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HomeMy WebLinkAbout0067 SEA MEADOW CIRCLE - Health 'Sea Meadow Circle Centerville rP�e n�.a.6€.2i:0A= 2.46—229 5 M E A D No. 2-153LOR UPC 12534 smead.com • Made in USA i �CYC(� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurfaca Sewage Di r�«7 g Disposal System Form-Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA CIA Spinney 1R TR,Sea Meadow Circle Nominee Trust, 24 Windsor DR f iinnforrmation is ner avn ►v im MA 02035 7/15/2015 en required for every page. Citylrown State Zip Code, Date of Inspection Inspection results must be submitted on thisform. Inspection forms may not be altered in any way. Please see completeness checidist at the end of the form. M pog rtantout When filing.out for A. General Information ms j 11,9 on-the cottputer, j use only the tab 1. Inspector key to move your cursor-do not use the return key. Mme of Inspector joe mafflnna ACCU Sepchetk Company Name 17 Nort si a r. S. Dennis, MA 02600 Carnpanv mesa CitylTown state zip Code Telephone Number o License Number ff 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: " P ses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -7/2 -7/Z 0 -5- inspector's Signahre 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. tSfs 3113 TdIe50fcieiIrspeedmFame Subsurface sereoispasai system•Pb9e1.aff-T Commonwealth of Massachusefts Title 5 Official Inspection Form Subsurface Sewage Diisposa'system Form -Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA PropeMO#1"Spinney 1R TR, Sea Meadow Circle Nominee Trust, 24 Windsor DR Information is avner'F&Toro MA 02035 7/15/2015 required for every page. City/Town State Zip Code Date of inspection B. Certification (font) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: L� 1 have not found any infonnationwhich 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 blow. Comments: B) System'Conditlonaily 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 orrepair, as approved by the Board of Health,will pass. Check the box for`yes","no"or"not determined'(Y, N, ND)for the foil " g5statements. tl"not determined,"please explain. The septic tank.is metal and over 20 year;old*or the c tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltr ' or tank failure is imminent. System will pass inspection if the existing tank is replaced complying septic tank asapproved by the-Board of Health. *A metal septic tank will pass i pection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that tank is less than.20 years old is available. ❑ Y ❑ N ❑ ND(Explain below Mm 313 Ti8e50rbdW 9spWtfMF0=.%tauface SeeegeDispasd System-Pape 20117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA eo"Mfffi Spinney A TR, Sea Meadow Circle .Nominee Trust, 24 Windsor DR hforr Owner'FdRalloro MA 02O35 7/15/2015 Inforrretion is required for every page. citylrown State Zip Code Date of Inspection B. Certification (cunt) ❑ 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 ter Level in the distribution box due to broken orobstructed pi (s)or to a broken,s or uneven distribution box_System will pass inspection if(with approval of Board of Heatt ❑. broken pipe(s)are replaced ❑ Y Q N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑. ND(Explain.below): ❑ distribution box is level or replaced ❑ Y ❑ N ❑ ND(Explain below): The sy m required pumping more than 4 times a year due to broken or obstructed pipe(s). The syst 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: �"""f ❑ Conditions exist which require further evaluation by the B o Health in order to determine if the system is failing to protect public health, safet environment. 1. System will pass unless Board of determines in accordance with 310 CMR 15.303(1)(b)that the system is nctioning in a.mannerwhich.will protect public health, safety and the environme . ❑ Cess 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 U-ns•3f13- Tiffe5 Official ImpecfmFan Subsurface SewOgeUisposaf System-Page3of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA F'10P1`11y.Y I Spinney.IR TR , Sea Meadow Circle Nominee Trust, 24 Windsor DR Owner Owner'� ir,forroiatian O(O MA 02€335 7/15/2015 required forevery page. cityr raven State Tip Code pate of hspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Pub ater Supplier,if any) determines that the systemis functioning in a ma r that protects the public health, safety and environment: The system has a septic tank and soil a rption system(SAS).and the SAS is within 100 feet of a surface water supply or tri ary to a surface water supply. ❑ The system,has a septic tank a AS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic nk and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a s . tank and SAS and the SAS is less than 100 feet but 50 feet or more from a privat er supply well"!. Method used to #ermine distance: Thin sy passes if