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0034 SHORT BEACH ROAD - Health
34 Short Beach Road Centerville A = 206 041 152113 ORA 100/6 P2 J i TOWN OF BARNSTABLE LOCATION 7 BYO{�'� ��j SEWAGE # /i me � P VIiLAGE le�'/I✓ ice (////� ASSESSOR'S MAP & LOT _DQ 'J INSTALLER'S NAME & PHONE NO. 0 ,//�4 Gi 1l, �, /�/ f J6,>n ; SEPTIC TANK CAPACITY �� ��G- LEACHING FACILITY:(type) /�{- ;.� (size) NO. OF BEDROOMS a�l PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: q/�) DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r Al. 1. , r �/ eivc VDA\ lF, slt�i�I,4 1 XNo - •.......... Firms ....�......... THE COMMONWEALTH OF MASSACHUSETTS eLa6' A P P R O V E D BOAR® OF HEALTH Barnstable conservation Commission TOWN OF BARNSTABLE V11F Signed tR �s��fi 9flit BililDiial larkfi Tonotrurtion rrmit J Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: ...34 Shortbeach Road Centerville .................................•--------•-•---•----........_.......__....--•------------ --•-•-----••••-••.....................-------------•-----•-------........----•---................. ocation-Address or Lot No. . Agnes Haven G ancy .................•-......----................---•------------------ ................................................................................................. Owner Address WJ.P.Macomber �l^-.-••-•-•-•------------------------•-•---•----------- --...•----•-••••-••••......-••----••-•---••----.......-----........-•-••----•--•--...------..... -------------- ------------••-•-• -- Installer Address dType of Buildin Size Lot............................Sq. feet 4 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a _ — pa Other—Type of Building ____________________________ No. of persons............................ Showers ( ) Cafeteria A4 Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of,Test Pit---................. Depth to ground water........................ -----------------------------------------------------------•------•-------.......-••--•-•-•-._...••.......................................................... 0 Description of Soil_Sanc7---•-••--•-•••--•--••-•--•-•-•-••-•---•-•---••••-•-••-•••••-•-•••••........................................................................................ x U •-••-•-••••-••-••--••--•--•-•-••-•----••-•-••---••••••••-•-•---•-•••••-•••-••-•---••••.........•••••-••••••----•••-•--•••••--•-••-••••--•----•-••--••••-•-•-•--•••--•••-••...............•............•. W 1-10,00 gallon tank,l um chamber U Nature of Repairs or Alterations—Answer when applicable______________________________..._________............._.......X?.............._.............. with li�'ht and alarm. 3 infiltrators --------------------------------------------------------------------------------------------------------------------------------------------------------------------------•••-•-•--•........_.....••-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has b n is ued by t board f health. Signed . .. r:------I------------------- -----9/..2 l91.......... Date Application Approved By . ---- --.0........ . . ... . .. . ... ................................. ................Date ................ Application Disapproved for the following rear s- -------- ------------------------------ ---------------------------------- --------- ------------------------------------ - - - ------------------------------------. ----------------------------- Da e PermitNo. �.�... .. ........... ............. Issued --------..................--.....------------........----------- Date _ 1 No Fps....3................. THE COMMONWEALTH OF MASSACHUSETTS Zofv BOARD OF HEALTH 641 l ' , TOWN OF BARNSTABLE1�1 �;�' �ttrtt# Mitt�nx �t���a,>��at >arr�.� .Cn�at�#�ttr#tDltt .ernti# Application is hereby made for a Permit to Construct ( ) or Repair'(X4 an Individual Sewage' Disposal System'at: 34 Shortbeach Road Centerville ................_................................................................................ ----...-•--------------••-----•-----------------------•-•-----•--•-----•--......---- ocation•Address or Lot No. Agnes Haven G anc,y ......................