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HomeMy WebLinkAbout0275 PRINCE HINCKLEY ROAD - Health 275 Prince Hinckley Road Centerville A = 171 - 118 L Town of Barnstable Barnstable Regulatory Services Department A*ACftV p B"NSTABM D 9. � Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1520 0001 2273 3388 May 18, 2016 Sydney Noel 275 Prince Hinckley Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic system located at 275 Prince Hinckley, Centerville, MA was last inspected on April 5,2016,by Michael DiBouno, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Distribution-box is rotted out and needs to be replaced. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. .PER ORDER OF THE BOARD OF HEALTH T o �sc Eean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Conditionally Passes Ltr\275 Prince Hinckley Rd Cent May 2016.doc Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments do, 275 Prince Hinckley Property Address Sidney Noel _ Owner Owner's Name 4'9 information is �v required for every Centerville Ma 02632 4/5/16 s page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in an� way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector key to move.yuut cursor-do not Michael UiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 8 Johns path Company Address S Yarmouth Ma 02664 Citylrown State Zip Code 508-364-9587.. S103522 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 I5]C Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/6116 In pector'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 Commonwealth of Massachusetts ` W Title 5 Official Inspection Form f Subsurface Sewage Disposal,System Form -Not for Voluntary. Assessments 275 Prince Hinckley -Property Address Sidney Noel ., Owner - Owner's Name information is required for every. Centerville.,.., Ma 02632 4/5/16 . page. Cityrrown 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: F ❑; I have not found any,information which indicates.that any,of the,failure.criteria described in 310 �OR 15:.&:3 cr in 310 CaMR 15.304.e r'st �,rly�aiiurr ci te�ia no't."evaluaew aye d indicated below." Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," lease explain. , P P 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 exfiltratio6 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 i 'Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage"Disposal System'Form -Not for Voluntary Assessments .�. _. .-_._275 Prince Hinckley.-_.. __...... Property Address " Sidney-Noel. Owner Owner's Name information is V" '"� °! t' required for every Centerville " ' `' Ma. - 02632 . 4/5/16 page: w.•.• City(fown '. . _ . 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.): ❑ O.bservation of sewage;backup or'break out or high static water level in the distribution box due to broken or obstructed pipes) 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): - Distribution Box is rotted and decayed with roots and needs to be replaced ❑ 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 F , j Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 275 Prince Hinckley _ Property Address _ " Sidney Noel Owner .Owrie*r`s Name Information is Centerville Ma 02632 4/5/16 required for every page. Cityfrown 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-cf a surface water supply or t ibutary to as.u rface watar:sunply. , ❑ 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'fhat 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"x No— , ;; ;-Backup.of,sewage into,faciIity.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 99 P ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Prince Hinckley __...Property Address Sidney Noel Owner Owner's Name information is required for every Centerville Ma.. 02632 4/5/16" .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 ce,sspotil'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 nt system passes if the well,water,analysis, performed rat a DEP certified s + /, 7, .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 riggered. 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,bo.considared a large s:yster:.;the system Must serve a facilitt, :ith.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 '•' '` " _ ` " " ""` W "'the system'is'located in a°nitrogen,sensitive area (Interim Wellhead Protection ❑ ' ',,_ ❑ Area—IWPA)or a mapped Zone ll"of a public'watersupply 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 tKe 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 L 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 . 275 Prince Hinckley , Property Address __ _. _ _ - ---.