the well water analysis,performed at a DEP certified laboratory;for fecal colifo acteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or s than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be ttached 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 ❑ 02r/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Ep,-' 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 Y day flow fsrs-W3 Ti%e50Mdd lrc pontimfamc Subufaox Serage0isposat System-Page4of 1:7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface S®wage Disposal system.Form-Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA R-openyJbWffN Spinney A TR ,.Sea Meadow Circle Nominee Truest, 24 Windsor DR aNner a"na"f o"�3oro MA 02035 7/15f 2(�15 Litt©nrolation isrequired:forevery page. Cityrrown State Zip Code Date of inspection B. Certification (cunt) Yes No Required pumping more than 4 times in the fast year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Lf Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ B 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. ❑ 1. Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ U�/ 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 wateranalysis, 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 S ppm, provided that no other failure:criterta 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, therefbre 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 a.no�to each of the following, in ad ' ' rrt3fhe questions in Section D. Yes No l] ❑ the system is within.400 fe a surface drinking water supply El {_T the system is n 200 feet of a tributary to a surface drinking water supply ❑ ❑ the em is located in a nitrogen sensitive area(Interim Wellhead Protection —IWPA)or a mapped Zane 11 of a public water supply well If you have wered"yes'to any question in Section E the system is considered a significant threat, orans `yes"in Section D above the large system has failed. The owner or operator of any large s em 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. tSas-.3113 Tire S OMb 1 Inspection Fame Subsurace Savage Oisp.osis system-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form Not for Vol untary Assessments 67 Sea Meadow Circle Centerville MA RwerIAbN Spinney JR TR , Sea Meadow Circle Nominee Trust, 24 Windsor DR aN ner infornBtbn is "P&Woro MA 02035 7/15/2015 requiredfor every page. M/rIlown State Zip Code Date of Inspection C. Checklist Check if the foilowing have been done. You must indicate'Ves°or"no"as to each of the following; Yees/ No L�' 0 Pumping information was provided by the owner, occupant,or Board of Health ❑ Q Were any of the system components pumped out in the previous two weeks? CP ❑ Has the system received normal flows in the previous two week period? Q tad' Have large volumes of water been introduced to the system recently or as part of this inspection? Lf/ ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? !4C Ed' ❑ Were all system components uding 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.. © Determine 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)1 D. System Information Residential Flow Conditions: , Number of bedrooms(design): - Number of bedrooms(actual): .DESIGN flow based on 310 CMR 15.203(for-example: 110 gpd x#of bedrooms): t5inr-am Tiffe50ffiaWtmpecUmFa=Su4sufam SewageDispceat System-Page Bof17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Sea Meadow Circe Centerville tVIA 110Per1yJWfflN Spinney 1R TR, Sea Meadow Circle Nominee Trust, 24 Windsor DR Owner a'"nw'Moro MA 02035 7/15/2015 information is required for every page- CityfTown State Zip Code Date of inspection D_ System Information Description: I�O 0 9 s�,� Id — x � ' sane .c.�u� W., . . Number of current��sid:::nt;: pe-.P A?" 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? A//*O Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(fast 2 years usage(gpd)): (Detail: ao a 6J� _ 2- has j ri Sump pump? ❑—Yes t No Last date of occupancy: Date -- r Commercialtindushial Flow Conditions: Type of Establishment: Design flow(based on.310 CMR 15.203): ns per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc - Grease trap present? ❑ Yes ❑ No Industrial waste h g tank present? ❑ Yes ❑ No Non-sa ' ry waste discharged to the True 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ms•X13 Ti6e5Orfid2d trspw6on Forme.Subs,0aw Sevme Disposal Sysbm•Page 7&17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface SevmPage Disposal System Force-Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA a'°f"JW" Spinney JR TR, Sea Meadow Circle Nominee Trust, 24 Windsor DR iOw ption is "Ft oro MA 02035 7/15/2015 required forev" page- atyf town State Zip Code Date of Inspection D. System Information (cont) Last date of occupancy/use: Date Other(describe below): General Information . Pumping.Records: i0*04� 