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0254 RIVERVIEW LANE - Health
254 RIVERVIEW LANE, CENTERVILLE A= 228.164 UPC 12534 Q No.2-11�53LOR HASTINGS. UN Town of Barnstable Barnstable Regulatory Services Department PjAnmeaC j BARNSPABLE, s p MAS& Public Health Division Q7 i639• ♦0 Q 2100 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO November 3, 2010 Mario &Julia Alagna 254 Riverview Lane Centerville, MA 02632 The Barnstable Health Division has reviewed the documentation submitted regarding the removal of the garbage grinder by a licensed plumber at 254 Riverview Lane, Centerville MA and has determined that the system "Passes"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) PER ORDER O4THE 2BARD OF HEALTH Thomas McKean,R.S.; CHO Agent of the Board of Health 10/25/2010 14:33 7818946572 SUMMA DEV CORP PAGE 01 19/25/2018 at 8 5087750404 BRIGGS HEINC PAGE 0i/82. U'1•f $i Hc1810 I�VV�V� p1tombin i41er<ting Co.,Inc. .Box 538 Cale Irnaco N C..anto ille,Mam. (0632 (508)778 16,(800)433-6"4 ItvM2010 115322 Bill TO Ship To Mario.Algnx Ma►lo Inagua 22 Laurel Road 254 RhMN'aw Imo Westtn,ivlai►s 91 CarNdrvr7le Mass.0203 Please detach top and rcwm with pa We Acre Visa and Mast Card P.O. No. Torn$ prqtd Ouc on towipt . De dpt1011 tity Rate Arrm ,t E O']?12010 Rc!novad d»Ircdnl Prop+kil<hen si NCA W that the mom kitcbcn Pa t looks and da*ttattinn. 1 1/2'PVC P7rrrp with Ow I 16.65 16.65T 1 1/:"INC fliAW65hpr 1 7,05 T.O..T I t/2"PVC Coupling i 6'f0 67orr 1 11""PVC pipe Pot P 2 LM 212" 1 1/2"P\C E►Csvvn 1 1 5.40 in"Tailpiece S.IOT I 1.50 7.50T 4"Hacket Suainnr 1 2y,5x� 29.90T Salvoni&Glue 1.06 3.00T Labor-Mechanic-Chri Richard I„7 98.00 I47,00 �r Tbmk you forynor Dash Subtotal ITHRIVI;NF130DAY4. Rance Chneof f,J%pQr month will Sc a to Alt"unums Halchw Due gal" TeX {8.2$91.� 34,90 Terming p1r1,eie 10 dayli a dA1a all txi(91Ral Rocelllt fHY6104. AAnlial irrnrn le uC1R4i Tallml $230,30 w Ww. 4grandheian.ctrm Payments/Credits $0.00 Balance Due 1230,30 f Town of Barnstable Barnstable Regulatory Services Department j 'lca j swxtvsrnst$. �3� Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO .October 22, 2010 Mario & Julia Alagna 254 Riverview Lane Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 254 Riverview Lane, Centerville MA was last inspected on September 07, 2010,by Ricky L. Wright, 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: 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; garbage grinder must be removed by a licensed plumber. Documentation of removal must be submitted to the Barnstable Health Division. You are ordered to make repairs within one (1) month from the date you receive this notification. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL#70083230000251783388 Documenfl Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 254 Riverview Lane Property Address Mario & Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 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 A. General Informatio � C r filling out forms D � I on the computer, use only the tab 1. Inspector: key to move your cursor-do notWrightS E P 2 d REC�� Rick L. use the return Name of Inspector key. /1 CJ OL B & B Excavation, Inc. 113y l Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 14595 Telephone Number License Number e 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 9/7/10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispos I System•Page 1�W/ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 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: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® 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): At time of inspection all system components appear to be in good shape - leaching was dry but dwelling does have garbage grinder which needs to be approved by Board of Health t5ins-09/08 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 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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-09/08 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 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 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 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. Dwelling has garbage grinder hich must be approved by Board of Health 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 'h day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 page. Cityfrown 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. 