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Home My WebLink About0146 SHORT BEACH ROAD - Health 146 SHORT BEACH RD., CENTERVILtF. A= 206 026 UPC 12543 NOR q`bs:coh? HASTINGS,CNN 1 r— No. J"r Fee t t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Applitatlon for Misposal *pstrm ConstrUttlon Permit Application for a Permit to Construct( ) Repair)0 Upgrade( ) Abandon( ) ❑Complete System Lidividual Components Location Address or Lot No. 1w Skr7 —8&,a TZ Owner's Name,Address,and Tel.No_j_1_?61 w (f�p�n.nyS /� aa� Assessor's Map/Parcel CdAJC V,Ile 6/7-3SR — Y'6,7 Installer's Name,Address,and Tel.No./ eri/orhooc CJcsk Designer's Name,Address,and Tel.No. sys- Ott asr Type of Building: /I Dwelling No.of Bedrooms /V� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) IIJA- gpd Design flow provided Mt 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) 1WeP6j j _C -,*,,71 Li yorroyl,r CC�ihe�rf 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 Envioqental Code an of to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Signed Date Application Approved by Date lo?j Application Disapproved by Date for the following reasons Permit No. �( _ � Date Issued �— Fee No. - 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ltlYlLatIon for:. IB�ID:B:aY pStEIYY Construction 3Permit Application for a Permit to Construct(M Repair Upgrade( ) Abandon( ) ❑Complete System 61dividual Components Location Address or Lot No. /Y6- 5kr� /�,1 �� Owner's Name,Address,and Tel.No��u v�c� �2/)rnn�S Assessor's Map/Parcel (�Gnfcrv, F6 ¢ Installer's Name,Address,and Tel.No./✓e yX/6,)Xwd' l,,.Je,sk Designer's Name,Address,and Tel.No. ,R Type of Building: Dwelling No.of Bedrooms /166 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) AL gpd Design flow provided IA gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Repairs or Alterations(Answer when applicable) .jk,'g_ Z�k,y,t 5:0 Vr�✓col//,C. �MP�I'�' 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 Envi , ental Code and of to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt . Signed Date%��//_? Application Approved by _ Date Z Application Disapproved by Date for the following reasons Permit No. Z01-7)_ Date Issued ----------------------------------------------- --------------------------------------------------------------------------------------- �� '� ! ThE COMMONWEALTH OF MASSACHUSETTS I" BARNSTABLE,MASSACHUSETTS sglli b 1, Certificate of Compliance THIS IS TO CERTIFY,that the p� On-site Sewage Disposal system Constructed( ) Repaired(6 Upgraded( ) Abandoned( )by /V �A 0 1 k 4AX7 4- at NC �5 h o✓>? O e GC A R u n*c✓y,'11 Q has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No,ZO dated �O It Zol Installer Designer #bedrooms A)A Approved design flow �It} and The issuance o this p�rmit shall not be construed as a guarantee that the system will,fi function as de igned. �( Date 101 / Inspector / f/ i,A No. �3' SC(9 Fee 1OU a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposat :�Ppstem CoustrUrtlon 3permit Permission is hereby granted to Construct( s) Repair(W Upgrade( ) /Abandon( ) System located at l q c 5�yd ./7em A P l0 GO 741-11)�e 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 must be completed within three years of the date of this permit. Date /a ��Zo�3 Approved by Epp SHF rpk Town of Barnstable Barnstable na MA&S. Regulatory Services Department M�ft�' 1 Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scalie,Acting Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 1005 November 7, 2013 David Jennings &Jennifer Krebs, TRS Hillcrest Realty Nominee Trust 228 Lowder Street Dedham, MA 02026 S ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 146 Short Beach Road, Centerville, MA was last inspected on October 9, 2013,by Jason Burnie, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Septic tank was found to be leaking You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health j Q:\SEPTIC\conditionally passed\146 Short Beach Rd cent Nove 2013.doc • Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14372 7ee- . AA 'AM t� �MASS Logged In As: Parcel DetailTuesday, November5 2013 Parcel Lookup Parcel Info _. . .. _.... _ .. ..............._... ... -- Parcel 206-026 _ '� Developer LOT 31 I D Lot �___ — Location 146 SHORT BEACH ROAD Pri Frontage 174 I Sec Sec Road Frontage i Fire Village ICENTERVILLE ) District IC-0-MM Town sewer exists at this Road — -� addressiNo ) Index 1488 Asbuilt Septic Scan: ,jt Interactive 4A A nf_ i 206026_1 Map 2060262 i Owner Info Co-, — Owner!JENNINGS, DAVID& KREBS, JENNIFER TR Owner�HILLCREST REALTY NOMINEE TRUST Streetl 1228 LOWDER STREET Street2 City EDEDHAM State EAJ Zip 102026 1 Country Land Info Acres i0� 21 Use Sin le Fam MDL-01 Zonin CBDLBSB N hbd 0114 Topography 1 Level RoadjPaved Utilities IPublic Water,Gas,Septic Location Imarginal View Construction Info Building 1 of 1 Year —__ — Roof, _ Ext �1955 ;Gable/Hip Wood Shingle Built Struct Wall Living Roof11534 �� over lAsph/F GIs/Cmp� Type None AC Area r � Cover Type eAs Y # p —) WallBed Int _—� Rooms ) `w �t7 Style Ca a Cod Plastered 3 Bedrooms Int —_.__ Bath Model(Residential Hardwood 2 Full Floor RoomsHeat re Total Grade?Average Type CHOt Water Rooms i Rooms 1 s Heat ram`--_.___ __ Found- Stories;1 1/2 Stories Fuel E�'as - ation Ilk/Pour Ftgs Gross http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14372 11/5/2013 Comm.mmealt i of Nhosachmeft T CCa 1 Fora bsurface Dispwal Syst�enn.fonn.Notfor VoluntaryAssessments 146 Short Beach Rd Property Address David Jennings 228 Louder St Dedham,MA 02026 Owner Owner's Name informatrequired for Centerville MA 02632 10/9/13 required far every per. City'rrown State. Zip:Code Date.of tropectiOn Inspection results must be submitted on t#ft form.Inspection forms may not be altered in any way.Please see mess c hecidist at the end of the form. '"' Wb.w. A. General Information fitiir�out forms on the computer, use to m the tab 1. Inspector. to �I key move your cursor-do not Jason Burnie use the return Name of irtspector key. Neighborhood Waste Water cclr�Name .. 350 Main St Cwparty Address W.Yarrnouth MA 02673 City/Town State Zip Code. 608-775-28.20 S15011 Teleptume Number Lkwe Number S.