-.......................................................................... ..........--......................................._.............................................. Owner Address J.P.M cS2rr P X...In................................................... -•------•-•--•----------••----._.....-----..__........---......---..........--•-•--............... Installer Address UType of Buildi 2 Size Lot...................:........Sq. feet I—. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter---............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft. z' Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------...................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1T4 Test Pit No. 2...........-- minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -----•-•----------------------------------•-•-•-•••------•••-•-•••---••••-------.....•-•----._................................................................ 0 Description of SoilLSaricT W ----------------------------- ---------------------------------------------------------------------------------------------------------- -----------------------=•-•-••--•-••.---•ri-----b••-- 1-1'' gallon purrp c a,., er U Nature of Repairs or Alterations—Answer when applicable............:.. ----------_---._-____-___.._.. with li ht and alarm. 3 : nfi1`rators -------------------------------•--------------------------------------------------•--.....---------------...--------------------------------••----------------....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions,of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has be issued by th board 6f health. Signed .. -f" . /�j� Dace Application Approved BY f�'�' ' -- �/_ ^---4— '--- Da e Application Disapproved for the following rear��s- -- -------------------- -- ---- ------------------------------......................................................--------- -----------------.............................................. Dace PermitNo. -��.. ..--r-- ---I--- ---------------------------------- Issued ...------------------------............................--....... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE &rtifiratE of ( raptiana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by J.P. Macomber Jr .........................................................---------------- .........---------............----------------------------------------------------------------.-.............................................. at 4 Shortbeach Road Centerville lnscalle, .. ............................... ..................... .............. .. .. ....................................................................... . ........ ................................................. has been installed in accordance with the provisions of TITLE 5 , he S#Xt., E vironmental Code as described in the application for Disposal Works Construction Permit No. .......�f �T'`. -.... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE ,THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ( 7"-, Inspector ector .............. / j DATE...............................f ( rl� ��THE 'COMMONWEALTH OF MASSACHUSETTS �✓ BOARD OF HEALTH (�( TOWN OF BARNSTABLE No. i. FEE.... ......: .... J. .Macomber Jr. Permission is hereby granted.............................................................................................................................................. to Constr ct or R a' n ndiv.:du Disposal System 3 f(hdrLbeeFc'1'� ( do teri ZLl P atNo.... •--•••-••---......•-•••-•.......•-•------•----••-••-•-•--•••--•-•---.....---•----•...--------------- t_: l...__..d........... Street .rt Dated..___.._. as shown on the app-cation for Disposal Works Constructio ermit No______________,__ ���/ ........__-..... 'n - �r--- ... G� Board of tHealth DATE �._...•.