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0020 SEAN'S CIRCLE - Health (2)
20 Sean's Circle Centerville A = 170 057010 P llll UPC 10259 o- No. H_ 163OR HABTINOS UN TOWN OF BARNSTABLE LOCATION ;249 Says l�2 c �� SEWAGE # -04-la S� VILLAGE />/e ASSESSOR'S MAP & LOT 170-00-alb INSTALLER'S NAME&PHONE NO./72 c H �(�-a-x/ 5r 7 -,�,j (3 C--)- SEPTIC TANK CAPACITY /00 0 Clr -5 % -"� LEACHING FACILITY: (typC2LD 0 C F2S (size)o2,5-`X -Z NO. OF BEDROOMS 3 BUILDER OR OWNER /"/-f A/ 4�ezzl 2 z PERMITDATE: COMPLIANCE DATE: N 2- 0 a Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by G 173 �= 02 � c - 1,17 Commonwealth of Massachusetts T tl 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Seans Circle,; Property Address' �€ M+► Erick Gustafson or Owner Owner's Name _ information is required for every Centerville ✓ Ma 02632 4/26/16 ►_�,• page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information S1 on the computer, use only the tab 1. Inspector: key,to move your cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain Company Name 8 Johns path, Company Address renun Yarmouth - Ma 02664 CitylTovvn p State Zip Code =, 64g._ 587 -- - - - S103522 Telephone Number License Number B. Ce`'1tificatlovi w 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 5/2/16 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. QG �t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection F®rrn Subsurface Sewage Disposal System Form - Not for Vol untary'Assessments = 20 Seans Circle �;•,"� �; Property Address 'i' > '::3"' r? Erick Gustafson - - _____ -------- -- ----,.e�,t•c,�r - ;- Owner Owner's Name information is` ' required for every Centerville Ma 02632 4/26/16 page. Cityfrown State Zip Code Date of Inspection ,� B. Certification (cont.)_ Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ` '- ® I have not found any information which indicates that any of`the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1'000 GI septic tank as well as a dbox and two 500 gl chambers installed 4/12/02. pumping is recommended at this time. Also trees over tank should be removed by home owner to prevent roots gaining access to tank and pipes. 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",f 4ib"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 tanl<I&Ur?b 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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title .5 Official Inspection F®rm, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f '1 20 Seans Circle _ - Property Address + . Erick Gustafson Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ , obstruction is removed ❑ Y '❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions'exist which require further evaluation by the.Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Co mmonwealth of Massachusetts W Title 5 Official Inspection For '" ` Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments a-r_ro;jf rrz .na; r,•�' ibF,,. 20 Seans Circle � .M \.. Property Address I • Erick Gustafson Owner Owner's Name r ` information is- required for every Centerville Ma 02632 4/26/16 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. i , ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ;, - ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the'well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria ind'icatiai `al sent and the presence of ammonia nitrogen and nitrate nitrogen is equal s9 or. ,. to or less than 5 ppm, pro< vided 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 t' ` Balckup of'sewage into facility or system comporient due to overloaded or ® clogged-SAS or cesspool -,r Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS,.or,cesspool.•,,:. , El ® 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".bTelow invert or.available volume is less than '/z day flow , t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i I , Commonwealth-of Massachusetts T'itle:.;5..: fficial Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Seans Circle Property Address Erick Gustafson Owner Owner's Name, information is required for every Centerville Ma 02632 4126/16 page. City/Town State Zip Code Date of Inspection B. Certification' (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of'the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of 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 i'system passes if the well.water analysis, performed at a DEP certified laboratory,for fecal colifo'rm 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 8 public water supply well If you ha4answered "yes"to any question in Section E.the system is considered a significant threat, or answered "yes*"'in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official_ Inspection Fo r Subsurface Sewa a D.is osa[,S..stem Form -Not for Voluntar Assessm'e'nts y„ 9 p Y Y 20 