43770- Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, wl.ume pumped: gallons / How was quantity pumped determined? Reason for pumping: Type of System: I Septic tank,distribution box, soil absorption system r❑` Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Attemative 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 UA system by system operator.0 nder contract ❑ Tight tank. Attach a copy of the DEP approval. Other(describe)-- bins-3M3 Tide50r€ckd ftPecdonForth SubstafaceSemegeDisposed Sy#em•Page8017 Commonwealth of Massachusetts Title 5 Official Inspection Form Sub su oe Sewage isposai System Form-Not for Voluntary Assessments 17 Sea Meadow Circle Centerville MA 9F0pecy Spinney JR TR,Sea Meadow Circle Nominee Trust, 24 Windsor DR; owner °"" ir�formabon is e'F oro NIA 0203S 7/15/201S required for every page. Qity own State Zip Gode [We of 6ispec&m D. System Information (cunt) Approximate age of all components,,date installed If known)and source of information: Were sewage odors detected when arriving at the.site? ❑ Yes I NO Building Sewer(locate on site plant' ` Depth below grade: feet 2. Material of construction_ ❑ cast iron 90 PVC ❑ other(explain}: r Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage,etc.): Septic Tank(locate on site plan): f Depth below grade: feet Material of construction: Kconcrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: yeas Is age confirmed by a Certificate of Compliance?(attach a copy 'of certificate) El Yes El No Dimensions: /"`�' X . ' 7 Y-17 Sludge depth: tFms•3113 We.5Offi 1InepectonFormSubsWaceSavage.DispoeMS)SIem•PageSof1i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA P10MIX1R V Spinney 1R TR , Sea Meadow Circle Nominee Trust, 24 Windsor DR owner owner information is ®r0 MA 02035 7/15/2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cons) Septic Tank(cart.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 6�--- Distance from tap of scum to tap of Duffel tee or baffle Distance from bottom of scum to bottom of outlet,tee or baffle , t, How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to.outlet invert, evidence of leakage,etc.): ct S OleCeSt- fnI&T-ee Li 6( Bever Y&�' jec�'61& 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 t5m 3M3 Ti0e50ffiiialhspectmFo=Subsurface$exegeDispesal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA s i"We T41W" Spinney JR TR,Sea Meadow Circle Nominee Trust, 24 Windsor DR Ow ir etion is "'� n x` Oro MA 0205 7/7 S/2015 required for every page. Citylrawn State Zp Code Gate of Inspection D. System Information (cant..) 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 m7;E01 at tim f inspection)(locate on site plan):. Depth below grade: Material of construction: ❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gins per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of I st pumping: Date Com ents (condition of alarm and Boat switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3M3 US5Offiga hmpecUonFame Subsurfam Savage 0isposS System•Page 11 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection 'Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA RJl Spinney!R TR , Sea Meadow Circle Nominee Trust, 24 Windsor DR information ation is ner °""�`� ora MA 02035 7/15/2015 required for every page. City(fown State Zo 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 Comments(note if box is level and distribution,to outlets equal, arty evidence of solids carryover, any evidence of leakage into or out of box, etc.): + h T Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No; Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pum mber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system i�aconditional Soil Absorption System(SAS)(locate on site plan,exequired): If SAS not located, explain why: - -- - - ---- - - t5 s•3M3 Tiffle50fWadtrspecdan Form Subsurface SowNeDispose System-Page 12.d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonm Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA ProPel,4"Wfi Spinney A TR , Sea Meadow Circle Nominee Trust, 24 Windsor DR Owner ora MA 02035 7/15/2015 information is required for every page. CSIyfrown State Zip Code Date of Inspection D. System Information (cone) Type: ❑ leaching pits number leaching chambers number -- ��� �k'c f G X�t leaching galleries number t Z�x ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: El overflow cesspool number. 0 innovative/altemative system Type/name of technology: CQmments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.):. 6r, ad e ro S - aP f7,Pd Zefr- ak g/n 6-e/t,- .� 7'�4-G.- foes 41 re s Doe Cesspools(cesspool must be pumped as part of inspection)(bate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer —-- — Dimens" of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No f5ina-3M3 Title50flical kspec§aiFain Subsurface Savage Disposal System-Page.13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA F�roPe,Vfd WN Spinney JR TR; Sea Meadow Circle Nominee Trust, 24 Windsor DR owner °"`"'Foro information MA 02035 7/1S/2015 requicedtor every page. Ckyrrown State Zo Code We of Inspectim D. System Information (cunt.) 