�- i -1.................................. t FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS r Town of Bar,: stable • Public Health Division �»� 'goes Po&'; Q k. RARIM 200 Main Street 111 0[a lie �� Hyannis, MA 02601 ' ' Y FS 02 1A $ 05.210 7006 2150 0002 1038 6674 0004606238 FEB11 2008 MAILED FROM ZIPCODE 02601 ® -' _ . ._. N1X2E: 0229 5C 1 02.E 02117/09 RETURN TO SENDER IJIi VACANT { UNAEBL-C TO FORWARD E-C: *0969-021 79-1 1-39 ®�� �� MII„►1,1►11„11,,,,,,11,1„I11,,,11„►►,1 fill),,11,,,,11111 I SENDER: • COMPLETE •N COMPLETE THIS SECTIONON DELIVERY to ■ Complete items 1,2,and 3.Also complete A Signature f " Item 4 if Restricted Delivery Is desired. X ❑Agent i ■ Print your name and address on the reverse ❑Addressee 1 I so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery I ■ Attach this card to the back of the mailpiece, I or on the front if space permits. I I D. Is delivery address different from item 1? ❑Yes A 1. Article Addressed to: If YES,enter delivery address below: ❑No I l J ran eS J JDu CK-0 - 3 He SM"J- 6,eA r-l �• 3. Service Type l� IN Certified Mail ❑Express,Mail I ,.. ❑Registered i Return Receipt for Merchandise I ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7 p 6 2 ,5� p 002 1038 6 6 7 4 I (rmnsfer from service laben ; � �; Ps Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 �p IHe rp� Town of Barnstable Barnstable If ( � . , Regulatory Services Department : IIARNST ABLE, D til T MASS. � Public Health Division o�ATfD'MA�A' 200 Main Street, Hyannis MA 02601 2007 Thomas F.Geiler, Office: 508-862-4644 ,Director FAX: 508-790-6304 Thomas A.McKean,CHO February 8, 2008 James Bourke 34 Short Beach Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 34 Short Beach Road, Centerville MA was inspected on July 9, 2007, by Joseph Smith, certified Title V Septic Inspector for the State of Massachusetts. r e ,( E1. .i e'r�c'•+� y r'' �'1 The inspection of the septic system showed that the system PASSES under the guidelines of 1995 TITLE V (310 CMR 15.00), however it passed for the realty transaction only. Therefore, you will be ordered to upgrade the septic system prior to any home construction or renovation. Failure to repair/replace the septic system in, accordance with this notification will result in future enforcement action. P ER HE OARD OF HEALTH k Thomas McKean, R.S., CHO ,`t r • Agent of the Board of Health `rn l:�R�`CF1�ar �VL. r- t , I 1. Q:\SEPTIC\Letters Septic Inspection Failures\34 Short Beach Road.doc TOWN OF BA TA)l3LE LOCATION S�� L7�w.��n SEWAGE# VILLAGE C'"A�f�/i I�Q• ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. ' SEPTIC TANK CAPACITY UQ '6i r 1(ti-� 14 LEACHING FACILITY:(type) i n�,1-�CAOCS V (size) NO.OF BEDROOMS OWNER BOU C 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 V T,. ®MNl =:vw.r�+� i4� Al 7 i3 I - I t f3Z - 15, ® ` C 3 - ZZ G u Z7 0 D3 - 14 rE yv r 6 SO f SHUi<i $EACR ?,,b . of Y eH roh- Town of-Barnstable Barnstable ti Regulatory Services Department "m,e, ac , nAnNS'rAnLE, : MASS. 0 039. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO February 8, 2008 James Bourke 34 Short Beach Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 34 Short Beach Road, Centerville MA was inspected on July 9, 2007, by Joseph Smith, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system PASSES under the guidelines of 1995 TITLE V (310 CMR 15.00), however it passed for the realty transaction only. Therefore, you will be ordered to upgrade the septic system prior to any home construction or renovation. Failure to repair/replace the septic system in accordance with this notification will result in future enforcement action. P ER HE OARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health C��T�E,G a ��, - -,�c� a�� a �o3a ��-►y Q:\SEPTIC\Letters Septic Inspection Failures\34 Short Beach Road.doc To:Laura Thomson Page 4 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal`System Form.Not for Voluntary Assessments P\roperlyAddresa - -- - _-- Owner informaltonia �=,� required to '�L1\` � r,7 every page cltyrre>wn ��O +_L_1J 0- Rate Yip Cods Date of q,dpedion Inspoction result*must be esubFnkWd On this forth.Inspection forms may not be altalvd In any way. important: A. General Informlition forms t illli out S - farrnl;on tr . computer,ate 1. Inspector: Only tha tab key to fnellro your r � � etNlsW'• 00 t4f Of Inc der ."