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HomeMy WebLinkAbout0464 PRINCE HINCKLEY ROAD - Health 464 rMISUE KEEY CENTERVILLE A i r Commonwealth of Massachusetts Title 5 Official Inspection Form f.. Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments ,`, :2. 464 Prince Hinckley Road, Centerville, MAC M j Property Address IN., Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name r. information is t= required for every Centerville MA 02632 5/31/2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Imng out forms A. Genera1 .1 nformation ��� 1 -3© t7 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Joseph M Martins use the return Name of Inspector key. Accu Sepcheck Comp Company Name 17 Northside Dr Company Address few South Dennis MA 02660 City(rown State Zip Code 508-385-5891 SI 147 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 6/11/2018 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 pe orm 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 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 5 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 page. Cityfrown 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: CONTINUE W REGULAR MAINTENANCE PUMPING - ESTIMATED DUE IN 1 YEAR, 2019. B) System Conditionally Passes: ❑ One or more system components/nhh onditional Pass"section need to be replaced or repaired. The system, of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not d ND)for the following statements. If"not determined," please explain. The septic tank is metal and over20 yeptic tank(whether metal or not) is structurally unsound, exhibits substantial infiltr n or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is r faced with a complying septic tank as approved by the Board of Health. *A metal septic tank will ss inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating at the tank is less than 20 years old is available. ❑ Y ❑ ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is Centerville MA 02632 5/31/2018 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board o Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water I el in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or even distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ ❑ N ❑ ND (Explain below): ❑ obstruction is removed Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replac ❑ Y ❑ N ❑ ND (Explain below): AW ❑ The syste/je(s) ping more than 4 times a year due to broken or obstructed pipe(s). The system wiln if(with approval of the Board of Health): ❑ br replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ oboved ❑ Y ❑ N ❑ ND(Explain below): C) urther 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '( 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 page. Citylrown 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 publ' ealth, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and t SAS is within 100 feet of a surface water supply or tributary to a surface water suppl . ❑ The system has a septic tank and SAS and the SAS is within a one 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is w' in 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is ss 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 anal y s, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no er 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 El ® 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 1/day flow t5ins-3/13 Title 5 Official Inspection Forth: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 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 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 rve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" a of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 40 eet of a surface drinking water supply ❑ ❑ the system is w In 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system i located in a nitrogen sensitive area (Interim Wellhead Protection Area—I A)or a mapped Zone II of a public water supply well If you have answered"ye to any question in Section E the system is considered a significant threat, or answered"yes" in S ction D above the large system has failed. The owner or operator of any large system considered significant threat under Section E or failed under Section D shall upgrade the system in accord ce with 310 CMR 15.304. The system owner should contact the appropriate regional office the Department. t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts 4 u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 page. Citylrown 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): 2 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 u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM , 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 GALLON SEPTIC TANK, DISTRIBUTION BOX, 4 INFILTRATORS W STONE IN A 11'X38'X0.75' STONE VOLUME. Number of current residents: 2 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 years usage(gpd)): 502 Detail: 2017: 186,000 G 2016: 181,000 G ; LAWN IRRIGATION =YES Sump pump? / ❑ Yes ® No Last date of occupancy: PRESENTLYDate Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., et . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ❑ Yes ❑ No Non-sanitary waste discharged the Title 5 system? ❑ Yes ❑ No Water meter readings, if av able: t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 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: PUMPED 6/13/2017 PER OWNER RECEIPT 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, 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 19 YEARS. PER BARNSTABLE HEALTH DEPT. INSTALLED IN 1999. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO LEAKS Septic Tank(locate on site plan): Depth below grade: 1 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: APP 10X6X5 1500 G Sludge depth: 5" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong 8r Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is Centerville MA 02632 5/31/2018 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 29" Scum thickness 1.51. Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? CORETAKER Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): HAS PVC INLET TEE, HAS PVC OUTLET TEE. LIQUID LEVEL IS 48"AT OUTLET INVERT. NO EVIDENCE OF LEAKAGE. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: El ❑ metal Iberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of s/to tee or baffle Distance from 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle conditio , structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped a me of inspection) (locate on site plan): Depth below grade: N/A Material of construction: [Iconcrete Elmetal ❑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 st pumping: Date Com ents (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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong& Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 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 AT INVERTS 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.): DBOX IS IN GOOD CONDITION . ONE PIPE IN AND 2 PIPES OUT. FLOW DISTRIBUTION IS EVEN. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: ❑ Yes ElNo* Comments (note condition of pump chamber, dition of pumps and appurtenances, etc.): N/A *If pumps or alarms re not in working order, system is a conditional pass. Soil Absorptio System (SAS) (locate on site plan, excavation not required): If SAS not cated, 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 464 Prince Hinckley Road Centerville MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): INFILTRATORS, H-20 LOAD BEARING W 4' STONE AROUND THEM. GRADE TO SAS BOTTOM IS 4.5'. Cesspools (cesspool must be pum ped as part of Inspection) cate 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 groundwat Inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is MA ill t enerve 02632 5/31/2018 required for every C II page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condi ' n of vegetation, etc.): Privy (locate on site plan)/of Materials of construction: Dimensions Depth of solids Comments (note conditiore, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts N _ _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments „M 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 page. Cityrrown 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 W II L01j, A B 0i 1 2- Jio.s` A 1 70' BZ: • A Z =3-11 83 = n , t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owners Name information is required for every Centerville MA 02632 5/31/2018 page. Citylrown 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: 11.7' FROM GRADE feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: BARNSTABLE GROUNDWATER MAP ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: FRIMPTER You must describe how you established the high ground water elevation: SIT IS 44'ASL. GRADE TO SAS BOTTOM IS 4.5'. SOIL IS CLEAN AND STONE IS CLEAN . NO PONDING. BARNSTABE GROUNDWATER CONTOUR FOR 6/1992 IS <30 ASL WITH AN ADJUSTMENT FOR SDW 252 ZONE B AT 2.3'. SEPARATION MATH: 44-(4.5 +30+2.3)=7.2 Before filing this Inspection Report, please see Report Completeness Checklist on next page. L15ins3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 464 Prince Hinckley Road, Centerville, MA Property Address Kweku Ampong & Lauren Weldon 464 Prince Hinckley Road Owner Owner's Name information is required for every Centerville MA 02632 5/31/2018 page. Cityrrown 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 7'' d f Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 = March 30, 2016 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, 94 / vvvv��66V use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number ti B. Certification o 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 AA April 1, 2016 Inspectors Siinatu-04 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 , 01# VS Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 page. CityFrown 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: The observations noted on this report only represent the condition of the system on the day of inspection March 30, 2016 and does not guarantee the continued operation of the system. 