Seans Circle Property Address -- Erick Gustafson Owner Owner's Name information is Centerville - - Ma 02632 4/26116 1 required for 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 b tle.owner, occupant, or Board of Health ❑ ® p 9 p Y p : ❑ ® 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? . . ® El 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 for1'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 no tr_ Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of.Massachusetts W Title,; ,:Official Inspection f orm a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Seans Circle Property Address Erick Gustafson Owner Owner's.Name information is required for every Centerville Ma 02632 4/26/16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System contains a 1'000 GI septic tank as well as a dbox and two 500 gl chambers installed 4/12/02. pumping is recommended at this time. Also trees over tank should be removed by home owner to prevent roots gaining access to tank and pipes. Number of current residents: 2 Does residence have a garbage grinder? El Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) - Laundry.system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 198 gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): 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: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5, Official Inspection Form,._ a Subsurface Sewage Disposal System Form Not for Voluntary�Assessments - - _ •s" lif�'i�f' ,. . . .;t�l Cr�M o ie�.°Ilya-... `�'1't.vl�.:.'.�,°>'"� I-;i} �. <'4�M 20 Seans Circle Property Address Erick Gustafson Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. City/Town State Zip Code Date of Inspection M System Inforlrr>tation_(cont.) _Last date of occupancy/use: occupiedDate Other(describe below): •- I�t General Information Pumping Records: Source of information: 6/3/13 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: L 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 4f:t• ._ ❑ VTight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5,Dfficial Inspection Form . - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Seans Circle Property Address i ^r Erick Gustafson Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed 4/12/02 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): `Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form, �. a Subsurface Sewage1Disposal'System Form - Not for Voluntary Assessments. ,..+, a .. .�. •. , .�a,eaiJ.k i..,1. 20 Seans Circle Property Address Erick Gustafson Owner Owner's Name information is required for every Centerville Ma 02632 4/26%16 page. Cityrrown State Zip Code- -- - Date-of Inspection U System -Information (cont.) Septic Tank.(cont.) Distance from top of sludge to bottom of outlet tee or baffle . 3 Scum thickness Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle'condition, structural integrity, _- -liquid levels as related to outlet invert, evidence of leakage„ No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ,. ❑ other(explain): Dimensions: Scum thickness Distance from top 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Cornrnonwealth of Massachusetts W Title 5 Official Inspection _Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y ` �M 20 Seans-Circle , Property Address Erick Gustafson - Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 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.): Tees are in place and levels are normal Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El con ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: . gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - W Title 5 ®fficial Inspection Form =k m Subsurface Sewage Disposal System Form Not for Voluntary,Assessmerits a jlt=�{1•;i ':i :t.:`t•li}1�1711JIi)'v '1Y ����9/a_I :•��`tLr�.Gs ;).:s:z's5;.4r^:S. (.�1� .�, 20 Seans Circle ,`-_ Property Address - -- -Erick Gustafson Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. Cityrrown ' ; State Zip Code Date oflnspectiofi D. System Information (cont.) Distribution Box (if.present must be opened) (locate on site plan): Depth of liquid level above outlet invert Normal level 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.): signs of carry over into dbox no signs of push back from leaching r Pump Chamber(locate.on.site plan): -,i , ', r. ,'ii.