�_ � ._"—r-,_• key. OOnV�ny Na"10 .. t r Rev-• yi _ `ter �Y�� - - CompmyA;daeea 111 0ti� 'lty/rtrrrn . . - - �1. ..... Zip C-04 1-Wise Number a. Certification _t I certify that I have personally Inspected the!farrago disposal system at thi7411 s adtlrAss and th8t the ` information reported beiesw is true,accurate mid vornplete as of the time of the inspectioh.The inspoCtion a3 was performed based on m training end e Y 9 xperlence in the proper function and maintenanie of on'site sawage dispos4s l syateme, I am a DEP t:QprOved 6y$t0m lnspector pursuant to SeGtI011'15,M of, Title 6(310 CMIR 15d000).The System: z. Passes (1 Conditionally Passes 0 Falls CD �'- Needs Fu r Evaluation by the Local Approving Authority • � ��aft The system inspector shall submit a copy of this Inspection report to the Approving Authority(130ard of Ifta th or DEP)within 30 days Of uumpleting this Inspection. If thb Systarrt is a shared System or has a d6si011 flaw of 10,000 gpd or greaten,the inspector and the system owner shall submit the report to tho appropriate regional office of the DEP. The original should be sent to the system l)or and copies sent to the buyer,if eiicable,and the approving authority_ This report only describes conditions at the time of Inspection and under the conditions of use at that Um+a_This InSPOCtion dons not address how the system will perform In the future under tho Rams or dirforontt Conditibns�of use. trl' r ckN'vY, Tl-% J Feria.bu0a�deo¢Sowa U+spes+lyatemC•Pyr- t 1 pr we, V-V.Nk vA-- .�1�p t'er.�3\/4A'"6— a'C' CA3 -`A-4'U IA;W-%) r To:Laura Thomson Page 5 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO , y Commonwcaith of Massachusetts Title .5 Official Inspection Form Subsurface Sewage ;Disposal System Form-Not for Voluntary Assessments ILA ProPertyAddreea -- - .� .._ ._.—. ••-- -- - Owner _... .— .... , owner's fume Infemieft Is evasypfte• 0wrown state Zip Code Dstebtlnsiectl _�_... B. Certification (con#.) - - Inspootion Summary:Check A,B,C,D or E i always complete all of Section D A) 5yatem Passes: Q I have not found any information which indicates that any of the failure criteria described in 3`10 CMR-16.303 or in 310 CMR 16.304 exist.Any failure criteria not evaluated are indicated below. Comments: � j 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 coropletwn 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[D for the following statements. If"not determined,"please explain. (j 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 extiltration 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 Heakh. A metal septic tank will pass inspection if it is structurally sound, not leaking and H a Certificate of Compliance Indicating that the tank Is Was 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 pips(s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Heard of Health)- ❑ broken pipe(s)are replaced ❑ obstruction is removed �IVB To 6 Qtlola!Inepecuon Foes SunaiMO 60"4*OirpoaW Sybtem•Pape 2 of 15 To:Laura Thomson Page 6 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO i Commomaemm of Massachusetts Title .50 icial Inspection Form Subsurface SewaSe Disposal System Form-Not for Voluntary Assessments Owrrer Infarmathnis %t Owner's erne !y� every prlga- CWTom state Zip Code bate bt IkIon B. CertlfiCatiOn (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 Hoard of Health): ❑ broken pipe(s)are replaced C7 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 15.30$(1)(b)that the system Is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of health(and Public Water Supplier,If any) determines that the system is functioninS in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and sail absorption system(SAS)and the SAS Is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ the system has a septic tank and SAS and the SAS Is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS Is within 50 feet of a private water supply well. lansp eoe-Ma 1 WO S OtGGal Impec6m Far:subaurram Sewaw Uroposw system•Papa 8 d 1b To:Laura Thomson Page 7 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO e . Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface$swage Disposai system Farm-Not for Voluntary Assessments Property Addresslug OwnerOwners — — tnforrriattatls riarr>e •----.. _— ._—. „— . requlmd if C�lv1�•tfiV\ -91 every P6201. Ctcyrt own —— — d v�__. 