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HomeMy WebLinkAbout0587 SHOOTFLYING HILL RD - Health " 7 Shootflying Hill Rd Centerville ,;P A _ 193 ;.019. nI11 AO 2J�0.ECYClF��^. X y UPC 12543 ,o Now � GONy HA$TINQ9,ON No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplitation for Disposal &pstem ConstrUttion 3dPrmit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System 5C Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1?�'� ( V f LC. _ 81ro AlAiA fc- AI&W�M. f4muVwd Installer's Name,Address,and T 1.No. 5d 9*77 M-17 Designer's Name,Address,and Tel.No. C4olo ME EV 4jssm c cG MIA 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 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 Certificate of Compliance has been issued by this oard of Health. S' d Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. "� Date Issued - i No. �l / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for MispoBal .pstem Construction Permit Application for a Permit to Construct( ) Repair 06 Upgrade( )' Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. $87 5'h I f PCl-(I XZ /Lk- Owner's Name,Address,and Tel.No. P) w/Mak, Assessor's Map/Parcel �3 Q ( d 1 V(G.+-_ $ ArNNG E v�,(„VTZ> Installer's Name,Address,and T 1.No. $O$�-477-n'77 Designer's Name,Address,and Tel.No. CAPRO IOE &VTM?4 S'6F- LW-C- �J/ 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Y Title Size of Septic Tank Type of S.A.S. ` Description of Soil j Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: 6 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 Certificate of Compliance has been issued by thi oard of Health. S ed Date Application Approved by f Date Application Disapproved by Date for the following reasons ,, Permit No. Date Issued r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance NTHIS IS TO CEERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( )by (_APC-u_-)I'bE eXA "(S� Us," at Sth2(aF4,y jjj& UILJ., n (l%VIU&-�as been con truce cor in ac e witk the provisions of Title 5 and the for Disposal System Construction Permit No r ted Installer CAREW(DC E ty 1(cfDesigner #bedrooms Approved design flow } / gpd The issuance of this permit shall not be cdnstru/ed as a guarantee that the system will'Z�ction-as.designed. Date ! 1 / InspectorJ / L,1 �--------- - - - -,----J--- ------ --------- ----- -----------t- --- - ----- -------- - No. 1/ 4L� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Nsposal &pstem Construction Permit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon System located at .�g7 .KligoTn-yiuc.,. H!LG. R rmh (� " and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. - Provided:Construction m7�%7W pie three years of the date of this permit. r P Date Approved by / �"'✓ ec031401:51p p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments e I"t"I 587 Shootflying HIM Road Property Address Ln .q Joyce Winer Owner Owner's Name x• information is required for eveq Centerville MA 02632 12-3-14 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 A. General Information filling out forms `\\p�►�unuurtb��i�,�� on the computer, ��� �I"OFt4,,q use only the tab ��ya •• q�;'� key to move your 1. Inspector: -'•yG cursor-do not .lames D.Sears =�: ,1AMES, ':,rn use the return Name of Inspector key. N ;*• ;*` CapewideEnterprises,LLC � r� Company Name C7, \� 153 Commercial Street ,��i��l1�mN Sp�� ` Company Address -- Mashpee MA 02649 Cityfrown Slate Zip Code 50B-477-8877 S 1623 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority QL 12-3-14 .fifspector'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. I t5ins-3ti 3 Title 5 Qffldal b1 specti 14.rc Stbstafece Sewage Dispos I System-Page r o(17 Dec 0314 01:51 p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 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 system is a 1000 Gal. Tank. D Box and four infiltrators 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 year;old is available. El.Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Form_SLksuface sewage Disposal System•Page 2 of 17 Dec 0314 01:52p p,3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owners Name information is requ ired for eyery Centerville MA 02632 12-3-14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpstalarms 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 J] 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 15.3030)(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•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Dec 03 14 01:52p p.4 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owners Name Information is required for every Centerville MA 02632 12-3-14 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 No i less than 6" below invert or available volume is less Y than day flow F/� yry,4 t5ins•3113 Tllle 5 Official Inspection Form.Subsurface Sewage Disposal system•page 4 of 17 Dec 03 14 01:52p p.5 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owners Name information is required for every Centerville MA 02632 12-3-14 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.] ❑ ® 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 I I 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 16.304. The system owner should contact the appropriate regional office of the Department. l5ins-3/13 Title 5 OtTidal Inspection Foam Subsurface Sewage Disposal system-Page 5 of 17 r Dec 03 14 01:53p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owner's Name reg fired for is every Centerville required for eve MA 02632 12-3-14 page. CityFrown state Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any,of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing infonnation. 