•____- _ - _. . Sidney Noel Owner , information is 3 "" required for every Centerville :,, - Ma 02632 4/5/16 page. City/Town 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 } ❑ E - 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): 2 DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 330 l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Prince Hinckley Property Address -- -Sidney Noel f" Owner Owner's Name information is required for every Centerville Ma 02632 _ 4/5/16 page. City/Town '. " State Zip Code Date of Inspection D. System Information Description: System contains a 1,000 Gallon septic tank as well as a 1,000 gallon leach pit. Leach pit is still functioning properly at this time. Number of current residents: Vacant 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? . ... .. v ❑ Yes ® No Water meter readings', if available 2 ears usage d 189 GPD 9 ( Y 9 (9p ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ❑ Yes ❑ No Industrial waste ho'ldin 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 Commonwealth of Massachusetts - Title 5 Official Inspection Form w p _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 275 Prince Hinckley _ Property Address Sidney Noel Owner- - Owner's Name ^.,.. information is Centerville Ma 02632 415/16 required for every . • page. CdyfTown State -Zip Code- Date of Inspection D. System Information Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source.of information: None provided. Was system pumped.as..part of the inspection?. -1 „_ ❑ Yes ❑ No If yes, volume pumped: _ .. _ gallons . . _ How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) - ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest --- - - - - -inspection of the I/A system by system operator unde.r:contract:'`( i. ' - ' ❑ Tight tank.Attach a-copy of the DEP approval,.-- v - ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 _ I 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal`System Form - Not'forVoluntary Assessments °�M •,'� 275 Prince Hinckley Address ` .Sidney Noel.. .._ Owner Owner's Name information is regtii�ed for every Centerville Ma_ -. 02632_ 4/5/16 page. City/Town ` State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 37 Years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, Jesting;evidence'of leakage;eto.):,` Septic Tank(locate on site plan): Depth below grade: f et Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age:`JO n- + years I Is age confirmed by'a Certificate'of Compliance?-(attach!a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form p - Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments 275 Prince Hinckley Property Address Sidney Noel .Owner -- Owner's Name information is Centerville , Ma 02632 4/5/1.6 required for every 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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 ofscum.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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 'y 275 Prince Hinckley Property Address Sidney Noel Owner Owner's Name ' information is Centerville required for every ` Ma _ __ 02632 . .4/5/16 .a page. Cltyrrown' 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.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: : Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Prince Hinckley Property Address Sidney Noel Owner_ __. .__ ` Owner's Name information is required for every Centerville Ma 02632 4/5/16 r 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 Rotted and decayed 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.): .•:< -_ 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. -Soil Absorption System (SAS) (locate on site plan, excavation not required):_ If SAS not located, explain why: t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - °°�M ' -275 Prince Hinckley Property Address .Sidney Noel. _ Owner Owner's Name information is required for every Centerville Ma- -- .. 02632 .. . 4/5/16 page. . _ Citylrown State Zip Code Date of Inspection D. System Information (cont.) - Type. ® leaching pits number: 1 ❑ leaching chambers ,.,:. number; ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure; level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids"layer ' Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 275 Prince Hinckley Property Address - Sidney Noel •Owner... Owners Name _... " information is Centerville Ma 02632 4/5/16 required for every ` '•` `"" page. Cityrrown State Zip Code Date of Inspection ' D. System Information (cont.) etc.Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, ): No ponding no break out Privy (locate on site plan): Materials of construction: Dimensions i Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 . ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ GSM 50 275 Prince.Hinckley _ Property Address Sidney Noel Owner Owner's Name information is required for every Centerville _Ma - -___..