5�te zip Code D818 of ipn 6. Cartiftatton (cent.) C) Further Evaluation Is Required by the Board of Health(cost): 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 weN'". Method used to determine distances: This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria trKrIC81e6 absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure cn'teria are triggered.A copy of the analysis must-be attached to this form. 3. Other: D) System Fallure Criteria Applicable to All Systems: You must Indicate"Yes"or"Now to each of the following for of inspectiorm: Yes No ❑ Baokup of sewage'l to 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 Sri due to an overloaded or dogged SAS or cesspool Sta be liquid level In the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is hues than 6"below Invert or available volume is less than%day flow 0 Required pumping more than 4 times in the last year NOrdue 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 6� tributary to a surface water supply_ �up.dac•papcs 716E 5 offlo l Iuspectim Form:SUDWJKOO SOWSP DWal System•PW 4 of 1S To:Laura Thomson Page 8 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO Commonwealth of Massachusoft Title 5 Official Inspection FormSubsurfaceI3@wage Disposal system Form-Not for Voluntary Assessments Aroperty}�ress —�'--- —..— Owner Owned—Nam meme —— —— — — — Inftxrrtathn Is — — — —— requrred br ,� — —J — —. every p9r ge. Gtytrown _ _— — Q�L 3� i� d State Zo Code Ci. Certfficiitfo (c(cry (ont.) �~— D) System Failure Criteria Applicable to All Systems(Cont,): Yes No ❑ Any portion of a cesspool or privy Is within a Zone 1 of s public Well, ❑ Anil Portion of a cesspooi or privy is within 60 feet of a private water supply ❑ 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 PMOS N the well water analysis,performed at a DEP certified laboratory,for fecal collform bacteria Indicates absent and the presence Of ammonia nitrogen and nkmt@ nitrogen is equal to or less than iS ppm. Providand chain of custody nwst be attsthat no other failure ehed tola are this 0 6Qpy of the analysis ❑ The system 16 a cesspool serving a facility with a design flow of 2000gpd- 10,0009pd. 4 The system Lsys.I have determined that one or mare of the above failure criteria exist as descidbed 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. lv , E) Large Syatems: To be considetatl 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"rW to each of the following, in addition to titre questions in Section D. Yee No ❑ >fj 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 d ❑ 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 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, i�sD.dOG tl6+ae TKtg s OhwMi inspeulon fam:6u05WO..P9$mape uvoaq System•Pap for is 1 To:Laura Thomson Page 9 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments — UV - PmpartyAddreag owrw Owners Noma '-- — — —-- — _ bfofmstbn Is — every pope. ollyrrown state Zip Code Dal of IAs on paw G. Gheyckli$t --- • - .-.— Check if the following have been done.You must indicate ayes"or"no"as to each of the following: Yes No ❑ X Pumping Information was provided by the owner,occupant,or Board of Heddth ❑ Were any of the system components pumped out in the previous two weeks? d Has the system received normal flows in the previous two week period? ❑ ?tr( Have large volumes of water been Introduced to the system recently or as part of t� this inspection? ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) f ❑ Was the facility or dwelling Inspected for signs of sewage back up? ❑ Was the site Inspected for signs of break out? Q Were all system components,excluding the SAS,located on site? ❑ WOM 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$oll Absorption System(SAS)on the site has been determined based on: C❑ fix Existing infa►matlon. t=ar example,a plan at the Board of Health, (�l q Determined in the field(If any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] Title 5 Offidal Irdp"an Fovw s4usutfeoe Sowape nf.poset system•pne 8 of 16 To:Laura Thomson Page 10 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage disposal System Form•Not for Voluntary Assessments Property Address ---•-- -. _._.,__._ . Owner O�4ers Name loformafbn Is required fa �L� �`� v�a 6 �_.