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Home My WebLink About0106 SHEAFFER ROAD - Health 106 9-" .— &R RD, CENTERVILLE j A=172-028 No. 42101/3 ORA ESSELTE 10% ® a o 0 G s t-0 i d, r Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. C y e Enterprises ,� Company Name 153 Commercial St. Company Address Mashpee Ma. 02649 c4rrown State Zip Code 508-477-8877 SI 4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/11/2011 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 syk tembowner shall submit the report to the appropriate regional office of the DEP. The original should;be°selit to the system owner and copies sent to the buyer, if applicable, and the appro IVIv g authorify:----— ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address ho"&: ystem ilF e'rform in the future under the same or different conditions of use. 15ins•11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal S am Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 106 Sheaffer Rd. Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 500 gallon leach chambers. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N,ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11l10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must Indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ S 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. t5ins•11110 Tide 5 Official inspection Form:Subsurface Sewage Disposal System-Page 5 of 17. r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owners Name information is required for every Centerville Ma 02632 8/11/2011 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? l ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR.15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name requinform r on is Centerville Ma 02632 8/11/2011 requiredd for every page. City/rown State Zip Code Date of Inspedion D. System Information Description: Number of current residents: 1 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 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date CommerciaUlndustrial flow Conditions: i Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If ,es volume pumped: 1000 gallons Y gallons How was quantity pumped determined? size of tank Reason for pumping: routine 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 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: Tank is original, system was repaired in 1997 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3.5 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 ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 2.5 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: 1000 gallons Sludge depth: 5" t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �~ 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness 2" I Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was cleaned as part of the inspection and should be done again every 2 years as maintenance. Water level was at bottom of outlet invert,tank was not leaking and was structurallysound. Middle cover is on a riser and should be used when cleaning tank. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name equir on Is requiredd for every Centerville Ma 02632 8/11/2011 page. City/Town State Zip Code Date of Inspedion D. System Information (cost.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was functioning as intended,water flow was even to both outlets, no solids carryover,box was not leaking and was structurally sound. Cover is down 2'. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments yt 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02532 8/11/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number. ® leaching chambers number. 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil and stone surrounding leaching chambers was dry with no sign of past saturation. No lush vegetation. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 -- i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every Centerville Ma 02632 8/11/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately w a A-t L(-7 t - Z(o ; A 0-Z- q3 3 H A-3 � 6.3 ys A-Y `70 B-q 3� t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owner's Name information is required for every, Centerville Ma 02632 8/11/2011 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of-design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) i ❑ Checked with local Board of Health-explain: Cl Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sawage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments q 106 Sheaffer Rd. Property Address Anneliese Heger Owner Owners Name information is required for every Centerville Ma 02632 8/11/2011 page. City/Town State tip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION AK 5;46��414 442p SEWAGE # VILLAGE l � �do s. i��i- ASSESSOR'S NW & LOT INSTALLER'S NAME&PHONE NO. 1 SEPTIC TANK CAPACITY LEACHING FACELrIY: (type)//Y (size) il"e906 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 4 Z on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fee of�ac ' facility Feet Furnished.by LA ^J CY i D Y31 7'e/? >? / e 7D. ® tC' DATE: 6/1.8/97 PROPERTY ADDRESS: Howard V. Kitchen 106 Shagg er Road Centervill.e ,Mass . 