 300 feet of leaching facility) � Feet Furnished by } �r l 33 G =. 31 x 2� 4 9� sl �G ( 1 ( °7 Lo� 6 No. Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Rppltca.tton for Mt!5poe;al *potem Congtructton Vermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components L cati ddress pP-Lot NoL 9 Owner's Name,Address and Tel.No. Assessor's Map/Parcel ! / Installer's ame Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 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 Nature o_f airs or Alter ti s(A swer when applicable) Date last inspected: Agreement: The undersigned agrees to nsur he construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Titl 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued thi Bo d of Hea _ Signed Date Application Approved by _ Date 9 Application Disapproved for the fol ing reasons Permit No. 917-IS-76 Date Issued - -9 f Z � U 0 -e Y5 e fix_3_ >� t_ TOWN OF BARNSTABLE LOCATION SEWAGE # 7� VILLAGE A SESSOR'S MAP & LOT 17 i -/N 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �7 LEACHING FACILITY: (type) (six NO. OF BEDROOMS BUILDER OR OWNER �. PERMTTDATE: —7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility --el- y Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) v Furnished by No. / Q S 7`� 4:__-4%, - Fee ��► / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pplication for Digomf *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Lo ti dress or4,ot No; ,! Owner's Name,Address and Tel.No. Assessor'sMap/Parcel f( �`-- 1 141 Installer's ame,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 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 R Nature ofq�airs or Alter i s(A saver when applicable) Date last inspected: Agreement: The undersigned agrees to nsure a construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued�thBo d oeaf H _ Signed 6 Date .. Application Approved by - Date Application Disapproved for'the foll isng reasons Permit No. 7 Date Issued 9 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFX that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandon )by / C -- at s been constructed in accordance with the provisions�°f Title 5 and the for Disposal System Construction Permit No. 9�'S_76 dated Installer T!- /h!LM Designer The issuance of this pe shall not be construed as a guarantee that the system\wilI function as designed. Date 7) -U Y, Inspector \l t -- g Fee --- -------------------------- --- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS 1witpo.5al *pgtem Construction Permit Permission is hereby grant d to Cons}( .)Repair( UTgrad )Aba o ( ) _— System located at .:? t�" 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 rmit, Date: %r 9p' Approved by .. i 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed y me dated 3 concerning the property located at A "eets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) _57� SIGNED (�'�-� DATE: J LICENSED S PT1C SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cent (06 LO C A T ION SEWAGE PERMIT NO. lot 2„90 Pri nap 'Hinckley Rd. 79'-529 VILLAGE Centerville, MA. INSTA LLER'S NAME i ADDRESS Alfred Fuller 9915 C"Ult Rd. Marstons Mills, MA. e U I L D E R OR OWNER Alan E. Small, Inc. Box 5316 Centerville, MA. DA T E PERMIT ISSUED 8-10-79 DAT E COMPLIANCE ISSUED Q e2�� 7f �r o i' �� 3�' �gd G�r No................_....... Fxs..... ................... THE COMMONWEALTH OF MASSACHUSETTS �^ BOARD F H ALTH /.'.. ..........OF..... ........... •...............•-••----•------....------.........._.......... Appliration for lbpvoa1 Works Tnnstrudinn tirrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys - , at: ...... ....Z;7 �/` ....... ZQ... ..... -•..... pp Location-IAd ess a f J Owner ddress a �, ...... ...._.. - ........ ...__. ... ..... Installer p� Address d Type of uilding Size Lot...._.... __ � a-•--.Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( r a Other—Type of Building ............................ No: of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow........... '___gallons per person per day. Total daily flow-----------3... : .................gallons. WSeptic Tank—Liquid capacity/,10.'_Plg_. allons Length................ Width................ Diameter.................Depth................ x Disposal Trench—No. .................... Width.--- ._.......... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------I----------- Diameter........ ..... Depth below in le t........�...__.. Total leaching area..Z.V..l...sq. ft. Z Other Distribution box ( ) Dosing tank ) D� faC/� _ q-S 7P- 1'4 Percolation Test Results Performed b -_ryrye�,. Y F�•- „JCt.�t_ .... Date - �. e 14 14 Test Pit No. 1................minutes per inch Depth o Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil----.�..... �. � -a�..- -- ----- -- --- �., ..... ......W .40M #-..k 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 iiT12 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the board of ealth. /(� ? Signe ..... _ ....--jj I ( / -----.-•................... , . D ...... tl Application Approved By...... L - . ---•----.