-02632 4/5/.16 page. Cltylrown' 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 275 Prince Hinckley Property Addfess ` Sidney Noel F Owner Owner's Name information is required for every Centerville Ma 02632 4/5/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft 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: 12/19/78 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: Test hole data indicates NGE at 120" 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 4/20/2016 Assessing As-Built Cards �E S LOCATION _� SEWAGE PERMIT N0. /afi , - J/7 VILLAGE .,., INSTA LLER'S NAME A ADDRESS �Ro'Br- OUR.. . R UILDE`R OR OWNER DATE PERMIT ISSUED DATE C0M►LIANCE ISSUED N / �y W J (_'AU ' P http:/twww.town.barnstable.ma.us/assessing/HMdispiay.asp?mappar=171118&seq=1 1/2 LOCATION EWAGE PERMIT NO. VILLAGE INSTALL R'S NAME i ADDRESS C - BUILDER OR OWNER . n DATE PERMIT ISSUED DATE COMPLIANCE ISSUED I/ ,2_ 7 7 - -- ------- - ------ --- --- - ---- - . ....------------ L 1 1 6140, y I ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 275 Prince Hinckley Property Address Sidney Noel Owner Owner's Name information is required for'every Centerville Ma 02632 4/5/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r� No. ,6 I t o Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYication for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Z11rdividual Components Location Address or Lot No. �� yV_ � Ole 's Name,Address,and Tel.No. 334_�Jq-e Wig �7 ;cvn Assessor'sMap/Parcel 7 — f)$' a/8 vp Rqf/ ,),4d4"U�/��jgV/ z Installer's Name,Address,and Tel.No. a5$I)-)I-?37) Designer's Name,Address,and Tel.No. A Y' l(Y:R J 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(min.required) gpd Design flow provided /( 1 - gpd Plan Date Number of sheets Revision at Title Size of Septic Tank Type of S.A.S. Description of Soil n Nature of Repairs or Alterations(Answer when applicable) Qx 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 Environment a of to plac�thee tem in operation until a Certificate of Compliance has been issued by this Board of He Signed Date 7 �'� le Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �U� (9 Date Issued Lt ' ` No. A611 — / 33 :y e.,• Fee THE COMKOONWEALAk OF MASSACHUSETTS Entered in computer: ,G PUBLIC HEALTH DIVISION - TOWN OF=BARNSTABLE, MASSACHUSETTS Yes 1 ' 2pplitation for Disposal 9)pstrm Construction 3permit t y Application for a Permit to Construct( ) Repair e ) Upgrade( ) Abandon( ) ❑Complete System [?'Individual Components ` Location Address or Lot No. a 05 - Owner's Name,Address,and Tel.No. 33<7 79-6W S Assessor'sMap/Parcel 7 — )& Wit? u,4c �!8/2u�� kJ Un•7- 07;C/ A),4d&ud�,L A46l94--_2 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. N Fyn s4ec-e-1.io/a,Liz c yS i�lUS f if°/ / //� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures AlDesign Flow(min.required) A gpd Design flow provided / Q- gpd r / Plan Date Number of sheets Revision 1}atel Title 'Size of Septic Tank Type of S.A.S. Description of Soil /? Nature of Repairs or Alterations(Answer when applicable) / Qx ' L 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 Environmmeentt"al,Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea Signe Date Application Approved by Date L1c�- Application Disapproved by Date for the following'reasons Permit No. �/ �� Date Issued ? �' d ------------------------------------------------------------------------------------------------------------------ - ------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS P Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( by P30r-+ U -A T7u-,at 0 has'been constructed in accordance with the provisions of Title 5 and the for ' posal System Construction Permit No�L"/3 3 dated "q Installer pp Designer AIM/�- 0—a C4-1 #bedrooms !/U Li- Approved design flow/\ gpd The issuance o this permit shall not be construed as a guarantee that the system will n tion l s desig" d. h Inspector r�(, ---------------------------------7------ ----------------------------- - -------- ----- ------------------- No. 3 _ Fee_ 3 �� THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Vermit Permission is hereby granted to C nstruct( ) Repair( V/J Up xade( ) Abandon( ) System located at 49 i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed ithin three years of the date of thi\s permit Date / Ip Approved, y No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for -Disposal *pstrm Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 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( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when ap.licable ` L ('v v el Date last inspected: G e Agreement: 11 E�ieJ 'If � y S a tn'1R vn2 e&. 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. Signed Date �6 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS i application for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 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( ) Other Type of Building No.of Persons Showers( ).Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when ap licable I / I C In loV U/' Date last inspected: 6 C_ Agreement: j 4;d I S"Inn e vnQ P�ln The undersigned agrees to ensure the construction and maintenance of the afore described=d 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. A//4- Signed Date Application Approved by « Date Application Disapproved by Date for the following reasons Permit No. Date Issued ---------------- I. THE COMMONWEALTH OF MASSACHUSETTS Eq f�� d�40V BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, h that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by � u� at 7 V or,,, R° has been constructed in accordance with the provis n of Titrle�5 and the for �ispossal System Construction Permit No.a P��q`��3 dated V/) A116 Installer G 107 h` C do 4 do f'i-+ Designer N ✓t V'hd f�o n y #bedrooms /J�/} Approved design flow /1/�,d} and The issuance of this permit shall not be construed as a guarantee that the system will(function designed Date �//o (� Inspector ( �, KL --------------------------------------------------------------------------------------------------------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction joermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date Approved by 4/25/2016 Assessing As-Built Cards �� � ... LOCATION _ SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME R ADDRESS OUR R U I L 0 E R OR OWNER �30 � .�3L G�NT�r2 u/� � /�x1•• DATE PERMIT ISSUED - 4 2-r 9'-4e'd - DATE COMPLIANCE ISSUED rh i r i http:/M,ww.town.barnstable.ma.us/assessing[H Mdisplay.asp?m appar=171118&seq=1 1/2 27S LOCATION SWAGE PERMIT NO. VILLAGE �llTdia�P C��Cv ~ INSTALL R'S --./NAME i ADDRESS BUILDER OR OWNER nn - DATE PERMIT. ISSUED DAT E COMPLIANCE ISSUED �� ,2_ ,7f �_ 1 r II , . No.--y--qa — .Fxs............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD O H EA T 0 .........:. - - 2- Appliratiun for Pi.4pos al Worko Tunitrnr#iun thrmit Application is hereby made fora Fermit to Construct ( ) or Repair ( ) an Individual Sew `ge Disposal .............t............. ...._.. .....'/� ............... ............. :r!..: ll.... Location_Address r4.1 ot�No ..... ............................................................... ....................... ......... �y er dr s Installer Address Type of Building Size Lot .........Sq. feet V Dwelling—No. of Bedrooms_____________ ---•-•---.Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures - --•--•--••••-•----------------------------------------------•-••-------------__-_.......-•--_...'-•----------_....... W DesignFlow______.�2___ allons per person per da . Total daily flow..__.___ gal g P P P Y Y �--�•-G2------•............. Ions. WSeptic Tank—Liquid capacity..Q.. ._.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_........._.......... Wi *thn . Total Length._________ Total leaching area____.________..._...sq. ft. Diamei . De th below inlet__ .Seepage Pit No.__ ._l��. _ p iP......._. Total leaching area..�_��.._.sq. ft. z Other Distributi n box ( ) Percolation Test Results Performed b-' _____`_A.w-\b_:ML.Ls___._____ Date a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r r_..._... t f... 0 Description of Soil = U .............................•-•______.....--•-____...._._._._._....:•••-•----------_....----•--------•----------------•-••---••----____---...•-•'-----•••----'--____._.......-----'--•-------•--•----•-- wx •--•------------------------•----•••-•----------•••-----••-•-------•-•---••-•--•-------•-•------•--------------•---------------...•---------••-•-•-------•-----•--------------'--•••--•---........... V 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 L IT .;,,. 5 of the State Sanitary Code—The undersig d further agrees not to place system in operation until a Certificate of Compliance has been • s ed by the r f health. Sign ate....... Application Approved By...... >tYr� � — 7 Date a Application Disapproved for the following reasons:..............................--•-•............................................................................. .......................•----------•---•--.....---------•-•--•----'-•-.....-----••...----'--•-•-------"----------'--•-------._____••----•-•---•------------•••--•--•--•---••••-----•--•--•-----'-•----- �_ 7 // �j ate PermitNo......................................................... Issued......_1...--------•--- ........................ Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA eVj*e t - J. No ... {, THE COMMONWEALTH OF MASSACHUSETTS ,. BOAR® O¢F, HE AI.T 4i PP ' .......... ... ............... ....... y... ...... ......:.. -_-_.a. ......... .._. 011 r N• ppliration for Bi Vo-qat-10ork C at r tr inn.; erutit Application is hereby made for.a Permit to• Construct ( ) or Repair ( ) an Individual Sewage Disposal System at*,--', f r� ur r / F C 41 11 °Vti t ! ��1`� l r°d td G }r _ ....... ... - 1 Location-Address• ,� � ��m'`�.� r jf�r•°r 7.ot No��•r�+.. -,� � .. �if.S........-1... ... 'd.................