02632 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1•-1000 gallon septic tank. 2•. 1 -61x8 ' block cesspool. Based bn my Insr�actlon, I certify the following conditions: 1 . This is a -title .five septic system. ( 78 Code ) .2 . The septic system is in failure . 3 . The sewage is up and over the invert & outverts of the septic tank and the invert of the cesspool. SIGNATURE: Name: J . P .Macomber Jr... ------ r--------------- Company: J-. P_M----- - Son- *Inc ., UC�M it q7 3 �j A d d r e s s _-8eac-bg------4------ I's 070�17 __Cent_erville LMass__02b32 60mv9 07 G " l Ph one:___,Sa&-7jc, . j 8------- - 1 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • r4OSEPPH P. MACOItiRBER & SON, INC. Tanks-C*upools-Leachf lelds Pumptd 4 Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 COMMONWEALTH OF MASSA;CHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS C DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617.292-5500 WILLIA%i F.WELD TRUDY COa3 Governor Sccrew ARGEO PAUL CELLUCCI DAVID B.STRUH.' Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissione PART A CERTIFICATION Property Address: Howard W. Kitchen Address of Owner: Date of Inspection: 106 Shaeffer Road Centerville (If different) Name of Inspector: ber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: * Mailing Address: L50x 00 Centervi.l e ,Mass . 02632 Telephone Number: 508-775-3338 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes eaeeds Further Evaluation By the Local Approving Authority ils Inspector's Signature: y hR Date: �O"�— The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: _ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http://www.magnet.state.ma.us/c$ep {'j Printed on Recycled Paper U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 106 Shaeffer Road Centerville ,Mass . Owner: Howard W. Kitchen Date of Inspection: 6/18/97 B) SYSTEM CONDITIONALLY PASSES (continued) Nc&n Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water �O 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 APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: l�1J' The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. d1L) The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presen a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 106 Shaeffer Road Centerville ,Mass . Owner: Howard W. Kitchen Date of Inspection: 6/1 8/97 D] SYSTEM FAILS: You must indicate ei;?,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No /� SC[7 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Pay 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 106 Shaeffer Road Centerville ,Mass . Owner: Howard W. Kitchen Date of Inspection: 6/1 8/97 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. L The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,,,.Aluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 106 Shaeffer Road Centerville ,Mass . Owner: Howard W. Kitchen Date of Inspection: 6/1 8/97 FLOW CONDITIONS RESIDENTIAL: Design flow jjLg.p.d�bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):_ze Laundry connected to system (yes or no):)L.� Seasonal use (yes or no):ziv_ Water meter readings, if available (last two (2) year usage (gpd): j9 q60_e 2 " rode' Z5 '/g Sump Pump (yes or no): IVO A " 6iA4 x),y Last date of occupancy:11& COMMERCIAUINDUSTRIAL: Type of establishment: 1171}- Design flow: A)t'� allons/day Grease trap present: (yes or no)AZO Industrial Waste Holding Tank present: (yes or no)-AA Non-sanitary waste discharged to the Title 5 system: (yes or no)-426 Water meter readings, if available: N19 -d24, Last date of occupancy: OTHER: (Describe) 42d Last date of occupancy: /J GENERAL INFORMATION PUMPING RECORD and ours of information: System pumped as part of inspection: (yes or no) If yes, volume pumped: _ 19 allons Reason for pumping: 4UN TYPE OFF Septic M _�Septictic tank/dr��soil absorption system 4)e Single cesspool / Overflow cesspool ,Ul') Privy AAA Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: oK-s'd Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 l 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 106 Shaeffer Road Centerville ,Mass . Owner: Howard W, Kitchen Date of