1 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•09/08 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 <CGM s 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: July 2010 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.): 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-09/08 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 254 Riverview Lane Property Address Mario & Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 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: 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•09/08 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 254 Riverview Lane Property Address Mario & Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 1/2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: > 20'feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good condition -no sign of leakage Septic Tank(locate on site plan): Depth below grade: 1 1/2' 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: 62"X 62"X 8'6" Sludge depth: no sludge t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum 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.): At time of inspection septic tank appears to be structural) sound - no sign of leakage Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i 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•09/08 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 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 page. City/Town 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.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 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 254 Riverview Lane Property Address Mario & Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): At time of inspection d-box appears to be in good condition -no sign of solids carryover 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 page. Cityffown 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.): At time of inspection leaching appears to be in good condition No sign of ponding or damp soils 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 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-09/08 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 254 Riverview Lane Property Address -- Mario &Julia Alagna Owner Owners Name information is required for every Centerville Ma 02632 9/7/10 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 4 T Fla /1 Act = 33 ' 13l = ► 3 ' A2 r, 41 2' 0 A3 : 53 "33 = ZJ4 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Riverview Lane Property Address Mario & Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 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: > 15'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: pate ® 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 a Commonwealth of Massachusetts A W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 254 Riverview Lane Property Address Mario &Julia Alagna Owner Owner's Name information is required for every Centerville Ma 02632 9/7/10 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 °Ft►,Er Town of Barnstable Barnstable Board of Health ""` Cift * -BARNSTABLE, y MASS. 200 Main Street,Hyannis MA 02601 i639• ♦0 iOlED MA'S A 2007 OFFICE:.508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Junichi Sawayanagi Paul Canniff,D.M.D. BOARD OF HEALTH MEETING MINUTES Tuesday, October 12, 2010 at 3:00 PM Town Hall, Hearing Room, 367 Main Street, Hyannis, MA I. Variance — Septic (Cont.): GRANTED Michael Pimentel, JC Engineering, representing Household Finance ' WITH Corporation II, owner - 41 & 43 Hiramar Road, duplex, Hyannis,' CONDITIONS Map/Parcel 292-012, 0.22 acre lot, several variances request, report of cost estimates in comparison to cost of sewer connection. Sewer hookup would be approximately $62,000 versus $14,000 for a septic.,-.:. repair of the tank itself. The owner would bear the cost of the connection which will allow three houses to hook up. The revised plan presented had a single tank. MA DEP confirmed this is allowed.. ;. because the previous system was a single tank and the property is not increasing its flow rate. The Board voted'to approve the revised plan dated October 1, 2010, with the following conditions: 1) pending a final staff review of the revised plan, 2) a four-. bedroom deed restriction be recorded at the Registry of Deeds, and 3) a proper , copy of the deed restriction is submitted to the Public Health Division. II. Variance — Septic (New): GRANTED Sarah Ojala, Down Cape Engineering, representing Janice Schade, WITH owner— 265 Fifth Avenue, Hyannis, Map/Parcel 245-037, 0.83 acre CONDITIONS parcel, requesting several variances. The Board voted to approve the plan with the following conditions: 1) four bedroom deed restriction, and 2) a proper copy of the deed restriction is submitted to the Public Health Division. III. Modification of Comprehensive Permit for Living Independently Forever, Inc — Chapter 4013: DISCUSSED Review plan to the Zoning Board for owner, Living Independently Forever, Inc. - 550 Lincoln Road Extension, Map/Parcel 272-025, existing affordable housing development "Life at Hyannis", currently j 16 units. The modification seeks to permit a fifth two-story multi- Page 1 of 3 BOH 10/12/10 r Y family building. The building would contain four, one-bedroom apartment style units. Each unit is approximately 705 square feet. The new building will include six on-site