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 Dept h.of solids Comments(note condition of soil, signs /hyaulic failure,level of ponding,condition of vegetation, etc.): t5m•3i13 Tide5orfrcialtr$pecru nFam Sutsufwe Sewage Disposal Ststem-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA a P113Per'YMPl`N Spinney 1R TR , Sea Meadow Circle Nominee Trust, 24 Windsor DR Ouv ner owner' h!a inforrretion is oxrBoro MA 02035 7/15/2015 requIred for every page. Cityrrown State Zip Code Date of kfspection D. System Information (cunt.) 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 Q drawing attached.separately 0 tnJ' S ivT t ti b 3 f9re-V13 Tas SOfficial 6apectan Fina Subadaoe Savage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage disposal System Form-Not for Voluntary Assessments 67 Sea Meadow Circle Centerville MA 'Pelftl V Spinney A TR, Sea Meadow Circle Nominee Trust, 24 Windsor DR hf`ner °"'"er'F oxZoro MA 02035 7/15/2015 Oformatiorz is required.for every page. city7own Slate Zip Code We of Inspection D. System Information (cont) Site Exam: Check Slope 93 Surface water B Check cellar U Shallow wells Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed_ Date El Observed site(abutting property/observation Dole 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: L— "PC Lk VIC R . (or t h e 10t v 2 nas a,AAInA- �� 7 s� goy 3 0 t Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ns•3S3 Title 5 official fitspectim Forth:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 67 Sea Meadow Circle Centerville MA 'Ope"'Ofi ill Spinney JR TR , Sea Meadow Circle Nominee Trust, 24 Windsor DR iinforr ation is °"` FOx Toro MA 02035 7J15/2015 required for every page. Cityrrown state Zip Code Date of Inspection E. Report Completeness Checklist RrInspection Summary:A, B, C, D,or E checked 0-Inspection Summary D(System Failure Criteria Applicable to All Systems)completed Cd"System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5rs-3H 3 Title 50Ffid2d Im pectin Form Suhsrfa s SeKege Disposal System•Page 17 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Sea Meadow Cir. - c M �? Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not use the return Name of Inspector key. Capewide Enterprises,LLC Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 rErum City/Town State Zip Code (508)428-4028 S14454 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 Evalu tion b Local Approving Authority _m 5 6v '7--' 9/04/2007 <:I l Inspector's Signat re Date =�i The system inspector shall submit a copy of this inspection report to the Approviing 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 o 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. 57 sea meadow cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time.Replaced Distribution Box Cover. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ 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 ❑ obstruction is removed 57 sea meadow cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 i Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every page. City/Town State Zip Code Date of Inspection R. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 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. 57 sea meadow cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts g W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , c�M 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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. 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 El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 57 sea meadow cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 57 sea meadow cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 • Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every 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 t ❑ ® 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? ® El available 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)] 57 sea meadow cir.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 6 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 Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2005:206,000 g ( y g (gpd)): 2006:156,000 Sump pump? ❑ .Yes ® No Last date of occupancy: 9/04/2007 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: Last date of occupancy/use: Date Other(describe): 57 sea meadow cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes;volume pumped: 1.500 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 57 sea meadow cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 l Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 - every page. City/Town _ State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1, Depth below grade: 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.