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): NA Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Wns-3113 Title 6 Official Inspetylon Form:SLbsuface Sewage Olsposal System•Page 6 of 17 Dec 03 14 01:53p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 587 Shootflying Hill Road Urf Property Address Joyce Winer Owner owner's Name requiredred for ef f is Centerville MA 02632 12-3-14 re page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.Tank D Box and four infirtrators. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2012-28,000Gals 2013A5,000GaI s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerclaUindustrial 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: t5ns-3113 Title 5 oHldal Inspection Form:Subsurface Sewage Dispose System•Page 7 of 17 Dec 03 14 01:53p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. CityfTown 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: 12/3/ 13 Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped, gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ InnovaWe/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-W3 Title 5 Official Inspection Forth:subsurface Sewage Disposal System-Page 8 of 17 Dec 03 14 01:54p p.9 Commonweatth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. C(tylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1998 Permit# 98-502 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 8 feet Material of construction: ® concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal.Precast H -10 Sludge depth: 1" t51na-3113 Tile 5 Official Inspection Form:Subwxface Sewage Disposal System-Page 9 of 17 Dec 03 14 01:54p p.10 Commonwealth of Massachusetts Title 5 Official Inspection .Form Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. Cityffown 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 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank and covers at 8"below grade. In and outlet tees. No sign of leakage or over loading_ 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 Sins•3113 Title 5 Official Impaction Form:SubwAece Sewage Disposal System•Page 10 of 17 Dec 03 14 01:54p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owners Name information is Centerville MA 02632 12-3-14 required for every page. Cirylrown State Zo Code Date of Inspection D. System Information (cunt.) 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 15ins-3113 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Dec 03 14 01:55p p.12 Commonwealth of Massachusetts Title 5 official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owners Name information is required for every Centerville MA 02632 12-3-14 page. City[rown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 16"x T-18" Below grade. Box is clean and solid w/one line out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): ' If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: tSins•3113 Title 5 ORLSai Inspection Form:Subsurleoa Sewage Oisposal System•Page 12 of 17 Dec 03 14 01:55p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typeiname of technology. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is four infiltrators w/4'stone. Ck D Box and camera out to chambers. No sign of over loading 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 [Sins•3f13 Us 5 Official Inspection Forth:Subsurface Sewage Disposed System•Pege 13 o►17 Dec 03 14 01:55p p.14 Commonwealth of Massachusetts t WTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments w" 587 Shootflying Hill Road Property Address Joyce Winer Owner Owner's Name requiT dfoton is Centerville MA 02632 12-3-14 required for every page. C41Town 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.): 15ins-W13 Tile 5 Official Inspection Pmm:Subsurface Sewage Disposal System-Page 14 of 17 Dec 03 14 01;56p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. Cityfrown state Zip Code Date of lnspW[on 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: 0 hand-sketch in the area below [l drawing attached separately 3 6f ja FAR -31 ❑� Mine-3rl3 -nft 5 WW4 Inspeialm Form:Subsurface Sewage oisposei System•Page 15 d 17 Dec 03 14 01:56p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owners Name information is Centerville MA 02632 12-3-14 required for every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar Shallow wells J� Estimated depth to high ground water: 91+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Past Report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Past Report Hand Auger Hole 9'. No G.W. bottom of chambers at F below grade. Bottom of chambers at f above Auger Hole. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5inv•W3 Title 5 Official 1nspedion fo w.Subsurface Sewage Disposal System•Page 16 of 17 Dec 03 14 01:56p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 587 Shootflying Hill Road Property Address Joyce Winer Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. Citylrown state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Of ial 1rMP8C60n Form Subsurieoe Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is .required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name ,ab P.O.Box 763 Company Address Centerville Ma. 02632 rerun City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fair ❑ Needs Further Evaluation by the Local Approving Authority 12/26/2007 _) N Inspector's Signature Date of ^�$ ' The system inspector shall submit a copy of this inspection report to the Appro ing AullMrity(goard of Health or DEP)within 30 days of completing this inspection. If the system is 3 Shared cyst or has a design flow of 10,000 gpd or greater, the inspector and the system owne shall submit the report to the appropriate regional office of the DEP. The original should be sen 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. 587 Shootflying Hill rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 •Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 1 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 587 Shootflying Hill rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times.a year due to broken or obstructed pipe(s). The system will pass inspection,if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary.to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 587 Shootflying Hill rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of.a surface water supply or tributary to a surface water supply. 587 Shootflying Hill rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner'should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 587 ShootFlying Hill rd. 12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Fora, _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 , every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have,been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [31.0 CMR 15.302(5)] 587 Shootflying Hill rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:23,000 g ( y g (gpd)): 2007:41,000 Sump pump? ❑ Yes ® No Last date of occupancy: 12/26/2007 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ .Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 587 Shootflying Hill rd.-12/07 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information- Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: r System installed 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 587 Shootflying Hill rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 1 + fee et Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through to house vents. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No , -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gallon Sludge depth: 4 Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness . 1' Distance from top of scum to top of outlet tee.or baffle 5" 8" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured 587 Shootflying Hill rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 587 Shootflying Hill Rd. _ Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NOTE:(Septic tank is in need of pumping.Heavy solids in tank.)Pump septic tank every 2-3years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 587 Shootflying Hill rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 587 Shootflying,Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 587 Shootflying Hill rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber,,condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number:_ ❑ innovative/alternative system Type/name of technology Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil. 587 Shootflying Hill rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts Title '5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection).(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 587 Shootflying Hill rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size El Zoom Out J J J J ,J J J In r7 - _ t V4 \ I 0 201 Fee t — -S Set Scale 1" =,20 I Aerial Photos -- - - C'—,,inh4 Innr.-9fV17 Tn... of P—.f.hlo MA.All rinhte roeenn http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=193019&ma... 12/26/2007. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 587 Shootflying Hill Rd. Property Address Maria Celia Da Silva Owner Owner's Name information is required for Centerville Ma. 02632 12/26/2007 every page. City/Town 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: Bottom of leaching 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole.within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card. ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: USED:Gaherty& Miller model 12/16/94 ground water elevations.USED:USGS Observation well data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 687 Shootflying Hill rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal'System-Page 15 of 15 Town of Barnstable p THE T°� Regulatory Services BARNF.ABLE Thomas F. Geiler, Director y MASS. . 0 `�ATE0.19. Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. COMMONWEALTH OF MASSM HUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION h� A350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 -- — : > TITLE 5 F x OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM =y' PART A CERTIFICATION +' MAP 193—P 018 ; Property Address: 587 SHOOTFLYING HILL ROAD CENTERVILLE,MA 02632 Owner's Name: FRQ4EMORE,ELIZABETH Owner's Address: 2582 S.MAGUIRE ROAD#130 OCOEE,FL. 34761 Date of Inspection JANUARY 13,2005 AP Name of Inspector:(please print) JAMES D. SEARS O Company Name: A&B Canco f,I�CEI.- Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approv;._:g 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 tot he buyer,if applicable,and the approving authority. Notes and Comments "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. Title 5 Inspection Form 6/1512000 I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: FINNEMORE,ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CENTERVILLE,MA 02632 Date of Inspection: JANUARY 13,2005 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 CUR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A 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 exfrltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with 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: Title 5 Inspection Form 6/15/2000 2 r Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: FINNEMORE,ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CENTERVILLE,MA 02632 Date of Inspection: JANUARY 13, 2005 C. Further Evaluation is Required by the Board of Health:N/A 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 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 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: Title 5 Inspection Form 6/15%2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: FINNEMORE,ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CENTERVILLE,MA 02632 Date of Inspection: JANUARY 13, 2005 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 leaching is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) i� 0 (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: N/A To be considered a large system the system must service 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 11 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 is 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. Title 5 Inspection Form 6/15!2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: FINNEMORE,ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CENTERVILLE,MA 02632 Date of Inspection: JANUARY 13. 2005 Check if the following have been`done. You must indicate"yes" or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes 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)[310 CIvIR 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: FINNEMORE,ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CENTERVILLE,MA 02632 Date of Inspection: JANUARY 13,2005 FLOW CONDITIONS RESIDENTIAL-./ Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2002-75,000 GAL./2003-63,000 GAL./2004-45,000 GAL. Sump pump(yes or no) NO Last date of occupancy: 6 MONTHS COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 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: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution boy,_soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or noxif 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 copy of the DEP approval Other(describe): _ Approximate age of all components,date installed(if known)and source of information: 1996—PERMIT#98-502 Were sewage odors detected when arriving at the site(yes or no): NO OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: FINNEMORE,ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CENTERVILLE,MA 02632 Date of Inspection: JANUARY 13,2005 BUILDING SEWER(locate on site plan): If Depth below grade: 6" Materials of construction: Cast 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(locate onsite plan): if Depth below grade: 8" Material of constriction: _ 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) Dimensions: 1500-GALLON PRE CAST Sludge depth: 12" Distance from top of sludge to the bottom of outlet tee or baffle: 18" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: AS BUILT&TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL—NOTE:TANK SHOULD BE PUMPED. INLET TEE,NO SIGN OF OVER LOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A 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 baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: FINNEMORE,ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CE RTERVILLE,MA 02632 Date of Inspection: JANUARY 13,2005 TIGHT or HOLDING TANK: N/A (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: (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 IS 16"X 16"-20"BELOW GRADE,ONE LINE IN—ONE LINE OUT. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. PUMP CHAMBER: N/A (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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: FINNEMORE,ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CENTERVILLE,MA 02632 Date of Inspection: JANUARY 13, 2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: 4 leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS FOUR(4)INFILTRATORS WITH 4' STONE,LEACHING IS 28"BELOW GRADE,DID TEST HOLE ABOVE DRY—NO SIGN OF OVER LOADING. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXlocate 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: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: FINNEMORE,ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CENTERVILLE,MA 02632 Date of Inspection: JANUARY 13, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i Title > Inspection Form 6/15 '2000 10 \ • M Page I 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: FINNEMORE.ELIZABETH 587 SHOOTFLYING HILL ROAD Owner: CENTERVILLE,MA 02632 Date of Inspection: JANUARY 13. 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 9 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: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND DUG TEST HOLE 9' NO WATER. BOTTOM OF LEACHING 4' ABOVE TEST HOLE. N� wi3Yz;t Title 5 Inspection Form 6/1 5i200i) . 1 TOWN OF BARNSTABLE LOCATION / S/>`B®�/�LY/�//� /�/<< SEWAGE # VILLAGE C£'y 7 ASSESSOR'S MAP & LOT 3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S ioiO C-- llt,-y""Or LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching�ffaci 'ty) Feet Furnished by N C 0 ��� '�..+..: .+-r.�.-JJi �A� 3� ��- o �� ��' �'3� y 1 No. ^' `, + <e Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppricatfon for Migpool *patent Con6truction Vermit Application for a Permit to Construct( )Repair( )Upgrade( ,)Abandon( ) $4.Complete System El Individual Components Location Address or Lot No. �!a �) e� Owner's Na�m+e-,Attddress and Tel.No. 1ta Assessor's Map/Parcel1 — 0 on Installer's Name,Address,and Tel.No. Designer'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 '_y9, gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1-iaz Type of S.A.S. -;air, Description of Soil Nature of Repairs or Alterations(Answer when applicable) 37 9q161 �� L 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 hi and of H `L c Signe Date Application Approved by 'Date Application Disapproved for the ollowmg reasons Permit No. © a-- Date Issued V No. — � ft��_ 4- Q!•. *� � Fee C� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for Migpogar *p!Aem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) ,Complete System . .El Individual Components Location Address or Lot No. � Owner's Name,Address and Tel.No. Assessor's Map/Parcel G � �� c. 1q3 Installer's Name,Address,and Tel.No. Designer'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 3 d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of SepticTank 1 jaD Type of S.A.S. t c,�pe C�fad i" 3 titi1 t , _ Description of Soil Nature of Repairs or Alterations(Answer when applicable) \ lT/�n \ T t^ 4l-Ca�lr�c�+Cj Date last inspected: Agreement: 41 The undersigned agrees to ensure the construction and maintenance of the afore described on-sitee 1 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 Bard of He t 1 SigneT Date Application Approved by to Date _/ Application Disapproved for the following reasons ,t F ( Permit No. d a— Date Issued --------------------- --ire'=----- -- , J THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS.IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(X) Abandoned( )by iWVV ,A ) 5 S'- cc, (Z_VZ�_ at 15497 ICJ T— has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 'dated Installer Designer i; The issuance of this permit sh 1 not be construed as a guarantee that the system will function as designed. w Date_ Inspector No. i 1-,�/7 a-, Fee ) r' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSET`I•S Migpogar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(V- )Abandon( ) System located at 7 wTI 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: T� Approved by 0 . 1 NOTICE: This Form Is To Be Used For the Repair,0 Faded tems Only. Y Septic Sys t CA'f I4N OF SKETCH AND APPLICATION FOR CERTIFI ITHOUT L WORKS CONSTRUCTION PERMIT .• DISPOSA -� ENGINEERED PLANS hereby a mify that the application for disposes works �f «shstnlction permit signed by me d concemingthe ¢ Bets all of the m � property ltd at y • s x: 7rte ire eewdland�leeeted wkhM 100 fkt oldie repwd lmbMs IkHy : ' • eeptic ! y t7 wells within 130 IM of the rvpo� Theme��prhNe M nse PraPo'ed Theta to fie Maease in f law�+d►or dame ,r � !d Theta de eeed. i halt r wf n be located wNhM DSO hd of anlr wetlands,the bottom ofthe' if Iqs than Ibmteen(14)fed above the maximum adjusted p�P- leahhtg hollow will be looted , i . d Mlle elev�tlon. . 4 late the>Tt oomess j :: please eetetP Dlvleien o.1.3.maps �`D . A)To of Oreund Bleratlon(aeeo�dhtt to the 6npMeKln6. �N►et1 Map)..�.- 9) , dtdwater Tebk Btenetien(aeCordMs b Neekh Dlvis TSB ; • 1 DATE: } F MGM rr Sf1 C��gM MSfA Llt M TNB TOWN off BARNSTABLE NUMBER F it a aft 4 Atha It 11oMd MNu ►"own plel d1M. Aid pgposig tAMA It IBM pMe doold be 611M U$ ' f p-....•.w �«-.. ..tiRnr..i.xW.. -.. .. ..� .. Vf+lvrinh-•W. ..MN[i+ewshAkWnMW411WwrM�y. , ` ' a��� '' ., , �,. D i � s a C TOWN OF BARNSTABLE LOCATION SEWAGE # � VILLAGE CAA X ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 9&41e/l IGcs�c-c ` SEPTIC TANK CAPACITY p'. LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUELDER OR OWNER r � PERMIT DATE: •_� _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 vv 2 A (37 !AIL, 3 A3 1 G TOWN OF BARNSTABLE LOCATION SEWAGE # � VII LAGE D A ASSESSOR'S MAP & LOT_�3-0y INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) r (size) Af1—uQ� NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: K C /f7 OMPLIANCE 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 Q CA - -----------a v � 2 - 37 2-1- 113 A3