� u7 every page. cityfrown state zip code Date or Inspedfon — D. Systems information - - Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 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 evailable(last 2 years usayu(gpd)): - — Sump pump? ❑ Yes No Last date of oompancy: 7 q7.0 7 Det ` Commerclalllrtdustriai Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gaao per day Basis of design flow(seats/persons/lsq.k.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, N available: - — Last date of occupancy/use: pate Other(describe): t51t1R0 sbC �� 7116 6 04QW1 IMMC9WI Farts;Stwarfaae SGW&p DisposM SySt"•Page 7 61 It, To:Laura Thomson Page 11 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO COMMOWOalth of Massachusetts lug �,�A 11.,A' 14 Title 5 Onicial Inspection Form BubaurfaCe Sewage blsposal System Form-Not for Voluntary Assessments Prop@rtyAddresg '— - -•.— ._. ..r. _.—.. . . _... _ _.—_— •_ Owner owno►'s N JnformatlC)Is re {l J,`\ ,, '— quired >ir V� � Ux n every Pfia 0. Cfty[Town _ State Zip Coda Pa of I aion D. System Information General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes fr'�"f No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: _ _. .. _... _... Type of System: KSeptic tank,distribution box,soil absorption system ❑ Single cesspool overflow ompool 0 Privy ❑ Shared system(yes or no)(if Yes,attach previous Inspection records,if any) ❑ Innpvative/Aftemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEFT approval. ❑ Other(describe): ApprroAmate age of all components,date Installed(if known)and source of information: Were sewage odors detected when arriving at the site? [] Yes No I tWWP.mc.oaas Tqb 6 ONrolpl kKp00BOf1 iBf/n:Sulairiace aOWApB 016poe81 Sye[erel•pap 8 d 1b To:Laura Thomson Page 12 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO q Commonwealth of Massachusetts Tine 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Ownef s Name req�recf bra _ every page- Cityll own We zip code Dal of IftpectiN — 0. System Information (wrtt.)T r �� Building e9wer(locate on site plan): I Depth below grade: . Material of construction: Xoast Iron ❑40 PVC (j 901or(explain): Distanoo from priVOte water supply welt or suction line: --_.__._.... ._..... feet Comments(on tond'ition of)oh1ts,venting,ovSidenoc of looKagv,vIv..): ` � ,ti,,, : J�c�- \499�c. Ij Septic Tank(locate on site plan): t Depth below grade: . --- feet Material of construction: q4eoncrete ❑metal ❑fibarows D polyetilytene otl►er.(explain) If tank is metal,fist age: ___ .._.._.._ ._... years Is age confirmed by a Corttfraatc of Complianoa7(attach a copy of vortificatc) ❑ Yea [] No ailtteil>fiarrs: cSv v 1r a� `6' (+►t(�.-7 ��+ �u� ► is `bt 4� f_ I 1 Sludoodepth: - i.. .._.... Dittanco from top of studde to bottom of outlet tee or baffle - - - -- , II Srum thickness — — -- Dletanco from top of scum to top of cutlet We or baffle Distance from bottom of scum to bottom of outlet too or baffle � J How were dimensions determined? i5lnsp.eae.09A8 7m 6 olrew Invw4w loam:So—& a Disaoad syuam-Pale C d 1r, To:Laura Thomson Page 13 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address _...._.... Owner informe tW►18 - mquked c Ram every pots eY State Zip Code Data of Ink*cuon 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.): l 0\ky -T.ms, c ..1►.j- ,-... 4 ��. `i�rvrJ►vtR\ ti1CAAi„0 I\ I' J rya r�n S!c'a;\ Gvlc�+tmC� ov Grease Trap(locate on site plan), Depth below grade: feet Material of construction: 0 concrete []metal ❑fibwgiass []polyethylene El 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: Rate 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: D concrete 0 metal Uj fiberglass ❑polyethylene other(explain): trdvep.aoe•oemis TRm f ofrzw Dlep ai System-ram 10 of u r - To:Laura Thomson Page 14 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System storm-Not for Voluntary Assessments Property Address -- Owner owner's Name intormatim is required for v:� .... _ QT gib.... of1 -— evory pays. Cflyr town mate D. System information (cant.) �.. Tight or Holding Yank(cunt.) Dimensions: Capacity: - - r gallons Design flow _....