� r 1Gi i) .ifiCs;t`t Iv,J Pumps in working order: (;ii, ; ,0._YeS., ❑ No Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. al Soil..Absorption System (SAS) (locate on site plan, excavation not required):s' If SAS not located, explain why: 'vier"aaeo io t(%•l211:=r�i(! t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I — - Commonwealth of Massachusetts W Title 5 Off .cial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Seans Circle Property Address Erick Gustafson Owner Owner's Name information is . required for every Centerville Ma 02632 4/26/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont) Type. ❑ leaching pits number: ® leaching chambers number: 2 500 GI ❑ 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.): No'break out no ponding 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 t Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official In W �pecti®n Forms; Subsurface Sewage'Disposal System Form -Not for Voluntary""Assessments °°�M ,•y'°r 20 Seans Circle Property Address Erick Gustafson Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. City/Town';'•. State Zip Code _ _ _. Date oflnspectibri a D -System Information (cont.) - Comments (note.condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out Privy (locate on site plan): Materials of construction: i Dimensions Depth of solids i Comments (note condition of soil, signs of hydraulic failure; level of ponding, conditionlof vegetation, etc.): M r- { i a ' 1 E j l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title .5,,Oftpcial Inspection' Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Seans'Circle Property Address Erick Gustafson Owner Owner's Name . information is Centerville Ma 02632 4/26/16 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all,wells,within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Seans Circle _ Property Address I ;,\/ Erick Gustafson Owner Owner's Name information is required for every Centerville Ma 02632, 4/26/16 page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Surface Ovater - ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ftfeet Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record ,= 4/12/02 If checked;:date,of-design_plan reviewed:. Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) c� ® Checked with local Board of Health -explain:-� plans on file ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation:. Plans on file indicate NGE at 10'+ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Assessing As-Built Cards Page 1 of 2 t vwty Ur bAK1VJ 1 AtSL1= LOCATION •Ay Sri) /S c I� SEWAGE N7:o l.—.1 5 VILLAGE._ Ile ASSESSOR'S MAP&LOT170—OOj,dfo INSTALLER'S NAME&PHONE NO.AQ e H C .sr_.. SEPTIC TANK CAPACrrY l oo O % ,K r LEACHING FACILITY:(type)SU d n!" rr r (size)D-S NO.OF BEDROOMS 3 // l BUILDER OR OWNER / i✓ �`.�f a�2 'n PERM[rrDATE: i O COMPLIANCE DATE: 0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the.Botiom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (if any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by O f= 4`7 http://www.town.barnstable.ma.us/Assessing/HMdisplay.asp?mappar=170057010&seq=1 4/27/2016 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Seans Circle Property Address Erick Gustafson Owner Owner's Name information is required for every Centerville Ma 02632 4/26/16 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. C/"—� I Sa Fee 50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: iz✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYtcation for &.5po.9 *pgtem Con.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Desi er's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms ✓ Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /4 m d X s T t Type of S.A.S. Description of Soil wl t .. Nature of Repairs or AAterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Bo d of Health. / Signed Date l�/ a a Application Approved by - Date Application Disapproved for the following reasons 15�Permit No. �c Date Issued No. �W�" �� R �S Fee rsV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2pphratton for Mtgo}gar *pgtem Con.94ruction Vermtt Application for a Permit to Construct( )Repair Grade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Desig er's Name,Address and Tel.No. 7s=� -2 6 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(N)"', Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures Design Flow 3 y gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank •f Type of S.A.S. Description of Soil W)L( r C tryt� i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Stgned Date 7 lag /a Application Approved by n �� _ �il��� _t Date ( AU Application Disapproved for the following reasons Permit No. 'S Date Issued b �- ----------------------------- ---------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certiftrate of Comphance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(1_1� Abandoned( )by ocf ro ..- 3 1— at a= , r rig c 4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No: lb-)- dated 4 Installer Designer The issuance! this' ermit shall not be construed as a guarantee that the sys a will "nction a designed. Date �lI �� Inspector A. No. T���'—�_��-------------------------Fee �Vr THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogar *pgtem Con.5trurtton Vermtt Permission is hereby granted to Construct( )Repair(`Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons ction(must be completed within three years of the date of tfiis permit. ! Date: L� !C_> - Approved byQ �_ .