parking spaces. Letter to be sent to Planning Board with notation that the dumpsters be properly screened and that the Board whole-heartedly approves the project. IV. Variance — Food (New): APPROVED Temporary Food Event: Susan Nickerson for Cape Cod Commercial Hook Fisherman's Association — Fisherman's Market Cooperative to be held at 3675 Main Street, Barnstable, each Friday from October 15 — November 19, 2010, requesting permission to distribute uncooked seafood. The Board voted to approve the temporary food event._ This.year, the event will occur each Friday from October 15 - November 19; 20'1.0 (5.ind vidual'days).. V. Body Art Establishment-(New): GRANTED Lorna J. Berger, operator, of bodyart business "Great Island Tattoo" .WITH,, . _,(formerly.of West Yarmouth),. proposes to. relocate, at 12 Enterprise.Rd,, CONDITIONS.Unit# 5,.Hyannis. The Board voted to approve a body art establishment license for Great Island..: Tattoo subject to approval by the Public Health Division after a final inspection is satisfactorily completed; x r V1. B.o y.Art Practitio (N ner ew): i :,, , GRAN TED �A. Lorna J..Berger-Proposes,to practice at a body art business at a A WITHOUT new facility, Great Island Tattoo, proposed at 12 Enterprise Rd, Unit CONDITIONS # 5, Hyannis. The Board voted to approve a body art practitioner license for Lorna J. Berger. GRANTED B. Kenneth W. Tetrault - Proposes to practice at a body art business at WITH a new facility, Great Island Tattoo, proposed at 12 Enterprise Rd, CONDITIONS Unit# 5, Hyannis. The Board voted to approve a body art practitioner license for Kenneth Tetrault pending the satisfactory completion of contacting the references. VII. Variance — Body Art Practictioner (New): GRANTED A. Lacie E. Sasville - Proposes to practice at a body art business at WITH a new facility, Great Island Tattoo, proposed at 12 Enterprise Rd, CONDITIONS Unit# 5, Hyannis., Page 2 of 3 BOH 10/12/10 The Board voted to approve a body art practitioner license for Lacie Sasville pending the validation of her work experience in Middleboro and pending the satisfactory completion of contacting the references. GRANTED B. Ahnastasia Jones - Proposes to operate and practice at a body WITH art business at a new facility, Great Island Tattoo, proposed at 12 CONDITIONS Enterprise Rd, Unit# 5, Hyannis. The Board voted to approve a body art practitioner license for Ahnastasia Jones pending the satisfactory completion of contacting the references. Vill. Use of foam at the demolition of Sandy Neck's old bathhouse. Withrdrawn. .No known environmental issues with the:use of foam. ADDICTION: IX: Variance — Food (New): "GRANTED t ,,.Tem,porary Food'Event:,.March of the.Horri.bles — Parade and.,'.Town Green.food event-from 12-:000m —4:00 pm on Sunday, October 24, 2010. ,.The Board,voted to approve-the tern poraryfood.-event. ; X. Comments / Other: 1) :Tight Tank,Project. Dr.`,Canniff will be in to review the project. ?"> 2) Ur:'Canniff asked Mr:`McKean to contacf the Falmouth Board'..of Health to .. '. ..`+ request a copy-of any studies performed on health issues concerning wind turbines. If any other towns in vicinity have similar reports, copies will be obtained. a 3) Restaurant Ratings - in process. 4) A draft report will be coming out soon identifying the TMDL levels for Lewis Bay. Once available, Mr. McKean to bring results to GIS to plot on a map. At that point, it will come to the Board for a vote of action. 5) The Three Bays recent study will be published. It showed that a large amount of the chloroforms detected were not human. However, at least two to three places were from human waste. The Board will discuss this in the future after further review. Voted to Adjourn. 4:30pm Page 3 of 3 BOH 10/12/10 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 254 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Name of Owner WHITEHEAD r v Address of Owner: C/O CENTURY 21COBB/NOWAK 1550 CENTER PLACE,CENT.ATT.JAN M. 77 .� Date of Inspection: 1/8/00 Name of Inspector:(Please Print)JOHN GRACI �q I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) O � Company Name: n/a c O J�Cy Mailing Address: n/a Telephone Number: n/a 49 t_ �'f CERTIFICATION STATEMENT I certify that I have personalty inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My flndings are of how the system is _ Needs Further Ev luation By the Local Approving Authority performing at the time of the Inspection.My Inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:1/10/00 The System Inspector shal submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:1/8/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: Wit 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. a& The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n(a Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass Inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced n/a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:)/8/00 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla-(approximation not valid). 