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 1 Depth below grade: 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: 10'6"x5'8"x57" Sludge depth: none Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness _ none Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? tank empty 57 sea meadow cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every 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.): Pump tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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 r Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 57 sea meadow cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Sea_Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma.. 02632 9/042007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has 5 outlet laterals with equal flow.No evidence of solids carryover.No evideence of leakage into or out of box. r Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes' ❑ No Alarms in working order: ❑ Yes ❑ No 57 sea meadow cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: . Type: ❑ leaching pits number: ® leaching chambers number: 5-Inflitrators ❑ 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.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil. 57 sea meadow cir.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is required for Centerville Ma. 02632 9/042007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):, Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): S 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.): 57 sea meadow cir.•08/06 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Sea Meadow Cir. Property Address Ron Perry, Owner Owner's Name information is Centerville Ma. 02632 9/042007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. I RP ,J` ; o ; i t t ;.i r 0 25 Feet 57: loft 5 Commonwealth of,Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Sea Meadow Cir. Property Address Ron Perry Owner Owner's Name information is Centerville Ma. 02632 . 9/042007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water Z Check cellar ❑ Shallow wells Estimated depth to ground water: Bottom of leaching 6' 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: As-Built Card ❑ Checked with local excavators, installers-.(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used: Gaherty& Miller Model 12/16/94 Ground water elevations. Used: USGS Observation Well Data June 1992. Used: Technical Bulletin 92-000-01 plate#2 Annual Ranges of ground water elevations. 57 sea meadow cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of,15 • Town of Barnstable op 1HE 1p� yam`• ti� Regulatory Services STABLE Thomas F. Geiler, Director Mass. '`� i639 �•� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. lA THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . (go ...-.-`.N�.'�.h!k.............0F. !as 6`.: 1>L V (?�O.Vkppfirafivu for Dispagal Workii Tantitrurtion famit Applicatig is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal sys � .. kV,. L&...------. ...... ..l©. . ............... e4i--._�-�� ca"ti Add s _ or Lot No. OCc o 1� ...t :�.=....—/�tLS , BX. 6 c"J:. e4e�tn1>S "l ............... tM W jo Q... Owner AddrQti � .................. a Installer Address Type of Building CO B i a Size Lot..�..1J_;.J4.q....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (I q Garbage Grinder okc) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures -------------------------•........................... W Design Flow........ ..........................gallons per person per day. Total daily flow-----3'3.0.........................gallons. WSeptic Tank—Liquid capacity.10C.0 allons Length_Si:_ ... Widt.=lQ. Diameter--.--- Depth_�_._43.. x Disposal Trench'—No. .................... Width.....I ........ Total Length----- ...... Total leaching area.—.G.....sq. ft. Seepage Pit No................ .... Diameter-------------------- Depth below inlet.................... Total leaching area...._..............sq. ft. Z Other Distribution box (E f5 Dosing tank (1l. _ _ '" Percolation Test Results Performed by..... ..__ _.W Ir Lro�' _..__... Date...�.`2S`. ........... 4 Test Pit No. 1..L Z-----minutes per inch Depth of Test Pit---I Q.!.._.._.. Depth to ground water_-__6_'_:y_......... fi, Test Pit No. 2----------------minutes per inch Depth of Test Pit................•... Depth to ground water------------------------ •--•------••--------•---. •-------'------------------•--------------'-'--'------------'----•--••------•-------•-----------•••--•---.._..........•--•........ _ O Description of Soil....Q -!---LbAOAA-5t?_¢5.p.i.---%-5.... !�►G ................ ��o.... m eo SNK.7 x W -•---•-•----------------•--------------••--•------•••----••'----------------------•----•-'--------••----••-•-------------...----...-----••-•--•'----•-----•-•-•-------•------------......---------••---- UNature of Repairs or Alterations—Answer when applicable-_ _. .__ . .................. DESIGNING ENGINEER f1AUST SUPERVISE ---•-----•-•--- •-------•-•..---- -------------------------------•--••--------------------------•--•--------------------•----------••----••-INSTALI.A`I`IbRI•A�� aERTIFIf IN WRITING Agreement: T�lE SY EM W �DIN T TPT The undersigned agrees to install the aforedescribed In vid�_aY§!� W F'L � T ii�Nac�ordance with the provisions of LI.Li: 5 of the State Sanitary Code— The undersigned furt ier agrees not to place the system in operation until a Certificate of Compliance has bee ' su by the.board of healjh. Sined......... ..• ----.5:�..-- ----� ...................... ................................ to q Application Approved BY �--------------------- -.....`......�k --- Ar`ylt� Date Application Disapproved for the following reasons:_...----••-------••--•---------------------•--............-•-----------------•----------------•--•••-•'--....... ------------------------•---•--•-'----'•--•-------------•-----'------------'------•----------------...-----•-••--"-------'---•-------••----•-----•-••---•-'••......................................... Date Permit No........ ���----7•--.... Issued_........ ---D=�-----•�-�------•-•----•--•---- �_ (�G� r, . '�'1( -. 'V m .9 _ ti' b .1� .� 4 ���� o- r a� r •� r.� ' -a �� i �. ,. / No..�?.�.� � LG� Fss G........ THE COMMONWEALTH OF MASSACHUSETTS --�~_ BOARD OF H EALTH oF..... � 1��. �. ?��------------------------------- Appliration for Disposal Works Tontrudion rrrmit Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal cm at: SyS ......... ................ ......•....C.....--- ..i i........................................................... Location-Address or Lot No. ................................................................................................. --•••-----•------------............•--•------•................................................... Owner Address W a ........ � - ----�.--....._•-------------------------•- � ,.Install er Addreses s ,", U TypeDwellinNo. of Bedrooms._.____..... Size Lot_!.: a. 7 .:...._Sq. feet Building of �., g— �................................Expansion Attic (l�c�) Garbage Grinder (tA ) 'CLI4 Other—T e of Building No. of persons............................ Showers — Cafeteria P4Other fixtures ..................................................................................................................................................... W Design Flow....... 5............................gallons per person per day. Total daily flow...... .........................gallons. 1x Septic Tank—Liquid'capacity.!Q-�allons Length Ea`i;'R---- Width.A7.t.Q_. Diameter__._.. ........ Depth=,-54-_ Disposal Trench—No..................... Width....A. ........ Total Length....:: ....... Total leaching area.:-_g�s>_c-�a.__...sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. kj Z Other Distribution box (/E> Dosing.tank ( u)a Percolation Test Results Performed by.....: >v'. ._ r_�?:.�. :�-.:.°�_ C-......... Date..`` .` ._w._'.�°` __.......... aTest Pit No. L.� Z.........minutes per inch Depth of Test Pit.. C. ........ Depth to ground water-___� i__.__--_.. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----•----•••••••••-••-------•-•-•----•--••................•-•-•-•-•---•--•--•---•-----••-•--•-••---.......................................................... 0 Description of Soil...D t it��z<<t `J:.c C?t�.- ......---."''=i`. `',,T-( `.;� NA > 3............................................... 4 � r` r A4 ......................................... ..........._. _.•..N........... W W .........._•-----------•................................................................................................................................................................................ VNature of Repairs or Alterations—Answer when applicable._._�'.�...-' _ram-?...i-�l.r!_::mo d `?........................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIZj 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee i su d by thebo�� of heal h. ... � � � �- g Signed•....... ........4.-•... �!P -. .......................... Date Application Approved By........... ......•--- .......... ._...... Date Application Disapproved for the following reasons------------------------------------------•-------------------------------------_.........•--•••---•-•••••....... ----------•...............•---------•----•--•------•--------•------------•----------------.............--•----••............-••••••-•-•-•--•-•-•--••-•---•......