<CeFfiftation I certify that I have personally inspected thipsewagedsposalsystern aUthis address:and that ft, in#ormation reported.below is true,accurate ark carrepirate of the.t roe of the if pest t it on was performed based on my training.and experience in the pro function Wit.mar ar. cf on site sewap disposal systems.I aryl aP tirI system.inspector euit to pecoorn tom.of Title 6'(310 CUR 15:000 The system: c ° ❑ Passes ® Conditionally Passes [j talus '; [] Needs Further Evaluation by the Local App► g Authority t9 10/9/13 Insptor's Date The system inspector shall submit a copy of_this inspection report to.the:ApprovMkithority(Board of Health oc DEP)within 30 days of Ong the irtspec#ion.tf tF .a.sharr :Sys System,or has a design flv of 10,000 gpd or greater;tile.inspector.and the system o sal stm-the report to the appropriate,regional offrce of the DEP.The ofiginail sty be sentto,the system and copies sent to the;buyer,if ale,and the apprw4 tg auttux*. ""This re fit.only describes conditions at the time of inspection.andunderthe Conditiorlsi of use at that tom.Tithe n does not addniss hew doe.sy" l Wthe t ,under UN same or different conditions of use: t5ins•W3 Tim 5 0MMdd hwpecbmf semp oisposd system•Rage 1 of 17 I I Commorwwea#th of Massachusetts Title 5 Offi- ciall Inspection Fora Subsurface Sewage Disposal.System Form-Not for Voluntary Assessrner,ft 146.Short Beach Rd. Property Ad&ess David Jennings 228 Louder St Dedham,MA 02026 owner Owners Name information isrequired for every Centerville MA 02632 1019/13 Page• City/Town State Zip Cafe Data of k spedion B. Certiftcation (font.) Inspection Summary: Check A,B,C,D or E/ahvays complete all of Section D A) System Passes: ❑ 1 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 conditional pass due to the septic tank leaking.We found the tank was at a lower level than the outlet invert.We filled the tank to normal operating level and we let A sit for.24 hours. We checked the level again and it had dropped 2"below normal opersft level-..'TheZovers on the septic tank are both 6"deep.There is NO distribution box on this system.The SAS,wasat a normal level and the stone was dry.Also per a phone conversation with Dave Slanton of#ve.Bamstibiee Health Department he said thessepe*ation o€1.6 from bottom of the SAS to ate.groundwater was acceptable. B) System Conditionally Passes: 0 One or more system components as descnbed in the"Conditional Pass'section need.to be replaced or repaired.The system,.upon completion of the reel tent or repair,as.approved by the Board of Health,will pass. Check the box for ayes",'no"or'not determined"(Y,N, ND)for the followingstatements.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 orexfikrtion or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying by the Board of Health. *A metal septic tank will pass inspection if it is sbvdura#y sound,not leaking and if.a.C40tificate of Compliance indicating that the tank is Tess Ulan 20 years old is available: ❑ Y , ❑ N ❑ ND(Explain below): The system is a conditional pass due toAhe septic tame leaking.We found the tank was at a klW level than the outlet invert.We filled the tank to normal operating morel and we W it sitfor.24 hours. We checked t#ae.tevel'at and it had operating level., tjelow normal: level. t5ins•3M 3 rifle 6 Mgt kq)NMM fame subsurface Sewage aWWd S.ydem•Pop 2 of 17 r Cornmonweatt of Massachusetts . Title 5: Official Inspection Form Subsurface She mil.System t Form-Not for Voluntary Assessments. . 146 Short Beach Rd Property.Address David.Jennings 228 Louder St Dedham,MA. 02026 Owner Owners Name information isrequired for every Centerville MA 02632 10/9/13 page- CiWTovm State Z►p Cade Date of ftper Lion B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more;than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval-of the Board of Huhy ❑ broken pipe(s)are replaced- ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Expert below): C) Further Evaluation is Required by the Board of Heath; ❑ Conditions exist which require further evaluation by the.Board of Health in orderto.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 340 CUR 16.31 t)(h)that the system..is ttot frsrtdtitmirg in a mannor. t: public health, safely 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 viand or a salt marsh Lfts•3113 Title 5 016dd kmpWft F=ulibs nUM SeM p Dkt=d&jSWM•Page 3 of 17 I Commonwealth of Massachusetts Tile 5 Official l4nspection. Fo m. Subsurface Sewage 131sposal System.Form-Not for Voluntary Assessments 146 Short Beach Rd Property Address David Jennings 228 Louder St Dedham,MA 02026 Owner Owners Name information is required for every Centerville MA 02632 10013 page. cityrrown State Zip Code Date of ftpection B. Certification (cunt.) 2. System will fall 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 DER certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen arts!rutste 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:ovedpaded or clogged SAS.or cesspool ❑ Discharge or ponding of effluent to the surface of the grand or surface waters due to an overloaded or clogged.SAS or cesspool ❑ ® Static liquid level in the distribution box above,outlet invert due to an overloaded or.clogged.SAS or.cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow t5ins•3h3 Tft 5 Oflldal Wapectlan Famr%ftxf.aw Sewage Disposal Sysbm-Page 4 of 17 L Commonwealth of Massachusetts TRW 5 Official inspection pm Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments 146 Short Beach Rd Property Address David Jennings 228 Louder St Dedham,AAA 02026 Owner OmWs.Name inf6ffnation is►equired pred for every Centerville AAA 02632 10/9/13 for page. City/Tomm state Zip Code Date of Impeciorl B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year A14T due to cogged or obstructed pil*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 weD. ❑ ® 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 primate water supply well.with no acceptable water quality analysis. [This system paste ethe weii water anallysis,,perferflied.at a DWAcerti d laboratory,for fecal coliform bas eetia indices atilt t#m ice of ammonia nitrogen and nitrate al . 'o rr#ess t art, providers that no.otter criera}are trrftl A cr,of the. and chain of custady must be. ❑ ® The system,is a cesspool serving a facility with a dwW flow of 20010gpd- 10,000gpd. ❑ to The system M.I have detWained that one or mom of the abov'failure criteria exist as described in 310 CMR.15 303;< the system fails.The system owner should con rm the Board of Heath to deteine:what Wi#be necessary to correct the failure. Ey Large Systems: To be considerW a,large system the.syatem t same a r ty a design flow of 10,000 gpd to 16,000.