3) OTHER n1a revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:)/8/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n1a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.if the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.' E. LARGE SYSTEM FAILS: You must Indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:118/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping Information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing Information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:1/8/00 FLOW CONDITIONS RESIDENTIAL; Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):$ Total DESIGN flow: IV Number of current residents:Q Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate Inspection required Laundry system inspected(yes or no):JLQ Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): nta Sump Pump(yes or no): NO Last date of occupancy: n& COM M ERCIALIINDUSTRIAL Type of establishment: n& Design flow: n(a gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):AQ Industrial Waste Holding Tank present:(yes or no): MO Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n(a Last date of occupancy: n/a OTHER: (Describe) n& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: nia System pumped as part of inspection:(yes or no):NQ If yes,volume pumped n&- gallons Reason for pumping: n& TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nfa APPROXIMATE AGE of all components,date installed(if known)and source of information: 1991 PERMIT 91-148 Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:118/00 BUILDING SEWER: (Locate on site plan) Depth below grade: i E Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: Wa Comments: (condition of joints,venting,evidence of leakage,etc.) Wit SEPTIC TANK: X (locate on site plan) Depth below grade: i Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n(a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nla Dimensions: L 8'6"H 6'7 W 4'10" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 2" Scum thickness:It Distance from top of scum to top of outlet tee or baffle:JE Distance from bottom of scum to bottom of outlet tee or baffle: nia How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: n& Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:.a& Distance from bottom of scum to bottom of outlet tee or baffle n1a Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Wit revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C V SYSTEM INFORMATION(continued) Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:1/8/00 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n/a Dimensions: n/a Capacity: nla gallons Design flow: nla gallons/day Alarm present: MQ Alarm level:_n&_ Alarm in working order:Yes—No—: 111Q Date of previous pumping: n(a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX: X (locate on she plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) IlLa PUMP CHAMBER: MQ (locate on site plan) Pumps in working order:(Yes or No): MQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nla rovicorl POOR Pan.R of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:1/8/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: -n& leaching galleries,number: _nLa leaching trenches,number,length: Wa leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: nLA Name of Technology: -n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRLICTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION CESSPOOLS: _ (locate on site plan) Number and configuration: m& Depth-top of liquid to inlet invert: n& Depth of solids layer: nLa Depth of scum layer, n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: _ (locate on site plan) Materials of construction:n/a Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 Page 9 of t t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:)/8/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a 1A �Sk ©C4 qo AA 33 At 3,y Rc LI) R� 53 0 33 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 264 RIVERVIEW LANE CENTERVILLE MAP 228 PAR 164 LOT 19 Owner: WHITEHEAD Date of Inspection:1/8/00 NRCS Report name: n(a Soil Type: n& Typical depth to groundwater: n& USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 OWN O BARNSTABLE LOCATION vt Wy SEWAGE # VILLAGE �ev��-tcJ�I ASSESSOR'S MAP & LOT--�' �IO`� ,INSTALLER'S NAME & PHONE NO. cOCG 1 Cefl -7`7) -1 0q0 tEPTIC TANK CAPACITY ' d < ,�EACHING FACILITYAtype) &eA6k (size) 1 ,000 �O'. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: (� DATE COMPLIANCE ISSUED: dt? oe VARIANCE GRANTED: Yes No t+ Lo f t( 1 No...h.=1.Y t F�$.......lB '....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -.-e ..........OF....., : - ...................................... Appliration for Elhipaal lVaxkg Towitrurtiun Prrmit Application is hereby made for a Permit to Construct Q<) or Repair ( ) an Individual Sewage Disposal System at: ..................