-••-••.... ........................... .Date Permit No......2: _ O .... Issued__..._. qtl THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (In#if irtt#r of Tontplinar THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----------------------------------;----------...----....----------------------------------------....------..........................---.....------------------.....................---•---•-••-•.--- Installer at..................................................................................................................................................................................................... has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... _.-':�"= _ dated___..__ �:L� ------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................... .. ---• .......... .!! ..f� ...-•-•------•--------•---- Inspector............-�.--- r.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... FEE...... :.........•--- Disposal Works Tontr ion Uprrntit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo. �-+ .......... .............................� . .;�r:_i................................................... ..................... Street _. as shown on the application for Disposal Works Construction Permit No..................... Dated........ / .Zf:..._....._. ...------. .------ DATE..................... 7....................... Board of He th FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS s r � C AQBIi:�E. 61z1 UDE2. � C=.C�+ �,_?..C;a.t✓. ?pt �elSrlc ' r'AJt4 e LtLiD % Is'o 6w GPD ToK ."75 P�Iµ OF Mqs, LIJ \Z �c_ PETER Ct2�I� �46+�� = to�ts.� OK �,��°fr y, s V RICNARD : SULLIVAN I eU ER ��J.;A. No. 29733 �o l:.A,TI o�► : . CZd.T� t" IJ�MIU. oR.LG�{'.: : . .. . . ..I . �FQ►� FSS�orvA L tom " I ' cam!� qo� tw C�I�r�>u.��.. �. 2•l9'•g� N G� �' � ' z�•9l 3' s�a= go S a'�ca' zsa Qu�c 3� IZ•93 I�-+ Low eE� • 4 �_ �� .. . 'DtrFu�iSotZ�, �csc5 1�$.1l ��AI"(E�Y��ti-� C......tc�.�i.�•- j C:-_ 7, c:t PLOT P L.& t l TI-•t FOf� NOW�.J.-_ u�g6ot L com pt-Y5 WIT" SIVEu.yE 44D :5 a� 2EQutreump11T5 cT •Tl-I E -ro,W 4J: v� ✓,\n ti.�. • t �EPa at �"✓ 1 4�CT4j ZE&t5T��b Ll&u� Ksit✓0�5 t � YAN M IS Pa2T �..��7•a�'� ..� : . `t l;yaw $ W 1✓I_t_ 21r�L O*T-r--ZV I►I S - A(M . z.2? t Q E.L 13.D 17.a t?.Co Iuv tt1J. D14T. IUv Loan-•�� S�g��(_„ C7/i L. 17.4 r7•Z Bv� R,O e 10 ,EPflc i T4u v, _ ..• ._.__. �� G�LViKErf� ;e 5 ota 2. X-4p; FLOW DIFFU55oe-s $�[ W ITLI A.'OF 3/4 Tn I V4i WASHED _ (3� t1 to.p Core. �o tiA .p -- ALL A-00"p. 2• o F ". �/�T=� -----...— — - - WQSLIEr> [�kASTONE oN TOL' W./E4,'.-rS�,I g 20"1-E PQOFII_t= C� PPAPOS�� we-ree > - q� a . A �2 ' i ( 5+ Coe 2.q sco% -� ALL'corvcPprvC"rs 8u2t C-O c►1 - s _ CO ?ErA Cq E.,a« U N$u ' SL is t�1� 21 Ik L Cj 25` E SYSTEMAj r t - - ♦`\ _ � 23q cif -I ! LAST FU LL Ptiao.:. SsA3 � , i • Orvl � t \ x 0 'T EGZ 1 ' x Yap. 00 Y S' t•2l. f = NOT'C' lt. OW nj co OFFICIAL c, M A, ON Postage $IM `�� Certified Fee 0 Return Receipt Fee f�o�st k5 1 C3 (Endorsement Required) Here O Restricted Delivery Fee r3 (Endorsement Required) U r.S9 rU Total Postage&Fees r—1 � Joanne F. Goldstein 30 Mill Street Newton, MA 02459 Certified Mail Provides: ■ A mailing receipt ' ■ 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 Maile 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 Return 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". a 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. • i IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02.000-9047 nF. SENDER: COMPLETE THIS SECTION COMPLE TE THIS SECTION ON DELI VERY ■ Complete items 1;2,and 3.Also complete 'f# Sgnatt{re J'' item 4 if Restricted Delivery is desired. X �! �❑Agent • Print your name and address on the reverse `Mddresse so that we can return the card to you. R ceived by(Printed Name) C. Ddte of D I' ery ■ Attach this card to the back of the mailpiece,: or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No Joanne F. Goldstein 30 Mill Street 3. Service Type j1 Newton, MA 02459 P Certified Maid® CJ Priority Mail Express' f 0 Registered ❑Return Receipt for Merchandise I ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number T --- — —m (transfer from service label) 7 014 1200 0001 0 3 5 8' 0 4 8 2 PS Form 3811,July 2013 Domestic Return Receipt � I I -s� ��+�,� UNITED STATES"fwC� a1:�9*ACE First-Class Mail A CORA. Postage&Fees Paid USPS 28 'FEB "IS Permit No.G-10 Sender: Please print your name, address, and ZIP+4®in this box* I I r i Town of Barnstable Public Health Division 200 Main Street I Hyannis, MA 02601 xry �iC✓ �� TOWN OF BARNSTABLE LOCATION&SO., C,r�f SEWAGE # VILLAGE r/yaHs��, /d �aryf��ll 2 "� ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. J04h 19 , �)& lid SEPTIC TANK CAPACITY LEACHING FACILITY:(type) S �"/n �,��tisv�s (size) /21f NO. OF BEDROOMS 41 PRIVATE WELL OR PUBLIC WATER �[ ,,c r-- BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �-� j VARIANCE GRANTED: Yes No G� �"� � �'t7� 6 :r ,�-� .�y � y`� A q-p - ��` 6�� B-p - i®` ® � �- o �