��� 6 f TOWN OF BARNWABLE LOCATIONS J-i)�/S 2 c /"� c /� SEWAGE #ZC',CQ` I VILLAGE n/^=�L y / f� - ASSESSOR'S MAP & LOT L jL! 7-Ot b INSTALLER'S NAME&PHONE NO.I'ge c H (�'.ti 57- 7 C SEPTIC TANK CAPACITY _11900 ts`i��( ate. �'X 'S LEACHING FACILITY: NO. OF BEDROOMS jf BUILDER OR OWNER PERMITDATE: / D COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by G ' - 'Y 7 fl �Z 333 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION Y / PARC ;05'1 O 10 LOT : 1 O TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: l) sec,05 C 1✓' MAR 2 2 2002 e:v, le U�63 Owner's Name: e .� . 1, /�� �J TOWN OF BARNSTABLE Owner's Address: O c v, C i ✓' HEALTH DEPT. o Date of Inspection: Z -as-oa Name of Inspector: ( lease print) Company Name: - �//i d Mailing Address: O /SOX %l9 Telephone Number CERTIFICATION STATEMENT 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 eeds Further Evaluation by the Local Approving Authority Fails / � ,. Inspector's Signature: 14 c Date: C C 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. HL Notes and Comments /i C ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �PG 0 5 Ci✓' Owner: Date of Inspection: r�L Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: IV 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. 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 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: i Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION(continued) Property Address: Owner: /><�bG� r�N Date of Inspection: ,;?-12 5_ n---;k 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. 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: �C Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes o _ 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 /z day flow c,/ 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. -7 Any Portion of cesspool or privy is within 100 fee t 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. _ y 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)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. 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) 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 1I 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: J C 0S C,"— Owner: 14,�bi r Date of Inspection: - 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 ere any of the system components pumped out in the previous two weeks I/ Has the system received normal flows in the previous two week period _j/�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 (,Z _ Were all system components,excluding the.SAS,located on site _V _ Were the uncovered,o n se tic tank manholes p 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: Ye" no 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) 1310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: "'Z o -SSG hs. C i•/ L H c,-✓i Ac Owner: i kg1r.1 Date of Inspection: - a S- FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -� Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no): I O Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): LO k10 Seasonal use: (yes or no): (j e- Water meter readings,if available(last 2 years usage(gpd)):d0C0 9q c6 o '0?o'0/ - Sump pump(yes or no):4/0 V C C Last date of occupancy: r/ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): -gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_____pllons--How was quantity pumped determined? Reason for pumping: TYP ,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 compe s,`date installW(if own)and source of information: Were sewage odors detected when arriving at the site(yes or no): //V Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: -'?--1�1 0,2 BUILDING SEWER(locate on site plan) Depth below grade: / Materials of constructti`on- cc`ast iron �/40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: v locate on siteplan) Depth below grade:�_ Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Sx Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or bale: Al Scum thickness: Distance from top of scum to top of outlet tee or bale: O Distance from bottom of scum to bottom of outlet tee o baffle:0 ' How were dimensions determined: ce Comments(on pumping recommendations,inlet and ou it tee or bale condition, structural integrity, liquid levels as related to outlet my rt,evidenc�of leakage,etc.): ) / �y�,J,n � ca >< �,- /u7 c1 110 J �l 17 C� GREASE TRAP: /(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or bale: Distance from bottom of scum to bottom of outlet tee or bale: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I-)C) Owner: Date of Inspection: d2 TIGHT or HOLDING