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 4.00 feet of a surface drinking,water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drit c ng:water suppy ❑ ❑ the system is located in a Win sensWm area(Interim tlx:Protection Area—MIPA)or a mapiped.Zone 11 of a pubic wi; supply Weh If you have answered"yes"to.any question in Sect.E the system'considered a significant thriewat, or answered'yes'in Section.D above the large system-has failed.The owner or opstator of any large system considered a-significant threat under Section E or fOod ur*Section D shall upgrade system in accordance with 310 CMR.15.304.The.system.owner should contact the,appros€iate regional office of the Department. mns•3M3 Title 51Wde6NgXKOW F&M Sum Sewage Disposal syek-•page 5 of 17 Commonwealth of.Massachusetts Tide 5 Official InspectionFonn Subsurface.Sewage E3tposat System Foist-Not for Voluntary Assessments 146 Short Beach Rd Rvperty Address David Jennings 228 Louder St Dedham.,MA 02026 owner Oafs Name infoffnation required �, Centerville MA 02632 10f9/13 page- City/Town State Zip Code Date of inspeWon 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 norms(floors in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recentlyy or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as WA) ® ❑ 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 mantis uncovered.opened,and the interior of the tank inspected for the condition of the baffles or tees,material of c onstnictibn, dimensions,depth of liquid, depth of sludge andd depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance.of subsurface.sewage disposal systerns? The size and location of the Soil A Sys(SAS):on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Heath. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacc able).[310 CMR 15.=(S)j D. System Information Residential Flour Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CIVIR 15.203(for example: 110 gpd x#of bedrooms): 330gpd Per irk at.BOH t5W*•3113 rise s oftd hopewon Pam& sewage oisposd systmn•Page a of 17 I Commonwealth.of Massachusetts Title 5 #rs.p Farm Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 146 Short.Beach,Rd Property,Address Davin Jennings 228 Louder St Dedham,AAA 02026 owner Owner's Name l��y Centerville MA 02632 10/9/13 page. . City/Town State Zip Code Date of inspection D. System Information Description: The system consists of a septic tank and ddkjsors.There is no distribution box on this system Number of current residents: 0 Does residence have a garbage grinder? Cl Yes ® No Is laundry on a separate sewage system?(include laundry system inspection Cl Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? Yes ❑ No Water meter readings, if available(last 2.years usage(gpd)): 12=167gpd 11=175gpd Detail: Sump pump? Yes No Last date of occupancy-. Summer 2013 �' Date CommerciaYWustrial Flow.Condkkms: Type of Establishment: Design flow(based on 310 CMR 15.203): Galbro per day(ms) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? D Yes. 0 No Industrial waste holding tank present? 0 Yes 0; No Non-sanitary waste discharged to the Title 5 system? El Yes [ No Water-meter readings,if available: tins•3/13 Title 5 Offiaal t ood w FOM Subs iface SOMM Disposal System,r Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 146.Shout Beach Rd Property:Address David Jennings 228 Louder St Dedhafm,MA 02026 Over ONmefs Name requir required is Centerville MA 02632 14/9/13 required for every page. Cityrrom State Ztp Code Date of Inspecdon D. System information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2010 Barnastabhe BOti 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) ❑ Innova#ive/Altermative technology-Attach a copy of the turrets operation to be obtained from s and maintenance contract( ystem;owner).and a of latest inspection of the l/A system by,system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•313 Me 5 Oftel 6apeOm Form Wwjfaw Swap Dispose!System Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form-Not for Voluntary Assessments 146 Short Beach Rd Property.Address David Jennings 228 Louder St Dedham,MA 02026 Owner Owner's Name information is required for every Centerville MA 02632 10/9/13 page. City/Town State Zip Code Date of Impection D. System information (cunt.) Approximate age of all comments,date installed(if known)and source of information: 1990 per info at the Barnstable BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑cast iron 0 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): We ran a sewer camera up the line and it was ok at the time of inspection Septic Tank(locate on site plan): Depth below grade: Covers and deck=6" feet Material of construction: concrete ❑metal ❑fiberglass ❑polyethylene ❑otter(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a.copy of certificate) [Q Yes ❑ .No Dimensions: 1000ga1 Sludge depth: 3" 05ins•W13 Me 5 OMCLW kmpaMm Fam&ftwface sewage Dispocel.system•Page 9 0 17 CotnnionweaM of ARaSsachusetts Title 5 Official rs ion: Form SuEsurfiace Sewage ftpo"System Form-Not for Voluntary Assessments 146 Short Beach Rd Property Address David.Jennings 228 louder St Dedham MA 02026. owner Owner's Name intomiatirequired�emy Centerville MA 02632 10/9/13 page. City/Toym State Zip Code Date of Wapect on D. System Information (cons.) Septic Tank'(cont.) Distance from Z+ top of sludge to bottom of outlet tee or baffle 0„ Scum thickness Distance from top of scum to top of outlet tee or baffle Ir,+ 8 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? tapemeasure Comments(on pumping recommendations, inlet and outlet tee or baffle condemn, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was found to be leaking.Both baffles are in place. Grease Trap(locate on site plan): Depth below grade: tee Material of construction: ❑concrete ❑metal Q fiberglass Q polyethylene ❑other.(eglain): Dimensions: Scum thickness Distance from top of scum to.top of outlet.tee or baffle Distance from bottom of scum to bottom of outfit tee or baffle We of last pumping: Dam t%m•W3 TNe 5 OfAt d kq;ecaon Form SWsfaoe Sewage Disposal System•Page 10 of 17 f Commonweatth of Massachusetts 'Fitt 5 Official Inspection Foy Subsurface Sewage[disposal S.y Form-Not for Vddurwy Assessments 1.46 Short.Beach Rd Property Address David Jennings 228 Louder St Dedham,MA -02026 Owner Owner's Name in Aredfoafion is Centerville MA 02632 10/9/13 per. cityrrown .State Zip.code Date of.lnspection 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: g Design Flow: gaons Per dW Alarm present: ❑ Yes ❑ No Alarm level: Alarm inworift,order 0 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 t1 M•ins TWO 5 OM*d kWP80-F—SW-dace se-ge OW08el.