•-•--•--••-.._........ _...--•-•---......--•--...----...-•---•-•--•••--...........---------........_..•••--......--•----- a V ewno Installer Address Type of Building Size Lot.... Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (WO) aOther—Type of Building Wll_Q.b..Fd!9* No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------•------•-------------•------••---------•------------------••---•----•-•-••-•-•--------•----•-•--•-._.........•--- w Design Flow.................�5............_....._..gallons per person per day. Total daily flow.._......3-39.........................gallons. WSeptic Tank—Liquid capacity IR11.(l.gallons J,ength................ Width................ Diameter................ Depth................ x Disposal Trench—No........1........... Width_..*......_._._ Total Length.................... Total leaching area.... __sq. ft. Seepage Pit No---------f.......... Diameter-------7-'-_...._.. Depth below inlet.....�a........... Total leaching area.G�19.a.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ `-' Percolation Test Results Performed b �-g�' k-.-Al Y1�= i y--..... . •....._-----i--------------------- Date. .........................../ Test Pit No. 1...�.9-____minutes per inch Depth of Test Pit.....t!�........ Depth to ground water----IVd............ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------_----__________ P4 -------------•-•---•-----------------•----•-•-----•-------•----•-•------------••----------•--- 0 Description of Soil--- y ---•--L0_ _ ...S UQ/L 1 a y! /�l�/�� ` 'S x w UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ........ ......••......------------•-------------•-------•-•.......-------•--------------•--•-----..._------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with (-1T t1c� LE the provisions of'TT LE5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the board of health. Signedk-22,ua-•---•-----•-•_._ . .._.. .............................................. Date Application Approved By............. _Y Date Application Disapproved for the following reasons:---------••---••----•------••--•--------------------------------••------------------------------------••-•••---- • ................................••---•-...---....••----•----- -••----- -•------------•---........................................... Date Permit No......... --•/......... t -------- Issued-------------------- . ............ - ae No...� -=( FRs.. . ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ----------- fJ '` :.........OF.... ApplirFatiou for Disposal Works Tnnstrurtiun Urrmi# Application is hereby made for a Permit to Construct°(tk ) or Repair ( ) an Individual Sewage Disposal System at ' G `f �f✓t ! ' J � f �.� d 2r! (ry 8� # i ,r ... .l. ............... ...... .... .........._..._.._ .........._. _....-• ___--- - -.._..---•-•--•.....-----•----------••--- R Location Address r i or Lot Xo e ----....---='� k------ .............................. �.�1 / if f 4.611i ---- ..---- ----------•------- Owner ' Address - Installer Address J r Type of Building Size Lot____ :it_c__±_ __Sq. feet Dwelling—No. of Bedrooms.............:).............................. Attic Garbage_______________:-__________- P ( ) (1' a e Grinder }) p., Other—Type Type of Building`'Y t t: �_ tr lf;�� No. of persons____________________________ Showers ( ) — Cafeteria a ( ) Other Fr:fixt 'ure.A ssr• , .�•. .�• �. .. W Design Flow.............. _ .......................gallons per person per day. Total daily flow-------_:a_ ............................gallons. x Septic Tank—LiquTd capacity/22;!'._gallons Length................. Width................ Diameter---------------- Depth................ Disposal Trench No,_______�______.___. Width... ............ Total Length.................... Total leaching area_.__:�__sq. ft. Seepage Pit No- '` ._________ Diameter______ .......... Depth below inlet.....6.__._____. Total leaching area_( 2 A_.___sq. ft. Z Other Distribution box ( ) Dosing tank / '—' Percolation Test Results Performed by............. =_ ... ____ Date.....�V' ��.___.____. --. Test Pit No. I. ". minutes per inch, Depth of Test Pit.....l A_`_______ Depth to ground water_._ ' ". ''• Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil.-..-").— ,' a' " u f f 9yl �_ V�� j6i`'� ....................' i - J ll-/ r, ;14 '-.1.� '-rj-Al J�, .............IL ••. U W -`ti VNature of Repairs or Alterations—:Answer when applicable----------------------------------------------------------------------------------------------- ........................................................................................................................................................................................................ --------- ---------••------------•-•-•---•---------------•---------------•••---•-...