TANK:2V(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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (f present must be opened)(locate on site plan) Depth of liquid level above outlet invert:0 O/ell;, Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of etc.): PUMP CHAMBER: /Cl (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -20 seQI�S Cr Owner: / v� Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Tyr/ &�'b leaching pits,number:L 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.): 122" - � c� • p h-e � �� r«k ;C Fes, AA 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: `l/(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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: "?c �/f Owner• �6�g. Date of Inspection: 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. LijL C 143 —act 3 S� Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: fi X—� v►S �, Owner: Date of Inspection: a-as-0,)- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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 establish the high ground water elevation: 4-1 zv✓� of I v/"- /v . v7' p Oo o 0 r., r tl�l v 0 e 10 - o o D 0 r r �0`� s�3 L O A T I ( Zb SEWAGE PERMIT NO. VILLAGE 1 STA L L E 'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUEDli 1 DATE COMPLIANCE ISSUED 0 . 45 0 34'4" " vr 5 1-5; W W 9�-2 Z- -8" -5" /I 1-;4 -------------------------------------------- Bedroom 2 Bath r oom C? room (0 Kitchen 6'-2" 5,6"---)l rn 3X-I -9=Ofl X- 4-8#r /r I2'-5" ------- ...... --------------------------------- CO -1 Bedroom I Livingroom X-10" v-%j 7-6 6'-8" A -3,-7`11 34-4"- Front of House i CURRENT SECOND FLOOR 34,4„ Nt ,- tV 3=T' 19=2" Front of House PROPOSED SECOND FLOOR 34'-4" 6'8" 11'4" 10V" N Laundry Bathroom 2 `° Room er *2'-4" c� o 9„ 15 ,°' 1, „ .............. --.-------. -------- Bedroom 3 2, 11 -77 c co J c1 N <p w3,5„ - o 19'--2 I 15'-0' I' Front of House 10 5b J • � ZZ F�s:. �............... No. ................ .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -----Towri... ....................O F..........Barnstahle----------•--------------•--------------------- ApplirFatiou for Dispwi al Vorkti Tomitrur#inu Frrutit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Itio -Za•S. ►xiIs...Circle,-- C-enteruilla.................................................................................... Location-Address or Lot No. James K. Smith Barnstable - ............................................... •.........•-•-•...........-----------•--------........------------------------------••---••------- Ow er Address W Vetorino Brothers Barnstable ,.a -------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------- ------------- Installer Address dType of Building Size Lot___5.s-59 -------Sq. feet U Dwelling—No. of Bedrooms................3.........................Expansion Attic ( ) Garbage Grinder (no) 04 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ W Design Flow...................5.5...................gallons per person g day. Total daily flow--__--__•___.330_........_...,........._gallons. WSeptic Tank—Liquid capacity�.Q .0.gallons Length___._.f.6��.. Width....4.'10.'biameter---------------- Depth4...0" x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit.No........ ----------- Diameter.......IQ...... Depth below inlet_...,6.......... Total leaching area....Z6l......sq. ft. Z Other Distribution box ( X) Dosing tank ( ) // Percolation Test Results Performed byC_ j? CQCI••SUY'Vey._CQnsu1ta11tSDate_._.___1 61-7 Test Pit No. 1.......2......minutes per inch Depth of Test Pit....i2 t........ Depth to ground water..nOne.......-_- (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •--•------------------------------•-----•------------------•--------.........-.......__...-----•---.....----------------------------•-•--••---•--------...._. O Description of Soi10.97:9,5..loam•,.... .5-2.0 subsoil, 2•.0-5.0 med. san- � ...--•-••............•-•---••••••graver 5,0 12.0...med....sand..............................................-••••-•• .. .....oF Mgssgo r��j --------------------------------------------------------------------------------------------•------------------------------------------ •.. Off—--Rmwte� ?n U Nature of Repairs or Alterations—Answer when applicably-------- o B-------------C---- -------------- ---•••--••-•------ -••••••••---•---••---•••••--•••••-•••-••••••••••-•••---•-••••--•--••-•--••--••--•-•• ..... Gz CHAPMAN `'' -• Agreement .oP.p�No. 2765�p��� The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys t s dwava N th the provisions of iIT?... 5 of the State Sanitary Code— The undersigned further agrees not t M� m in operation until a Certificate of Compliance has been issued by the board of health. Signe .... --••••-• ................•---- -- Date Application Approved By... .. .. ..._1� �. �.....