Inspection:6/18/97 BUILDING SEWER: (Locate on site plan) f Depth below grader Material of construction: _ cast iron �0 PVC_other (explain) Distance from private water supply well or suction line khL Diameter_Al/) Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:�(I o1 ;Q A,) (locate on site plan) Depth below grader Material of construction: l'concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age))i(/ Is age confirmed byCertificate of Compliance (Yes/No) Dimensions: Sludge depth:_ Distance from top��Ydge to bottom of outlet tee or baffle:�l Scum thickness: !r Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom'of outlet tee o baffler_ How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Pump septic tank every 2-3 years • Tnl Pt Rr nutl at tPPq are i UP]ace :T i oyJ d 1 PVPJ a t Wit] Pt inirgrt is tt Tarim-gL;ra no suns of leakage . GREASE TRAP:1+ff8— (locate on site plan) Depth below grade: l Material of construction:ol�oncrete4i metal�oiberglass4)2Polyethylene.(/,LQother(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle:.-A264 Date of last pumping: 4 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Grease trap is no . 12reaent, (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 106 Shaeffer Road Centerville ,Mass . Owner: Howard W. Kitchen Date of I nspection:6/18/9 7 TIGHT OR HOLDING TAN K:Z,12(g(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grader Material of construction A2rconcrete,4Ameta1AXFiberglass/#ZPolyethylene4other(explain) Dimensions: AjA Capacity: gallons Design flow: gallons/day Alarm level: Alar �working order — Yes; — No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) light or holding tanks are not present DISTRIBUTION BOX:/(.0 /`— (locate on site plan) Depth of liquid level above outlet invert: QUA Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Distribution box is not present PUMP CHAMBER:A�kd'- (locate on site plan) Pumps in working order: (Yes or No) A),4 Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump chamber is no -present (revised 04/25/97) Page 7 of 10 a f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 106 Shaeffer Road Centerville ,Mass . Owner: Howard W. Kitchen Date of Inspection:6/18/97 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 0 i leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: �t)'I Name of Technology: Aig Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand o medium boney sand: There is hydraulic failure : Wnste wat.ar is in & over the invert pipe to the ce$snnnl _ , and mast 'hp upgraded +tithe ;1;Lcode o e e o pondinglAii vegetation-- is normal. CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: 1 7 Depth of solids layer: 4 Depth of scum layer: ' Dimensions of cesspool: t Materials of construction: Y" Indication of groundwater: Ajn%AV_ _ i nflow cesspool must be pumped as pan of inspection),a//a J�%1G /�¢�� ,k) Ai2W Comments: (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to medium boney sand: There is hydraulic failure : Waste water is in & over the invert pipe to the ,cessnool:No level nf =ondingo All vegetation is normal. Cesspool is failure . Must be upgraded to the 95 code . PRIVY: .(/Q (locate on site plan) Materials of construction: �/¢ Dimensions: el19 Depth of solids:W Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) rivy is not present (revised 04/25/97) Page 8 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 106 Shaeffer Road Centerville ,Mass . Owner: Howard W, Kitchen Date of Inspection:6/1 8/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 2,* 0 ' w'�g i (revised 04/25/97) Page 9 of 10 Iv SUBSURFACE SEWAGE DISI .. SYSTEM INSACTION'FORM C SYSTEM INFO! IION (continued) Property Address: 106 Shaeffer Road Centerville ,Mass . Owner: Howard W. Kitchen Date of Inspection6/18/97 Depth to Groundwater Dep Feet/'� Please indicate all the methods used to determine High Groundwa.. e:ation: Obtained from Design Plans on record -,Zo6servation of Site (Abutting property, observation hole, bat sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groun : Elevation. (Must be completed) J. P.Macomber & Son Inc . Have installed many systems on Shaeffer Road Centerville ,Mass . Water was never encountered at 12' 39 Shaeffer Road #90-305 ;49 Shaeffer Road #94-207 ; 129 Shaeffer Road #92-216 139 Shaeffer Road #85-891 ; 186 Shaeffer Road #89-25 ; (revised 04/25/97) Psly 10 of 10 �G W V THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title LL CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8. 1995 Acting Director of the - ton of Water Pollution Control TOWN OF BARNSTABLE LOCA11ON ��(� -S�e/4 I'`'�� /P SEWAGE # 7' VILLAGE Ca ASSESSOR'S MAP& LOT L 22. O B INSTALLER'S NAME&PHONE NO. _�T�'_� �.