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 ;M 464 Prince Hinckley Road Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 - page. Citylfown 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 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 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 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 - 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. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 464 Prince Hinckley Road Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 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 ® ❑ 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 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is Centerville MA 02664 March 30 2016 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 years usage (gpd)): Yes Detail: 2014; 140,000 gallons and 2015;154,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 page. Citylfown 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: Board of Health 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, 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): l5ins•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 ^M 464 Prince Hinckley Road Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance issued 8/19/1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 10 inches 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: 1500 Typical Sludge depth: 4" l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 page. Cityrrown 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 36 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. Tank is 10 inches below grade. 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 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 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30 2016 page. CityrFown 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: 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 page. Citylrown 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 Effluent level with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of solids carry over. 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: No inspection port in infilitrators due to age of the installation. t5ins-3/13 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 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑" 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.): 4 infiltrators with 4'of stone around. Probed soil and no ponding observed. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 page. Cityrrown 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.): 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts L r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is Centerville MA 02664 March 30 2016 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 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 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 page. Cityfrown 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: 16' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater Contour Map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 464 Prince Hinckley Road, Centerville Property Address J Johnson Realty Trust Owner Owner's Name information is required for every Centerville MA 02664 March 30, 2016 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 Assessing As-Built Cards Page 1 of 2 pub �OWN OF BARNSTABLE �LOCATION Ib43og t- r,\�cre gindl�SEWAGE N ?q• 19/ VILLAGE Cf_V%+fU 4 -e- r -_ ASSESSOR'S MAP&LOT 17n. 1 h'1 INSTALLER'S NAME&PHONE NO. ,,-Cl c. 9ftpd2A '67g4_O l 6 k SEPTIC TANK CAPACITY I_� = 41 LEACHING FACILITY:(type) w l-I �4Zd(sizej-�J-I'y,j,I a__!� NO.OF BEDROOMS 3 BUILDER OR OWNER C61e PERMrrDATE: 4 '7. 