$yem•Page 11 or 17 r Commonwealth of Massachusetts utue 5 c l Inopect�on Form SuWurlace.Sawage. l:Sys Eorrn Not for Voluntary Assessffmft 146 Short Beach Rd Property Address David Jennings 228 Louder St Dedham,MA 02026 owner Owner's Name rein o e Centerville MA 02632 10f9l13 per. Cityrrown 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 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.): *****THERE IS NO BOX ON THIS SYSTEM***** 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 fequiced): If SAS not locked,explain why: SAS was.kocated. tails•3H3 Ti®e 5 0MGW fast[Stow t w sewage.D40SRl system•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official InSpect can Fa I Subsurface Sewage D*wsa3 System.Form-Not for Voluntary Assessments 146 Short Beach Rd Property Address David.Jennings 228 Louder St Dedham,MA 02026 Owner Owner's Name regal ��y Centerville MA 02632 10/9/13 page. Cityrrown State Zip Code Date of Inspection D. System Infolrmation (cont.) Type: ❑ leaching pits number. ® leaching chambers number. 3 flow diffusors ❑ leaching galleries number. ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: Cl overflow cesspool number. ❑ innovative/aftemative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure, level:of,ponding, dares soil,Win.of vegetation,etc.): ,. We ran a sewer camera to view the SAS. It was.found to be at a normal.operaft level..We also used a probe to check the stone.and it was dry. Cesspools(cesspool must be pumped as part of inspection)(locate on site.plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3M3 TWO 5OfAdal Form S Swap MWOOd SYSWM•Page 13 of 17 r Commonwealth of Massachusetts Title. 5 Official Inspection Farris. Subsurface Sewage Disposai System Form-Plot for Voluntary Assessments 146 Short Beach Rd Properly Address David Jennings 228 Louder St Dedham,MA 02026 Owner Owner's Name inforrnafion is required for fb every Centerville AAA 02632 1019/13 page. cKyrrown State Zip Code Date of inspection D. System Information (cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan)`. Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Otfidal kQP.0Won For[St03WIeoe Sexage Disposal System•Page 14 of 17 COMMOM"am Pit fie It at Subsurface.Seymp Disi •blot for VokmWy Assessaaft 146%at Beach.Rd David.1enMM 228 Lauder St Dedham,10b1 020M Owner Owes t+0ame °1 rmaw is MA 02831 i0�9N3 CerrbxVft B+ Y ( jp�p Ste ap Cad® tde af:hmpeckin paw D..sysiam hviommidon (cont) Skew Of Same Dash System:ProMe a view-of the se�arQe SyOmn, ties to at West two permanett reference lanftarks or berichmatks.Locale all wed 100 feet.Locate where public water supply eribers the bWdmg.Check.are of the bons below: ® timd-aketch in the area below drawing afts:hed-separately % f%I ell ;t/J♦Y I I♦I♦I`t/\\- t � ♦ ♦ ♦ �.. a ♦ ♦ ♦ ♦ ♦/♦�♦/♦ \ tom/\IC4 %Z♦ \ t/tt \J\�\\ tf ♦/\/\\t/♦/1;� , \\ \ \/\r/\/♦ I III I I / I f Y f ! I / / / I I I/ II I 19 . 27. . 24 34 IROW Of 1440) paY4�� oac Commonwealth of Massachusetts Tit 5 Offi a! Inspection Firm .Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 146 Short Beach Rd ProWty Address David Jennings 228 Louder St Dedham,MA 02026 Owner Owners Name information is Centerville MA 02632 10/9/13 required for every page. Cityrrown swe Tip Code Date of Irapedion D. System Information (cunt.) Site Exam: ® Check Slope Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4T water found with hand agar 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: ❑ Checked with local excavators;installers (attach.documentation) Accessed USES database-explain: MIW-29 Zone A water level 7.9 1.5x12= M adjustment You must describe how you established the high groundwater elevation: did a hand aggar to find groundwater.Water was found at 4'T,front grade.From grade:to bottom of the SAS it is K This gives you a proven seperation of 1'6"from the bottom of to SAS to,where groundwater was found. Per a conveisation with David Stanton of the Barnstable BOH`the distance is acceptable for a seperation. Before filing this irk.Report. ase see Report.ConvieterAws;Chedd'tst:cn tit gage. tins-3/v3 TWO 5 Oftd kq)Bdan Form&bUfaoe 5WjW Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dial System Form-Plot for Voluntary Assessments 146 Short Beach Rd Property Address David Jennings 228 Louder St Dedham,MA . 02026 Owner Owner's Name information is Centerville AAA 02632 10/9/13 required for every Pam• cityrrown state zip Code Date of trupection. 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-3(13 TWO 5 OtA�dal MV800n FGMt&ftxfaCe Some 04osd Sm!sim-Page 17 of 17 Commonwealth of Massachusetts Title 5 spe Official i I Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 146 Short Beach Road Property Address - - Roncone Owner Owner's Name information is required for Centerville MA 02632 May 3, 2010 every page. Cityfrown 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mllls MA 02648 City/Town State Zip Code 508.428.1779 SI 12855 Telephone Number License Number B: Certification _ LU 00 1 certify that I have personally inspected the sewage disposal system at this address and that the rMsa . inform Ilion reported below is true, accurate and complete as of the time of the inspection. The inspection N was pe ormed based on my training and experience in the proper function and maintenance of on site 0 a sewag disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 @10 CMR 15.000). The system: rn z Passes ❑ Conditionally Passes ElFails ton 1 `" �.., ❑ '° l `i 1 oc I A .ter ,;—,,1 �41}I"Inri} ::�- �izeds Furthct Evaluation by ��e �.,:,a, -,N�„c`.,,,�. . ;., M'tA( ay 3, 2010 Inspector's ignature 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 115ins•09/08 Title 5 Official Inspection Form:SubsurNSewsposal System•Pag 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3, 2010 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I$I 1 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: Tank is not in need of pumping at this time, leaching system shows no signs of surcharge or saturation. 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 'Lank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3, 2010 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM , 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3, 2010 required for every 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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than _day flow t5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is required for Centervilley MA 02632 May 3, 2010 every 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 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. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3 2010 required for Y 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) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3, 2010 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes Z No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 29,000 gal. _ 9 ( Y 9 (gpd)): 39 gpd. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: UnknownDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3, 2010 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped two years ago. 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.) 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): 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Y' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is required for Centerville MA 02632 May 3, 2010 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date: 8/9/90 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 3" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 0" 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 1 i Commonwealth of Massachusetts I'f,Y Title 5 Official Inspection Form x ns p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3, 2010 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured 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 had liquid only, no solids. Liquid level was found slightly below outlet pipe due to vacancy and evaporation. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3, 2010 required for Y 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Y Centerville MA 02632 May 3 2010 required for , every page. Cityrrown 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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3, 2010 required for Y every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: ThreeFlowdifusors. ❑ 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.): Interior of flowdifussors were video inspected and stone and soils were probed, found no evidence of saturation or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 ' I Commonwealth of Massachusetts Title 5 Official Inspection Form r a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is required for Centerville MA 02632 May 3, 2010 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 19 27 24 Water 34Service short Beach Road I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..'" 146 Short Beach Road Property Address Roncone Owner Owner's Name information is Centerville MA 02632 May 3 2010 required for Y every page. Cityfrown 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: 5-6 feet 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: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Surface water at rear of property is 5-6 feet lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ••'" 146 Short Beach Road Property Address Roncone Owner Owner's Name information is required for Centerville MA 02632 May 3, 2010 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 L Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Rd. �( (� Property Address 1 Katherine RanconeQ (J� Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 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. ImpoWhen filling A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification s I certify that I have personally inspected the sewage disposal system at this address and that they information reported below is true, accurate and complete as of the time of the inspection— he 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,Sectio'- .346 of Title 5(310 CMR 15.000).The system: '" cn ® Passes ElConditionally Passes ❑ Fcaail GJ co ❑ Needs Further Evaluation by the Local Approving Authority c- - cst 8/12/2008 Inspector's Sign Ere 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. 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41M , 146 Short Beach Rd. r Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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 146 Short Beach Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 i Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 every page. Cityrrown 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. 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 a Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 0 ® 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. 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 146 Short Beach Rd. Property Address Katherine Rancone Owner Owners Name information is required for Centerville Ma. 02632 8/12/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. _ Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 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) [310 CMR 15.302(5)] a 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments , 146 Short Beach Rd. Property Address Katherine Rancone_ Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110,gpd x#of bedrooms): 330 Number of current residents: 2 J 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 2006:70,000 g ( y g (gp ))' 2007:16,000 Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? 0 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): 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ❑ Yes ® No If yes,.volume pumped: gallons How was quantity pumped determined? ' Reason for pumping: Last Pump was 6/27/2007 for maintenance. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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): Approximate age of all components, date installed (if known)and source of information: System installed 8/09/1990 Were sewage odors detected when arriving at the site? ❑ Yes ® No 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 6„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gallon 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured 146 Short Beach Rd.,03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of leakage.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): 146 Short Beach Rd.•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•''y 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 every page. Cityrrown 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 D-Box not present. 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑, No Alarms in working order: ❑ Yes ❑ No 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 F ' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 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: 3 Flow Diffusors ❑ 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. 