�► �.� !SEPTIC TANK CAPACITY I �� LEACHING FACIL=: (type) aL (,��► N (size) 6 Ck NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: :�! 9 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r i� ,. �� . �, � � � � � � �� vt �� d; i � � `� ® 'S` � � / � � r . �� / . \ � I � � � Q � No. 77 Fee $ 5 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS I Z[ppYication for Mi5pogal bp!5tem Congtructton Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System XX Individual Components Location Address or Lot No.1 06 Shaeffer Road Owner's Name,Address and Tel.No. Centerville ,Mass . 02632 Howard W. Kitchen Assessor's Map/Parcel 106 Shaeffer Road Centerville ,Mass Installer's Name,Address,and Tel.No. 5 U — — Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 Box 66 Centerville,Mass . 02632 Type of Building: Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder�O ) Other Type of Building RES No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily now 3 x 1 10 gallons. Plan Date 7/8/9 7 Number of sheets Revision Date Title Size of Septic Tank Existing 1 000 Type of S.A.S. Omitting cesspool Description of Soil R n n P y nand to m P cl i u m s;a n d _ Nature of Repairs or Alterations(Answer when applicable) 2-500 gallon chambers packed in two feet of stone . Omitting existing cesspool 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 issu by this B f th. Signed Date 7/8/97 Application Approved by Date Application Disapproved for the alow g reasons Permit No. -) > 3vtDate Issued ——— ——— ———— — —————— xh °� l 50.00 No. `. _ Fee Entered in computer: THE COMMONWEALTH.:OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOV p OF BARNSTABLE., MASSACHUSETTS 2olication for Migpotar *`potem Construction Permit V r Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System XM Individual Components Location Address or Lot No.106 Shaeffer. Road Owner's Name,Address and Tel.No. Centerville,Mass. 02632 ;,�, Howard W. Kitchen Assessor'sMap/Pazcel N 106 Shaeffer Road Centerville�Mass I t r' ame,A ress,an Te No. .. Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 Ir : acomtver Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building:� Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder�o) Other Type of Building No.of Persons Showers( ) Cafeteria_( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow_ 3X1 1 0 gallons. Plan Date 7/8/978 Number of sheets Revision Date ' Title Size of Septic Tank Existing 1000 Type of S.A.S. Omitting cesspool Description of Soil Bonet sand to medium sand. L/ J Nature of Repairs or Alterations(Answer when applicable) 2-500 gallon chambers packed in two feet of stone. Omitting existing cesspool Date last inspected: t t . Agreement: `I'" 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 issu by this B ar of th. 7/8/97 .I Signed . Date Application Approved by Date 7. 8 Application Disapproved for the Mlowinjg reasons 1 Permit No. L// Date Issued ---------- ----------- ------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 1 (tertificate of (tompriance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired.�X:j Upgraded( ) Abandoned( )by J.P.Maeomber & Son Inc. at 106 Shaeffer Road .Centerville Mass. ev has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 743V dated Installer Designer The issuance of this vertnibohall4ot--lbe construed as a guarantee that the system will function as designed. Date ' " / ! Inspector No. ��:,3L,�� --------------------------Fee $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogal Opotem (Construction Permit Permission is hereby granted to Construct( )Repair(XX)Upgrade( )Abandon(Y ) System located at 106 Shaeffer Road Centerville.Mass. 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: Construction must be completed within three years of the date of this permit. Date: —7 - ' c1 7 Approved by x .. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISP(-, , WORKS CONSTRUCTION pC,Iml l'I' (WITHOUT DESIGNED PLANS) I, Joseph P.Maeomber__,Ir_.. cQrtily th;�t the application for disposal works construction permit signed by tile J,.1tcd 819� , concerning the prjperty located at 106 Shaeffer Road Centerville ,MA meets all of the following criteria: • There are no wetlands Within 3UQ fc:t of the proposed septic system • There are no priv= Nvells Nvithin 15U IveL of the proposed septic system • The observed groendwater uibk: ftet or gicater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or nccdcd. SIGNED : /v DATE: 7/8/97 LICENSED EPT1C SYSTEM INSTALLER IN'1HE TOWN OF BARNSTABLE NUNMER47 (Attach a sketch plan of the proposed S)s:em. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). � - . .�. �. . �. i _ � . ,,,