9 9 COMPLIANCE DATE: % 1 [ cli 9 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by D PK_t Ate' w/N I Ot St6wx- WE 3ZI-(p a' BL3oI-tot, A(s P)F,41 U 33� �G Z9 http://www.townofbamstable.us/Assessing/HMdl splay.asp?rnappar=I 70167&seq=l 3/30/2016 AV"'^Cle OWN OF BARNSTABLE G •Cr LOCATION '30 .SEWAGE # q 9'/ VILLAGE C'Cy1+ef1J, 1Le- ASSESSOR'S MAP & LOT /7n. 167 INSTALLER'S NAME&PHONE NO.C - Sc#A—O SEPTIC TANK CAPACITY I SOO '1►4 LEACHING FACILITY: (type) 11 X 3 W I I NO.OF BEDROOMS-3 BUILDER OR OWNER PERMTTDATE: � - 7 f I I COMPLIANCE DATE: 9 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 r A PTC_ (3� Ll pcw f w /q ot� Std R6 3 Z'4 a 6CI30I- pi 41 9 No.. 9/Q , L FEE Y COMMONWEALTH Of MASSACHUSETTS Board of Health, 13AIW cJ I A OLO, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Constructg Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location Owner's Name () Map/Parcel# t -7 0 I G-7 AW Address 2 L�J Lot# 3 L Telephone# '71j6 "I6 Installer's Name�e� � Designer's Name A AIKi�e SGJQd�� Address Address l,o J2 0 Telephone# Telephone# LY 2 e Type of Building s 1 N C- F F A Lot Size I S/O 7s 7 sq.ft. Dwelling-No.of Bedrooms 2 Garbage grinder Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow ,�Q Design flow provided K? gpd Plan: Date /G�29 Number of sheets Revision Date Title S/�G f s!ii✓ � }�(�}� ®R /'�A'�L.l� �j• /�yl C"s/t/�/� Description of Soil(s) LO AO-V J4AJQ "jr- ' -,L Q 1.12'v^1 D 5AA1,0 Soil Evaluator Form No. Name of Soil Evaluator W1M.L Date of Evaluation l D 2J DESCRIPTION OF REPAIRS OR ALTERATIONS The undersign a ees t the a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree o not to ce e t in operatio til a Certificate jqCompliance has been issued by the Board of Health. Signed Date FEE COMMONWEALTH Of MASSACHUSETTS ./ n- / P Board of Health1�2(�, � / ,Jc T 1�IS L.C. , mA, APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Co `ruct(K Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location t� - t ` -� Owner's Name G-V Y / Map/Parcel# ( 7 0 1 C 7 Address 2 ( C Ca.�-���� L Lot# 3 Cfi L 1�+ Telephone# -7-7 l - G -1 C- Installer's Name �� { _ Designer's Name `��f��(r� S t.,j2✓G_, Address Address Telephone# , 'r s� Telephone# y z — vca Type of Building �> ( i�r(9-( � +� tr ►=A Lot Size l S, V7 sq.ft.: Dwelling-No.of Bedrooms C>12 1M Garbage grin(jer/k.) Other-Type of Building - No.of ers`oils g p Showers ( ),Cafeteria ( ) Other Fixtures -"' qt.. Design Flow (min.required) U gpd Calculated design flow ?5? / /. Designflow provided TV I. gpd Plan: Date �< Number of sheets Revision Date �. Title ra I l.�r IQ ©AL t4A kZog-r- Description of Soil(,) L�-�" L-0 A w%V 4 rAn.sli �'' _,4 ` r-A r S A,,%d -' 2.t`,` .-/3 a a r4,4 D 5-1n1D 6yeW,4y � Soil Evaluator Form No. Name of Soil Evaluator GIN,.L t+abc--- eta Date of Evaluation t (P/2.1 I cj 7 DESCRIPTION OF REPAIRS,ORALTERATIONS The un&rsigne ag r'ees to t the bo/�'e described Individual Sewage Disposal System in accordance with the-provisions'of TITLE 5 and I further agrees on to ace the ton in operaho til a Certificate plCompliance has been issued by the Board of Health. Signed / Date F 'i .'. » �7 J,� V L19 No. 4 T FEE Board of Health, A '►�,�r't"fA i CERTIFICATE OF COMPLIANCE Description`of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;;,.Constructed��,Repaired ( ),Upgraded ( ),Abandoned ( ) by: �/ l // at has been installed in accordance with the provisions of 31 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) Installer Designer: Inspector: � Date: i The issuance of this permit shall not be construed as a guarantee tha'Cthe system will function as designed. No. FEE COMMONWEALTH OF MASSAC14USETTS Board of Health, 9426,19 A / , Nm DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( Repair( ) Upgrade( ) andon( ) an individual sewage disposal system at &"�&_> e described in the application for Disposal System Construction Permit No. s �/ ated '' Provided: Construction shall be completed within three years of the date of this vermit. All local conditions must be met. Form 1255 Rev_.5/96 A.M.Sulkin Co.Boston,MA Date �� - jlioard of Health e I TOWN OF BARNSTABLE G ,r LOCATION '300( .SEWAGE # VILLAG ASSESSOR'S MAP & LOT 17n. 1k-2 _ INSTALLER'S NAME&PHONE NO.�cS1f'L � �}- Sct,�—O l 0 SEPTIC TANK CAPACITY --I Sao �1►4 LEACHING FACILITY: r=— size ���t. NO. OF BEDROOMS BUELDER OR OWNER Crs It PERMTTDATE: 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 � 1,Z.')rd ��Ih �rl l 11°) J�s t -E✓rz tl BOARD OF HEALTH DEED RESTRICTION The undersigned Harold B. McShane, being the owner of a parcel of land in Barnstable (Centerville), Barnstable County, Massachusetts shown as Lot 309 on a plan of land recorded in Plan Book 306, Pages 17 through 24 and more particularly described in a deed dated November 4, 1997 and recorded at Book 11045, Page 86 at the"Barnstable County Registry of Deeds hereby agrees to a restriction which shall run with the.land referenced herein which limits the number of bedrooms in any house to be constructed on the premises to a maximum of two. WITNESS my hand and seal this ! 