__.. _...._..._... gallons per day Alarm present: d Yes © No Alarm level: -- - Alarm in working order: E) Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping eontrw(required). Is copy attached? ❑ Yes CJ No bistribution Box(if present must be opened)(loca(e on site plan): Depth of liquid level above outlet invert -- - �-� Comments(note d box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): \ � CAKf cNtr �• Pump Chamber(locate on site plan): Pumps in working order. Yes ❑ No Alarms in working order. Yes ❑ No ewmnaoc•oeroe rue s oar�inpeNlon Form.S�cw1�o.&ow.�.dwpaeat system•Pafle n a 15 I To:Laura Thomson Page 15 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO Commonwealth of Massaobuseft Title 5 Official Inspection Form Subsurface`Sewage Disposal System porm-Not for Voluntary Assessments �A propony OWneInformatim Is _-- requlrod 6t every par. CO/Town tip Code ` pedlorr D. System Informatlon (cont.) Comments(note condition of pump chamber,condition of pumps and appurtenances,eta.): r.. �_ r. o u � ��sue_. ,,� c•�. 1.n ��e�, Soil Absor on System(SAS)(locate on site plan,excavation not required): If SA£not located, explain why: Type: ❑ teaching pits number: - ($'� leaching chambers C ir .l5� number -.._ ❑ leaching galleries number: - - ❑ Waching trenches number,length: — ❑ leaching fields number, dimensions- — —- ❑ overflow cesspool number. - - -_ ❑ innovativetaltemative system TYpelname of technology: _.._. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): pp taaa•oeros Tlfk 6 ClftlalAl Inepedw rwm:l+ubv�feoo 8ewaye rhyp,sei byRem•f'apo 12 0l 15 0 - r m c _ HW Co co 0. WL- -, --- � - - f -�" STK �- 5.4 F,LE a 5." GS ! 5.87 G'� Gs 6 1NPIIE ✓ GS s rr; 6.50 GS - • 6 26 6. .2 G5 SH SHD Hv =- 6.85 6'.56 G 6.43,SH J H� j GS i - 6.96 W r _ FOP OP co .67 t O --� EPrcvR 99 15 H20MH G . Q7 GS G5 f58 �d , — 7.61 SSG R $ r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dlspossl 8yrtem�7Form-Not for Voluntary Assessments Properly AddressOMNI — — Irrformatlmis owner's No — every pass. Gtyrrom state Zip Cade Dale dlon D. System Information(cunt) �l Cesspools(cesspool must be pumped as part of inspection)(locale on site plan): I Number and configuration Depth-top of liquid to Inlet Invert .— Depth of solids layer — Depth of scum layer Dimensions of ces" -- — Materials of construction —• — Indicatlon of groundwater Inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure,level of pending,condition of vegetation, etc.): �l�{ Privy(locate on site plan): Materals of construction: — • ........ _ Dimensions — - - - --- ------ Depth of solids - . ---• —_.... _ Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): o• •asps tAbsoemm1.W#aWF&_¢,Wane.s-47GWad*Vow•P499Oar* Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disppoosal System Form-Not for Voluntary Assessments J�Slrwl� tIJCt,.C�n �c�� Property Address --- —.. .--- — --••— To:Laura Thomson Page 17 of 18 2007-07-19 21:54:09(GMT) 15084370708 From:DENNIS KERKADO .-a \ Commonwealth of Massachusetts lugTitle 5 Official Inspection Foray Sub$Urfaca`Sewage Disposal System Foam-NO for Voluntary Assessments Propedy Address Comer Gwrter's Name ...._-- 10mvriation is l — — required br wY`��e,ry. • t>.. �� ----..— ew pglae_ atyrrown �? - U ry Slate Zip Cade Date I I Ion De Sy$tom Information (contj Site Exam: Chock Slaps (;) J� �•��•� Surface water W ow A„ Check Cellar Shallow weft W on t 1 Estimated depth to ground water. teat Please Indicate all methods uteri to determine the high ground wator elevation: �] Obtained from system design plans on record If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) (_7 Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) 0 Accessed USGS database-explain: You must describe how you established the high ground water qlavalion, C'�YtJJ�n� �,,�.�,w.._c,�.�:w�, E.� �.Y�r S�-G ���_ C,�K";S� �-►.,(' TMIe 6(ftm In*60im Fom:V wb%wyce Sewage Pluasei symbm•page i s or 16 Town of Barnstable OF IME Tp� ` yP� Regulatory Services snxxsrnsie Thomas F. Geiler, Director 9$ 0 MASS. ••� Public Health Division AjFp�.�A 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.