- .. Date Application Disapproved for the following reasons:----•------------------•---•-•-----. ......•-----------------------------•- - •-- •--•------•-••--------------------------- --------•H-------•-----------------•------•-•--- �/ Permit No......................................................... Issued------( DatDate a L 07f No--- FEi3............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........._OF..../"D ........................ Appliration for Uhipasal WorkS Tonstrurtion Prrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Sy;sr at: ............. .... .. ................... I-A. "P .............................. Location A ess No _��Adr............ . ................................ '0;n�r k c"" . ............4 . ...................................... ...................... ........ Installer Address e ot...Iz 6 Type of Building S12: . .........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—T e of Buildin g ............................ No, of persons._._...._...._._.__.________ Showers — Cafeteria yp Other fixtures Desi Flow._...._ ..... ansperpersonper da Total dailyflow.......... C,4................. lons. 9 Septic Tank—Liquid capacity/,t4..".gallons Length................ Width................ Diameter__.-............ Depth................ Disposal Trench—No..................... Width.._ ............ Total Length............._...... Total leaching area....................sq. ft. Seepage Pit No......./----------- Diameter.........;0....... Depth below/inlet.......4.�o....... Total leaching area.2..V_./...sq. ft. Other Distribution box Dosing tank. Percolation Test Results Performed by.. ............. Test Pit No. I................minutes per inch Depth IoTest_ Pit.._.__.........__-- Depth to ground water.._._.__............___. 04 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._......_._........._._. ............................... ........*---------------0 ......:...... ------- Description of Soil .. 0 .... ......... . 7.1.1...... ................................ I-ow-po.- ......................................................0----------- -------------------------------------------------- ---------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ................................................................Agreement: .......... f.. ...F ' .............. ........ ..................... I........................................................................... The undersigned, agrees to install the aforedescribed Individual Sewage Disposal'System in accordance with the provisions of TLITIL 5 of the State Sanitary Code— The.undersigned agrees not to place the system in operation until a Certificate of Compliance has'beenAissued by the board of ealth. ----------------------------------------------- ................................ Date Application Approved By...._ �"7— ...... 4� ...1VO Application Disapproved for the following reasons:................................... Date ............................................................................ .......................................................................................................................................................................................................... I Date PermitNo......................................................... Issued:- ..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS,+ BOARD OF HEAI_Tt� ......... ....OF............. . . ..... ................. (9rdifirate of Tantpliattrr TH S -TO TI hat the Individual Sewage Disposal System constructed (1< or RepaQ h .............4.... .............................................................../........ ';ia 4, --- --------*Install ....... 4�4 at---—---- ...... ft) Al.......AA44......... has been installed in accordance with the provisions of T 5 of T e State �"� Code as described in the application for Disposal Works Construction Permit No ............. dated-_-1-:7�F— -1------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY., ................... Insp&tor... . .. ... ..... DATE i.. 7------------ ............... ...... _7 ------- _---77................. THE COMMONWEALTH OF MASSACHUSETTS &71) *77 BOARD O/F3 HEALTH ......;t .. ..OF........./j 0 6-;z ...... 0-d No................. FEE. rk' strudion famit Perffiission ereby granted,...... ..................................................................; to Construct. or,�R*e an I140i ual Sewag'e,DWoskl S st� • ys at No.... Street as shown on the application for Disposal Works Construction P r. No... ........... . ated..F74.:77�............... TI hat vie .......... .... .... ... . ............... ......... Board of Health DATE... ........... -------------------- FORM 1255- HOBBS & WARREN. INC., PUBLISHERS uv GAccs,t-tZr Get q Indt L.:,4 V:Lc>w -- 1 to .4 3 = 33C3 G•P17• � I USA- l.C>OU 4CAL. A ✓ /ALL A GA = ('So S.F. tip St= �c 2.S • �7S G.P.U. � ��+� �''� $c rrmxtl azEA c -ET--. PT� TOTAL T?ESIGIJ = 4SS G.t?D. Tc:>TQ L Dat f FLAW trflGDLd.TIDU G." E �"�U 0lZ tk% 1 I o '4-' f'�" ✓.t� fir, �!t Tor F•N4. �OAvyl �! gpe iuv q1 v r IOao l►N. 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