------ j" z Application Disapproved for the following reasons:.......................................................................... ..Date--•-•----..... -•.................................................•-------------•-------•-----------•-•--...---------------•-•---•-----•••••-•-•-•-----••••----••--U----.....I . h I s ,11 Date . �---------------------- PermitNo......................................................... Issued-.--- .................................................. 11 No.........4 FE ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......TOVM. ........................OF........... aT'A # sc'3 3 Ze---------------------------------------------- p. ppfiratiou for Disposal Works Tonstrurtion Vrrmit Applicatio, 'is hereby made for a Permit to Construct (X) or Repair an Individual Sewage Disposal System at: .................. ....1649jaanAp .................................................................................... Location-Ad Address or Lot No. James K9 Smith Barnstable ... .......................... ........n......................................................................................... Vetorino Brootwe-rs-1. Barnstable Address ...........................g................ ......................................... ............................................. ..... .. .....InstallerAddressTypein Size Lot--Garbage ot---1.5.,-591-------Sq. feet j" U -3-------------..........Expansion AttiA( Garbage Grinder (rio)Dwelling—No. of Bedrooms................ Other—Type of Building ------- --------------------� No. of,persons._._.____._______.____..._.. Showers Cafeteria Otherfixtures ............... .................................I..................................................................................................... Design Flow___________________55.................7.gallons per person per day. Total daily flow.............3.30......................gallons. Sep Length----8-16"- Width...-1+110 jic Tank—Liquid capacitylOOD.gallons 'biameter------------ ... Depth4'.W!.... Dis- _po§al Trench—No..................... Width____._.__.._._.___.. Total Length._______.___________ Total leaching area....................sq. ft. Seepage Pit No........1.......... Diameter.......10....... Depth below inlet.___._!1......... Total leaching area....26.7.....sq. f t. Z Other Distribution box ( X) Dosing tank Percolation Test Results Performed byc.ape...Cod...smrxey...ConwlltiantSDate........7/16/7.9............ Test Pit No. I........?.......minutes per inch Depth of Test Pit.....12-d.......... Depth to ground water---1.1=0---------- Test Pit No. 2... .............minutes-per inch Depth of Test Pit._.__._._.____.____. Depth to ground water...____.._..___.__.__... ------------------------------------------------------------------------------------------------------------------------------------------------------------- 0 Description of Soil.Q.4.Q QJ....loams---- �k A....mt.. .... .........OF ................................. ....................................................... ................................................ --------------I-------------------------i------------------ ........................ - -------------- U Nature of Repairs or Alterations—Answer when applicable_ -- ----------------A ... ... ................. 4F- ______---__a:-________._ AAM ---------*................................:............................................................ .. . .. . . . ... . . .............. f. ....CHAPI Agreement: No. 27654 Q_ The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to Qkkt in Certificate of Compliance has been issued by the board of health. tion until a 7 1 . . . 1 L67--- ............................................................ .......................... Sign ell Application Approved By. . ..... ............ Date Application Disapproved for the following reasons:............................................................................................................... 1 . 1 .7....................................................f.......... .......................................................................................................................................... Date Permit No. -I Issued........................................ ................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH • ....................`CAM...........OF.....58.1mes.table...................................................... wrtifiratro of Tompli'aurr THIS IS`TO CERTI,,FY, That the Individual Sewage Disposal System constructed ( x) or Repaired by.._...........Yqtortno -Brothers ................................................................................................................... ........................................................... Installer at...............Lot----10...S-ean.l.s Circle. MWAMU Centerville. Massachusetts.