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 I Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 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.): 146 Short Beach Rd.•03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 a 'Map Page 1 of 2 Town of Barnstable Geographic Information System y Parcel Viewer Custom Map Abutters Map Size ® ® Zoom Out .J In i _ol, a /1 a a l = 1 a ------ r 1 - 1 - 1 1 ' I 1 1 1 1 � 1 l j S a 0 20 Feet Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER (`nn..rinhf 7lV15-')n0A Tn... of P.—t.hln AAA All rinhfc reeen.. http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=206026&map... 8/12/2008 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 146 Short Beach Rd. Property Address Katherine Rancone Owner Owner's Name information is required for Centerville Ma. 02632 8/12/2008 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 4' 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:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. 146 Short Beach Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 J TOWN OF BARNSTABLE LC?CATION ((-IO Sher+ 7J �#`�r,�P VILLAGE( xo r-V J`kk ASSESSOR'S MAP&PARCEL NAME&PHONE NO.7]�Z�r;ck- (3�2404yu SEPTIC TANK CAPACITY 1 CCO Qltli LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER�,vnCorns— PERMIT DATE: CIOMPF99WE DATE T,n g P J 5 I 1 O 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 J f f f r f r f J f f l l 4 4 k \ \ 4 h 4 h \ \ h h k h h 4 4 h k 4 \ 4 h \ \ 4 h h h h h h 4 h h 4 h 4 4 h 4 h 4 4 4 4 4 h h 4 4 f f / f / I ' h \ h h h h h h h '+ 4 h 4 \ \ h h h 4 4 4 h 4 4 1 l f f J / f f l J J / f f f f f ! f 4 h \ h \ \ 4 4 4 4 • \ 4 \'\ \ \ \ 4 h \ ! f f f f f ! I f I ! f f f f f ! f / f f / f ! h h h h 4 4 h h h 4 4 4 .4 4 4 h h h 4 4 4 4 4 h 19 27 24 Water 34 Service Short Beach Road I 4 , COMMONWEALTH OF MASSACHUSETTS `I EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECII vN is ; , v... 1 ONE WINTER STREET, BOSTON, NIA 02105 617-292-5500 WILLIAM F.11'ELD 400 TRUDYrxG XE Governor j 14 - Sjwr tan• ARGEO PAUL CELLUCCI oy�or 1t`3 D B. HS I Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR FA�Ty FpjrAg� Co 4oner tt i PART A j CERTIFICATION j! Property Address: /Z/, 0,11e,✓' Jle Address of Owner: SIP-V Date of Inspection: V-7-c{7 (If different) Name of Inspector: FeHr 7 T am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) 1 Company Name: -, 'a i4e2 EkS YY H 4.& OZ4 Mailing Address: Z D�e� , foie (� Telephone Number: l50$� a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experien oper function and i maintenance of on-sZasse5 ge disposal systems. The system: ZH.OF. PETER T. N — Conditionally Passes o MCENTEE _ Needs Further Evaluation By the Local Approving Authority CIVIL y u Fai NO.35109 1i n Date: 9o�9f; Inspector's Signature: Cam. T� �1 ��/ONALEENG The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) y completing this inspection. If the system is a shared system or has a design flow of.10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original.should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: 1 A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. '; Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: j One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon I completion of the replacement or repair, as approved by the Board of Health, will pass. ( Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. j1'' The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of 4I Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or 1 the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank 1 failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/57) Page 1 of 10 DEP on the Wbdd Wide Web: http:/Jwww.magnet.state.ma.us/dep ej Printed on Recyried Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �r CERTIFICATION (continued) Property Address: /yip SA v/-,, /�3e a G 1, Rd. (f{.,)fit?�✓� Ac NA O Z 6 3 -2— Owner: ShavrJ Lyr��1 C7r ,+a lei. Date of Inspection: F_7_97 B) SYSTEM CONDITIONALLY PASSES (continued) i _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed j pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the ;I Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION.IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation.by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT.THE.SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ •`11 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 APPROPRIATE) DETERMINES THAT P THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. 1 _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a I private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that iI the well is free from pollution from that facility and the presence of ammonia nitrogen and nitratrr nitrogen is equal to or f�l less than 5 ppm. Method used to determine distance (approximation not valid). ; I 3) OTHER ;j 'I t =i i �I (revised 04/25/97) Page 2 of 10 ''. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: M4, eel, MA dZ(o Z Owner: Lynn �r�rn ley Date of Inspection: �-7—q"7 D) SYSTEM FAILS: ' You must indicate ei;i;er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in.310 CMR 15.303• The(oasis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to,an overloaded or clogged SAS or cesspool• j i Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. f Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). i Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. — — Any portion of a cesspool or privy is within 100 feet of.a surface water supply or tributary to a surface water supply. Y — Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no. I acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for ? coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: You must indicate either "Yes or"No" as to each of the following: . The following criteria apply to large systems in addition to the criteria above: , The system serves.a facility with a design flow of 10 000 or greater (Large System) and the system is a significant threat to #C Y tY g � gPd g g Y Y 8 public health and safety and the environment because one or more of the following conditions exist: f, • �I f Yes No the system is within 400 feet of a surface drinking water supply j the system is within 200 feet of a tributary to a surface drinking water supply r 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) j The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program', requirements of 314 CMR 5-00 and 6.00. Please consult the local regional office of the Department for further information. ai ;i E i E e (revised 04/25/97) Page 3 of 10 i' �i, r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: lyl S�0,4 /3e,,cA Rc/ Ce.4 Pe.,v I to M.4aZG3Z li Owner: 5Aavr7 4 Ly✓1 r1 (�/�.