✓... ...0 KwC:✓'f Y`......... l....F'r �•��. l Owner t r Address r ` •• .�'-,�;;J �✓ - •` =t-�-- ........................................................t a J f. . - --___-_ --- -----•-•-•--•-- ______ - �r (" Installer lAddress .. W a;l, d Type of Building §, #r Size Lot `" __ ........Sq. feet JDwelling—No. of Bedrooms... • No............ of persons Attic ( )showers GarbageCGfet dia V164) 'p.l a Other Type of Building p ( , ) ( ) dOther' fixtures . ----- ------ _... -••••-. •. ••• -• - ---- ................... ' W Design Flow.........." A... gallons per person per day: Total daily flow.............................................� gallons. Septic Tank—Liquid capacitvJi�'L,"..gallons Length ............. Width ...... Diameter__._,___ -- Depth................ r 'Disposal Trench—No ........ Width ...... Total Length Total leaching area...................sq. ft. 'eepage Pit No._ fF?..fig r _. Diamete��'?. __. Depth,below inlet.__........... Total leaching area "_. _.aq. ft. �- mfZ Other Distributio/ box ( ) Dosing nk ( ) tz 00 Percolation Test Results Performed b tI _. t _ _ .' •4j � 4 "''y I:< Date._ ' _ 0� t� � . �a i Y. -- ,. Test Pit No. 1________________minutes per'Inch Depth of Test Pit. _ Depth to.ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit: ............. Depth to,ground water........................ R+' _ -- r� - #� �rY " ,r• x Description of Soil °._... § ° , c ",� `rN' a'�.rc `•• ---- ' U ✓' ----------------------------•---•----------------•- ------......_ - -------- .................................................. U, Nature of Repairs or Alterations—Answer,when applicable �L_ ... > .. 11.1 . V Agreement The undersigned agrees to install the,aforedescribed Individual Sewage:.Disposal System in accordance with the provisions of TIT .;;. .._� `� p 5 of the.State Sanitary Code The undersigned furtl er agrees not-�to'place the system in . operation until a Certificate of Compliance has been issued,by the boardl.of health. I� " . ' Signed { ' _ �� Application Approved BY w ti ,wE C, ---- � Sk.. .,...... ............... .. .. Dateej ,# Application Disapproved for the following reasons.:-- ......................................:.................................... Date PermitNo n..... . .. Issued....................................................... Date THE COMMONWEALTH'OF MASSACHUSETTS BOARD OF HEALTH .. ..t :C 3 `".4 OF.............. ...................................... &rtifiratj ;af T"" It attrr TH AS TOE RTIF ' That the Inu vidual Sew age Disposal System constructed ( or Repaired ( ) b ................................. --- ----- ----• ----- ------ . y. s Installer + b at..: _ ......... € �f _.... _!1._ �d-.E _ ___.t` ..:__f�:�C._ 1_�'°_r___. _-_ .7Sr' y_ _. _A...._ •� yt_ dR. .................... has been installed in'laccordance with the provision,§o TtrT� j of The Stater Sanitary Code as described in the application for Disposal Works Construction Permit No �.._ x ----------- THE, dated "': F ___, � . ..... ......... <- 1 ISSUANCE,,OF,,THIS CERTIFICATE SHALL NOT BE:CONSTRUE® AS A GUARANTEE THAT THE SYSTEM. WILL FUNCTION SATISFACTORY. DATE.............................................................. ----•-------- Inspedor .---•------•--•-•--------•-----. •--- --------••-•-•-----•..........--- THE COMMONWE'ALTHOF MASSAC°HUSETTS '> m, .. BOARD OF HEALTH 1 t No ....- .._. >' FEE . • .. .- - irr�tit X. F -Permission As hereby, ranted...........' --------------- !.,pa !' '3 e g r to Construct�( )..'Or Repalr ( � ) an Indivl ewage��D>sporfy Systei atNO # .......................... Street as shown on the application for Disposal Works Construction PermiNo.................... Dated -9+ _......... 4 'r Board of Health DATE---- -- ---- -------•---- FORM 1255 HOBBS & WARREN INC PUBLISHERS S4 MT ttb 4 Sx S'30 ls.P-V- 'ri-Q�('tG TA*�►k = 33o,, Fro % • 4915 6-P.D. A . �x,�O�,c,.t___PIT - use. looca gal._. �, ;..5✓, c,q*WALL AV•F-A = thy[% S-9- flap Sd't-ro�vt vet,_ sr-, q- his/i cr PT ► .o C-,.Rt7. Ct f%�aat TC>TAL 42S I;..P.D. � T`aVK) '�� �- .�I -roTa t_ GEtCGDL1�TtG�t J C�ATIr : 10 sm IQ' 02 Ly--% J 4Z'+. Sf Tar F�•IA c IOp.O l.oawt � Q dive (noo tkv. `a� S�►aSDiL 4rppEs D.�, IW. G�o.t. 9U�8 INV, TA of W. l 000 {i!"v iNy' IW. CrAL. LsH �AFb� w w WA%►�IBD rr 57osJ� qa�C rizor-'tl.•-..f t_ocATlo" �+�►1' ►��1u.c.cam 11 Lim ►.�© s�A.L�- .�. cn -_ � 1 d© AQ.T t�lp UUdTEiLr. Qt_ t�t...i �T,C=c+tZr��1G� T 14 A.T T N c- o u ar>xm o),� S taa\�l►J N f,t�t�t5►-i r:,w�t't.`tS \V I TcA T►a�: I v s`1►.ice 1,,U°�" �c V G 4 LJ 1 EM a lr 'r' +t;, t213GlS�.i��L? i..A\►.tG SU2�i�..Y��- TtAl5 17t_/>,t.l i !UT L'ASEc7 of ► A•►•1 ►1t:� ti ii•IGlJt.7� A.PPt—I (-_�t'- I--.J-r.tom i tI•.t . . r., t�c.�'t:T�MlwJl-:= t_O"C l_►t.t�;,°.> � l�.t.�A4.1 � �rl ' + _ �v ;e # Z75 LOCATION EWAGE PERMIT NO. 6 X VILLAGE I N S T A ll E R'S NAME i ADDRESS C e U I'l D E R OR - OWNER ��77 DATE PERMIT ISSUED DAT E C0MPLIA 9