--•• -` ------------------------------------------------------------------------------------- has been installed.in accordance with the provisions of T i 5 of The State Sanitary Code as described in the application for Disposal Works Construction,' er ........... ............... -THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILk FUNCTION SATISFACTORY. Ins �ttor......... .......................................... DATE.........../4:::.../Jr 7..7...... .................... ........... THE COMMONWEALTH OF MASSACHUS`ETTS BOARD OF HEALTH '79 .......Town......... OF........Parnstable , .......................................................................... No E,.... ........ Disposal Works Tonstrudion Vinutit , Permission is hereby granted................Vetor l.no..B...r.o..th..dr..s . ......................................................................................to Construct'-( X) or Repair an Individual Sewage Disposal System at No.____Wtl.10_.Sean s Circle. Centerville ...................................................................................................................................................................... as shown on the application for Disposal Works ConstructionP Str i eet N Dated.... ....... ............. ..... t1l oar o ea lth DATE ........ .... ................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 5 CA3 l0 ATI 26 SEWAGE PERMIT NO. j , VILLAGE Cam, I 1 S�ALlE 'S NAME ' i ADDRESS i BUILD OR OWNER I \ 7 DATE PERMIT ISSUED L- DATE COMPLIANCE ISSUED lb l O 0 i I � SOIL LOG r _ _ / Y t•VlAdTONE ..LOAM S fILL ' 12" NA% to o • ° I .,�,� 4"C. I. DIST. 1000 BOX I I;.••. ,° 1000 GAL. I ° • I n l0 MIN. GAL. �_ __-______J le:%'° PRECAST OR ��• o 24 4 SEPTIC BLOCK ° . • ' I MIN Arlo I,'• I • ' • • ix TANK 6' I ''eeeD SEEPAGE e.• °i PIT 1 • Ism � . � •0 1 I 20' MIN. --- - — --+� .s • d FOUNDATION I 1 %2" WASHED STONE I I i I ELEVATION SKETCH 10' 1 PERC. RATE: x.� ..f.; SCALE I" = 4' TEST BY : �1 TOWN INSPECTOR BACKHOE OPERATOR:- n TEST MADE ON : rl i 5 is y? 4 K 9 . e a+� �c 14 e� I ill .06 / T aG , • - �7• £t 7 ScaP+•� bees. 1 y .x L t �J�} .�o T ✓O � _ i tit - , TOP--;re- it Kj(,' LO r/o JF 44 y't. f _,Z' f/,G ai.4"4•S Y G'�.c'Y✓s-- y Ti�.•3• T Ti./�" �v-t0��✓C+ .S�/oc...rN �/C`.�'�G�n/ !._3MS .. r✓ �r y � ,�✓-/� .�� UCS C©../.�O✓as✓{iI TO T/�`:" ,G�p✓1,✓r^,/61 - ■. _.roz T"--�.-�. c..c' .K"�4"4�, •2cs7�..7.IL'svr.�' oL Ti+�i�' � 7•s'�c.✓,,.i O�= /�✓=�'�4°✓Y✓ma's✓-r'�✓„�G� �-,..a9 .3S - - - �iti0 (j;4 p(1,4(i X /10 4, t'%A,L /..( CII. ,k' S 7 7 r. too r 9 rr 'SICK s r% � f, ELEVATION SCHEDULE / PROPOSED SITE' PLAN I. INV, AT FOUNDATION `ty SEWAOLr SYSTEW DESIGN P. I N V. INTO SEPTIC TANK IN 3. I:Nv 4UT`OF SEPTIC TANK = `�Jf ��i'F/5�'s?f��`+g.� i�,iy��� 4. INV.. INTO DISTRIBUTION BOX s " Z ? .`. SCALE: 1r-v,20 JQ 19 5. INV. OUT OF DISTRIBUTION BOX _ •�a` 6. INV. INTO SEEPAGE PIT CAPE .COD-.]SURV Y ~WN`SAILi-Al TS ROUTE I32 7, BOTTOM OF PIT o tYA3>rNASS ilk �n ASSESSORS MAP : t7o TEST HOLE LUGS NOTES: s PARCEL: 6q 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH FLOOD ZONE:G SOIL EVALUATOR : M q.6� J.S JHIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF WITNESS : NIA 2 2 A 'b eA E _ BOARD OF HEALTH REGULATIONS. REFERENCE: ` DATE: ao L fiS g C A 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLATION RATE: G m1z / SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO GL-?6 .T S2061.- 0.7 INSTALLATION. TH- I �; p�' TH-2 3 THIS PLAN SHALL BE USED FOR O SEPTIC SYSTEM INSTALLATION ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE f 1 L'L.' Q DETERMINATION. �U,W y Ib ,/ 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS SANS Z- SPECIFIED OTHERWISE) LOCATION MA P(N:T.S 21 I6 � 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A r Pj 16%c/w GARBAGE DISPOSAL. aJ3 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) �l�!i/�VJ MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON S � 2'sy (31 A BASE OF 6"OF CRUSHED STONE. 132 -7,A6 qe0VNVA14-TeX. ?5� 90 vet �. SEPTIC SYSTEM DESIGNAlb wtn4 A) IS-016f- FLOW ESTIMATE .�...._ . 3 BEDROOMS AT fiv GAL/DAY/BEDROOM - GAL/DAY SEPTIC TANK 330 GAL/DAY x 2 DAYS - 6�6 GAL USE �,/060 GALLON SEPTIC TANK-' XlS�N -- � "u/�/ScGfY��vnJ SOIL ABSORPTION SYSTEM 0Nvc&s17¢•y0, 1 C7 `Y (15t> Zafttk& ,e S T GE C' rt& 1� S I DE AREA:rf25)2 1-((- Z1 x 2 k 0,?¢ l Z t — 1 - BOTTOM AREA Z�A /3 x a 2+ - Zoo too SEPTIC S �3w qR0 req�� SYSTEM SECTION � uXrsTtti4 srr , B�t�rr-t�t � , E`, I ,,- o �/ S7)hxx� =:r.4�sye" d� f�41511O k. � a //.33 . �� v6l ec U 7 � , GAL D- OX TO � -- SEPT I C TANKS 17 L!-. \Ia Z3 r j SITE AND SEWAGE PLAN LOCAT ION : 20 3 rn1' 6Re,,iE _ 01140 FRED SPA PREPARED FOR : o 0 [BARREN M. MEYER, R.S. SCALE: a 43 VINE STREET DATE: OUXBURY MA 02332 z DATE HEALTH AGENT (781) 585-0293