+��Ey Date of Inspection: ' �+ 9-7-9-7 �s Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No — Pumping information was provided by the owner, occupant, or Board of Health. — None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and xaminert. ote if they are not available with N/A. \ �. CJrtCo�y2C/' 7� /CS Yo [a� d,`truSAi-- CorrC ct' t�es �tcc �J �` — The facility or dwelling-was inspected for signs of sewage back-up. t — The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. l /hGwC/ing All system components,a g me Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _ 'I The size and location of the Soil Absorption System on the site has been.determined based on: f X. _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of $ Sub-Surface Disposal System. f: 'j— Existing information. Ex. Plan at B.O.H. — Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] ]I tf 9 } 9 } } y • i (revised_04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: . IV6 $Lion 8eq cA ed. Ce,?fe ✓r llt, "A Owner: .SA'Qu'-) t! L nn 6'r"'k Date of Inspection: y y 8- -7 r 9 7 FLOW CONDITIONS RESIDENTIAL: I Design flow: 33a g.p.d./bedroom for S.A.S. 1 Number of bedrooms: 3 Number of current residents: 3 Garbage grinder (yes or no): 1U0 Laundry connected to system (yes or no):_Le-S Seasonal use (yes or no): /Ua Water meter readings, if available (last two (2)year usage (gpd): ref a�<<�la 6te Sump Pump (yes.or no): /Un /trot CeIlG/') Last date of occupancy: �L� occuP ec� COMMERCIAUINDUSTRIAL• Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ i Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if-available: Last date of occupancy: I OTHER: (Describe) Last date of occupancy: 1 )i GENERAL INFORMATION k� r; PUMPING RECORDS and source of information: two yegrse� System pumped as part of inspection: (yes or no),AVo �a�t /ion /Cc�tlT/� �pu/rlPi�lg : 6y SMfe If yes, volume pumped: Rallons t SMX Reason for pumping: C/'f ems• q `�f �►t �/K e✓rf >� iE Vt TYPE OF SYSTEM Septic tanWd+siributyen box/soil absorption system. Single cesspool Overflow cesspool ? Privy { Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: his Sewage odors detected when arriving at the site: (yes or no) No s (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: c_/, 124/, Ce.9 r2i -,'/l t M 1 Q Z&3"Z i Owner: S'hAur, ¢l y 417 62r,'1,, /e Date of Inspection: / �•—"7—cl7 J BUILDING SEWER: MIA- Depth J (Locate on site plan) III below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction line Diameter I Comments: (condition of joints, venting, evidence of leakage, etc.) i SEPTIC TANK:_V (locate on site plan) Depth below grader Material of construction: X_concrete _metal _Fiberglass Polyethylene —other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) � o r Dimensions: A max y X /DOO q l k 11 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: �g Scum thickness: D" 0"klef rr Distance frorn'top of scum to top of outlet tee or baffle: Distance from1bottom of scum to bottom of outlet tee or affle: /8 I How dimensions were determined: a ut;l) 1 t Comments: (recommendation for pumping, condition of inlet and outlet tees or,baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, e J .� `t n U ✓Gfvra//�s sooa j: /Ao -e✓,`d eAce er i n P, i-ra�+o� ei� Pert'*1 f/?a�+`prr. Oe s nn ren Vse DucD iAn i �j �j GREASE TRAP: (locate on site plan) / Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) �i Dimensions: `1 Scum thickness: 9 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) i g (revised 04/25/97) Page 6 of 10 i 6. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) i Property Address: �7/�v �ryo�� 13ekG� /Z j �`�f��✓�'j�� M� 62�v 3 2 Owner: Sliau:n � Lrn rl �•.Y+/may Date of Inspection: I TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) AJ Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) I Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: - (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) R, Depth of liquid level above outlet invert: i Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) I PUMP CHAMBER:_ u J (locate on site plan) / Pumps in working order: (Yes or No) Alarms in working order(Yes or No) t Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) flgl 1 (revised 04/25/97) Page 7 of 20 t f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �7 SYSTEM INFORMATION (continued) Property Address: y } gager Date of Inspection: 5-7-97 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) I If not determined to be present, explain: I Type: leaching pits, number:_ leaching chambers, number: 3 -{LJX$) F/ocv +•} ' Siorl-P— Sc�rroc�,�,�9 S` S leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: { (note condition of il, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ow ! n Si4.s i u i 'n io- level below ate c crr 'it CESSPOOLS:';_ A,11 l (locate on site plan) A f Number and configuration: i Depth-top of liquid to inlet invert: Depth of solids layer: 3 Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) t r 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: _ 3I Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) t� (revised 04/25/97) t' Page 8 of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �� SYSTEM INFORMATION (continued) Property Address: //%�v $l,��f 1j7eq, ��, CGn�Gr1', . /�f� Q z(0 Z is 3 Owner: �11gv>> f Lylry! �✓irw �C i! Date of Inspection: , l SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'•(Locate where public water supply comes into house) i. i The,-e a,-e ho we1JS GU Beel room 9we it l n, b :a i i A 3 ` O� 2 ►a o o C�,�-c:co.� '�, + O 5•Pn c t,-wK 6 FC SETS r --- - - /} Z Zq. S t , - - - -- - I A 3 ;; .S,A S. 3 Shi /?-7 1 FA C H ZAP (zeviaed 04/25/97) , Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ge-4r-4 l2el Ce-,1-t,-✓i M,4 6 2(v S Z Owner:. Date of Inspection: Depth to Groundwater 7 Feet j. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions I' { Check with local`Board of health Check FEMA Maps Check pumping records_ Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) J/o oS /v��©ecfr o,� �G1e�7 n�/`7 L� ro 2 2/a b y J. P. /I'!Q CO M b ems'J/. 4 t /Low + CI t , D v 1'1'4 9 I �17 is i n SPeL�r'or► aeS r lio�Q wQ S d�5 }Y, 4 l,o `r hel�w 6gbtrse1-V4f'0-0'1 v�4.s Thad-� -} 3, 30 r,.l �/�/�7 �h-y �► t��) Qn� nd y'ra�,�a�w�E-ems was obs�rre�, q . Afglo4"4 wQS -IS��d of t►`olal �Ivc al-ra.