-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'ITL% ;of the State Sanitary Code—The undersigned furl er agrees not to place the system in operation until a Certificate of Compliance has bgen issued by the board of health. Signed. --. -i - --� r. Date. Application Approved By..........1 a �;�,,,.�.. � ...•.-.---- !_.�.•�`= 1 Date Application Disapproved for the following reasons-................................................................................................................. -•----•----••--•--••-•---•-----•------•-----•-•-•-•-•----•--•------••--•......--•-----•---•-•------•-•-•---••-•-•----••--••••••-••-----------------•----•••---------------•---••--------•---•--•-•----- Date Permit No..------Cy�-- ---/Y-�----------------- Issued-----------------------------------------___---------- THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH � . ._........ .1 ,i Jl M Trrfif irFa#rr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( =�) or Repaired ( ) `^� 4a , 'K. Fr J J ................................... Installer '................................ . •-`"•'-E' ..------•---..5`.......................................... e.' + 1 �. .-/ has been installed in accordance with the provisions Of TITT_. 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---------- .- . ------- dated_--.-__________________-____________-________ THE ISSUANCE OFT IS CyERTIFICATE SHALL NOT BE CON UE S GUARANI T AT THE. SYSTEM WILL FUNCTI SA I ACTORY. lI DATE..................... . ....��__/---------•---•------- Inspector _.� --1-. --•- -•- l �1 v THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c ,, 4,. OF iy PTO. ,/' •� FEE._'/X70.----.... Disposal forks ('16nns#rnr#ion nutit bie d E;,` I.t Permission is hereby granted---�----_- :--•------------------------------------------------------------------------------------......... ........ -------- ... to Construct Off,) or Repair ( ) an Individual Sewage Disposal System at No.___.1�'.. ---••-- :�)_ f�; ''g_ k_. t'�....................................l � v «pia. -_--- • •-•--•-------••-••----•-----••••-----•••-------•••-----•...•--•--_.... Street l as shown on the application for Disposal Works Construction Permit No.. Dated.......................................... ........................ .....• . ---•- , ..�--•---....--••----•- e Board of He +i� DATE------------�---�-=--------�-- •--`�----•--•-------------------- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS . 1 i Qom•�t G t� UQ,T�A ' ' , ..* __ --El lit=DepON� to4-9 ,c USA t'00� 6QL. it 1 lC>•v SI= ,c 2.S �1S G.P.D. �:5'�:�.P�� - �.�• �� ' , _� ,!_ ��G__ ToT,&L -Z25 97 3 330 6.PID. /zo 97 2GbL6,TIOU C7_!JT<= l��t�.l 2-Mlu 021�SS. \ '! tit OF 29733 ra,xi��41 No.24 p� 1 / .a n �F iA� �� � C •- 1 !/ i li ►.ram , �p A��M� ; f i 5,-7737 —sit- s . 98./ TOP. l-u o LaAr� pivb.. , Y .t:uv'47 D►ST. I W. °GAL. Z Boy . .. 9G.G f, I INV. f SEQrIC , t IDDp 9G ( T74n4 GAL. Iuv. . tlN 1 I P '. �/ WITH - V61D. 1 t � , J I I i /2 G1�TIo?J CEfi1TEiZ.�/It..1-Ca` `.i 1 Ct;tz71p,,e T l-1 G LPL (S W I'Yf-t � J E�->~,,�c l; SZ E q::�t�E,c�t,`uTy o� -r-� _ '., ; Lc1T , (� ' • J • t-1-+ . . 120S, -! 17y wIY�Ihl n4C- PLpc7p PLgIN Nb lS �I . i PLiQN AAte�, �DATE- F�'QI L 'l2 Tt-Al-s I� (_/A►�l lam, 6_10-C p.A.- :'lAWb SUevCYUlz� TE2�/IL ..0 � - UF•�.:Sir;. SI�•Gtah + _. � , i , i • 01✓ uSC�� A F?P t_ ; �< ' ��U S •Postal Service TM Y ,.,-1", (!?omest�c Mail Only,No Insurance Coderage,Prov�ded),,�� „. =w 1J&Forjdeliveryeinformation,wsit"our,website'At w"usps come. bp1 W c1Q a0 Q1 1 wLL1C LL y owl a'¢1� O w-IZ U!W N=1/� ` U 0 Soy _■ _. � � � � / 1 � � 1_ k'Form 3800,August 2008.Y See Reverse for Instructions Certified Mail Provides: 0 A mailing receipt it A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years ; Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. • Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For , valuables,please consider Insured or Registered Mail. •For an additional fee,a Retum Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the-addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000.9047 a I I SENDER: • •N COMPLETE THIS SECTIONON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature I Item 4 if Restricted Delivery is desired. 0 Agent I ■ Print your name and address on the reverse X ❑Addressee so that we can.return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, a I or on the front if space permits. D. Is delivery address different from Item 1? ❑Yes I l i 1. Article Addressed to: If YES,enter delivery address below: ❑No i I I I rl 3. Service Type C/ 11&r ified Mail ❑Express Mail I Registered O Return Receipt for Merchandise I ❑Insured Mail ❑C.O.D. 4, Restricted Delivery?(Extra Fee) ❑Yes ( 2. Article Number I 7008 3230 0002 5178 3388 (Transfer from service labeq i E i I PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 I 1 jl UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS I I Permit No.G-10 I! I li I I • Sender: Please print your name, address, and ZIP+4 in this box • I � I I �wj� o4 ��0��I� I I I li f al+h ( -wisIOki it ,I �I I I I � li