6 day of June, 1999. • Harold B. Mc hane COMMONWEALTH OF MASSACHUSETTS Barnstable, SS. G/9 Then personally appeared the above named Harold B. McShane and ackowledged the foregoing instrument to be his free act and deed before me. Notary Public: My Commission Expires: VARIANCE REQUIRED. f � o BOARD OF HEALTH PART VII .5ECT10N 8tn TO DISCHARGE 330 G/D ON A 15,087 S.F. LOT -- FROM 330 CID PER ACRE HSE. _ REGULATION. 4 ° I I I m o =___ = LO T 308 LOc CA7rH BAS LOT b 58413'S8"� EASEMENT 255 — — — — —EAS 148 3' t4lENT h t — — �[ _ _ DRAINAGE o 4 ~'� \ 1pp.y v goUT5 W I a k I / / _ _ — _ ti _ _ EASEMENT O e� I 52.3' \ - \ 1 LOCUS - �_ 1pp.p PROP. ; PROPOSED ASSESSORS MAP 170 I I I o DRIVE o GARAGE o \ PLAN REF. 386193 4 1 l 7 99.5 13—� _ _ 99.5 0 VERLA Y DISTRICT GP o� 21.7 — �- - � FLOOD ZONE.• "C" P. RES. ZONE: "RC" I cn 4 � SETBACKS.• t Cl FRONT 20' T o I REAR 10 r W I � -c � \ ® I N iz . _ �s' SITE & SEPTIC PLAN o_`C ` I 16' 2, 0 0 0 12'..... IL 0' o I I \ 6 o'PROPOSED 6 3' 10• O ~ , PROJECT L OCA TION \ HOUSE _ . - � � mna LOT 309 e.3'w 67 LOT PRINCE HINCKLEY RD. LOT 309 .- � �� ASSESSORS LOT 1 AREA=15,087f SF ,254 CENTER VILLE, MA. 37.5 3z o, 1,� '. ,. APPLICANT.• G UY COLETTI 130. 55 I� YANKEE SUR I/EY CONSUL TAN TS wit I N83'23 51 E /' LOT 310 A of Mess P. O. BOX 265 I z� "ny UNIT 1, 40B INDUSTRY ROAD g WILLIAlvI " MARSTONS MILLS, MA. 02648 LIEBERMAN , +' BENCHMARK \ _ --_____ - '11 PH.(508)428-0055 - FAX(508)420-5553 100,0 TAG BOLT \ �I _ __ .o p No. 239lk ON (ASSUMED)HYDRANT ` \ _ = _ ---____- �oF`rs ONAL E SCALE.• 1'=20' DA TE.• MA Y 25, 1999 = HSE. - - _ REV JUNE IA 1999 REV.• JOB NO. 51965C SHEET 1 OF 2 _100,5' TOP OF FOUNDATION 20' MIN. ? 10' MIN. CONCRETE COVERS 4' SCHEDULE 40 P. VC MIN. PI7rH 114" PER FT 2"LA YER OF EL= 99.5' / I I 1/8'! 2" CONCRETE COVER WASHED STONE !§" MAX / / i i i i i EL=99.0' Z. 4" SCEDULE 40 PVC PIPE ' (OR EQUAL MINIMUM CLEAN SAND 36" Z. PF CH 114 PER FT MAX 16' FLOW LINE EL--97.6 INVERT 1 VN 14" 12' 0 0 0 EL.=98 2 INVERT LEVEL 6 0 °`b _ o 0 e INVERT`FFLE _ 97 55' INVERT 6 SUM 0 Co ° ° =95.8 10 INVERT � EL.- _ 97 25' ° ° EL.= 97 B EL.-__-__ EL.=97 41 4' 1 (7V BE PLACED ON FIRM BASE) DISTRIBUTION INVERT ZZ MECHANICALLY COMPACTED OR 6" OF S70NE BOX EL.__9_6.8" ll'x3B'xi, __1 5-QQ__GALLONS TO BE WATER TESTED TRENCH FORMATION rid SEPTIC TANK IF MORE THAN ONE OUTLET PLACE ON 6" S719NE V4" To S NE" SOIL ABSORPTION PROFILE 0 F WASHED SYSTEM (SAS SEWAGE DISPOSAL SYSTEM NOT TO SCALE NO OBSERVED WATER TABLE (10121197) ELEV.=_87 OBSERVATION HOLE I ELEV.=_98_ GROUNWATER PROTECTION PERCOLATION RATE _ MIN./ INCH AT 60�9B"INCHES OBSERVATION HOLE 2 ELEV.= 99 0 VERLA Y DISTRICT "GP" DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH JHORIZ TEXTURE COLOR MOTT. OTHER 1� 0"-8" AP LOAMY SAND IOYR3/2 NONE GRANULAR 0.•_8•+ AP LOAMY SANDY 10YR312 NONE GRANULAR 8"-24" B SAND 10YR518 NONE I MED 8"_24" B SAND 10YR518 NONE MED 1 24"-132" Cl SAND 10YR718 NONE MGRA EL SAND 24"-132" Cl SAND IOYR718 NONE MED SAND GENERAL NOTES W/GRAVEL 1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. NO WATER NO WATER TITLE 5 AND THE TOWN OF _ NSL49LE____ RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. SOIL TEST " °F"'gssq 2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO DATE OF SOIL TEST 10121/97 SOIL TEST DONE BY WILLIAM MEBERMAN RRE. WITHIN 6 OF FINISHED GRADE, OTHERS WITHIN 12 WITNESSED BY: JERRY DUNNING c WILLIAM M 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF LIEBERMAN WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN DESIGN CALCULATIONS.• No. 239/1 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE 2 ��0/s T f- USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. NUMBER OF BEDROOMS . . . . . . . . ' s� AL EN 4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL GARBAGE DISPOSAL . • • • • . . . NO 4 STONE SIDES Ai'✓D ENDS DAY BE MORTERED IN PLACE. SIDE LOAD 4 INFILYRA TORS WITH TOTAL ESTIMATED FLOW 220 GAL/ ,L 5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH- ( 110__CAL/BR./DAY x __Z__ BR.) ' DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO - 11'X 38'X I' REQUIRED SEPTIC TANK CAPACITY 1500 GAL OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. SOIL CLASSIFICATION . . . . . . . . 1 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR DESIGN PERCOLATION RATE . . . . . < 5 MIN./IN. IS TO CALL "DIG— SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS EFFLUENT LOADING RATE • 74 GAL/DAY/S.F. PRIOR TO COMMENCING WORK ON SITE. 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS LEACHING CAPACITY (AREA X RATE) 381 GAL/DAY SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. RESERVE LEACHING CAPACITY . 381 GAL/DAY •+ +• PERC TEST � 90,2� 8) PARCEL IS IN FLOOD ZONE___C (38xllx. 74)+(38+38+11+11x. 74) 9) LOT IS SHOWN ON ASSESSORS MAP _170 AS PARCEL _ 167 JOB NUMBER _ ---- SHEET 2 OF 2