-,S ;..� ll af' i,✓-eJA-'SQbdIrl ale ? 41"d /luc II-✓a/-/'cm , 3I. (revised 04/25/97) Page 10 of 10 � 6:. r TOWN OF BARNSTABLE --1.i)CAT10N sG0�e.-1 SEWAGE # ,® VILLAGE ZY-4e 411z-q ASSESSOR'S MAP & LOT,-;?66-°-O6>.o' INSTALLER'S NAME & PHONE NO,c�21'7Gm;;VJ SEPTIC TANK CAPACITY LEACHING FACILI'TY:(tgpe) ��LO (size) NO. OF BEDROOMS -,3 PRIMATE WELL OR i7BLIC WATE BUILDER OR OWNER�� DATE PERMIT ISSUED:______ __ Q DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes N® F >4' �P may. a may' No.1. _ Fps.. © ba� THE COMMONWEALTH OF MASSACHUSETTS 0 BOARD OF HEALTH TOWN OF BARNSTABLE XpVfiratton for Dhipooa1 Works (fonuitrnrtton ramit Application is hereby made for a Permit to Construct ( ) or Repair X) an Individual Sewage Disposal System at: ...... ��1.. ...............::. .... . ... 0.................. Q� ..----.----.-----------------------...------•-------.........--- .-. Location-Address ..- or Lo No. a --7�-- Addr�r!!! L Installer Address U Type of Building Size Lot_."�B a Sq. feet t-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................. Showers — Cafeteria P4 Other fixtures ................ ................ W Design Flow................—53._ ................gallons per person per day. Total daily flow............. -------------------gallons. WSeptic Tank—Liquid*capacity,--04".gallons Length................ Width................ Diameter................ Depth................ x p Disosal 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......................................1.4 .. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G%, Test Pat No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---•-----------•-----------------------•--•--•-•--------------.....---------------••---------------..................................... Descriptionof Soil......................................................................................---------------•--------------•--------------•--------------------...........•... x w ........................................................•---•-•------•------------- -•---------•-•-----•------.......----•-----------•------------•-------•----....................................... U Nature of Repairs or Alterations—Answer when applicable. :.. _ ... L......... ,IDDD .c ...... . sUil.�.... �Q..K ...... ...... '�GQ�-......��:�..s.S'r��.L�.. 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 Compliant as een issue by t board of health. Signed -------- ------------------ -- ----- ------------- ------- � D.........-- e Application Approved BY - - v_ ----------- ----- -------- ..... ----------------------------------------- ' c Dace Application Disapproved for the following reasons: ........................... ................................. ...................... ......................................................... ................. t-� Date Permit No. ~ ✓--.'� ,g r" :--.Q . ----------- ----------------------- Issued ......-.. .......-----------. Dale No.- .. _...... Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS __ BOARD OF HEALTH TOWN OF BARNSTABLE A liratilan for Disposal Works C�nnotr io�� 1 rk nrt n thrmit Application is hereby made for a Permit to Construct ( ) or Repair (>() an Individual Sewage Disposal System at: ! Cf9...J .................... ..... Location-Address or Lot No. ..... 'U�/ ----------------o..Z__..6.......... S.t..'b�....... I�z�..7�.......--c-..----............."'��lf'_0..................................ue �...� a Cow �.�Owner y /J Ad re ------------ ........ ............. Installer Address Type of Building Size Lot.-_441a ...Sq. feet U Dwelling—No. of Bedrooms.................. ........................Expansion Attic ( ) Garbage Grinder ( ) PL4a Other—T e of Building No. of persons____________________________ Showers — Cafeteria QI Other fixtures ........--•••-----------------•-- --•--- W Design Flow.................. .................gallons per person per day. Total daily flow_______---_--_E�a_6..................gallons. WSeptic Tank—Liquid capacity,lVM.._gallons Length................ Width................ Diameter---------------- Depth----____-_-___.- x Disposal Trench—No........./....... Width...........7.... Total Length...,_--n-�!c-.... 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........................ 44 Test Pit-No. 2................minutes per inch Depth of Test Pit._............__._.. Depth to ground water........................ / ---•------•------------•--•--•------•--•--•---•---•-----------------------------•-----•-•--......-•----•----------•-----------------................-•.•--•-- -Description of Soil....................................................................................................................................................................... U -•-•-•-•-•----•-•-----...---•--------•-------••-•-------------•-•-----••---------•-•-•-----------•-•-----•--------------•--••--------•••-•--•-•••-------•----•--•---•--•----._..._...-----••-•---•----•. w -----------------------------------•-------._...----------------------------....... ---------------------------------------------------------------------------------- -----------•-•--••----•----•--• U Nature of Repairs or Alterations—Answer when a licable� s ........................... 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 Compliance-►as been issued y th board of health. Signed ---L� .' , . �� 1 Application Approved By ��. --- . .... ...- `.. ............................................_-___ Date Application Disapproved for the following reasons: ....................................... . .................... .......... ....... .. ................................ ----------- -------------------- ------ -- -------- ----- --- ----- ------------- /'si �y Permit No. ......_.. v �" "' �Issued -------------------»ate...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE TV.Er#ifira e of C�nntylianre THIS IS TO CERT FY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �) byQ- Cd-�-----... '..GoV57'r--- - - - ----- ------------------------------------------.................................................... Installer at . �� . 7�? s f� i ............. ------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No- -------------------------------------- -,--- dated -_ -------------.-------................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR 16 AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ( .(��.. .........,--........................--------------------- Inspector ......... -� � 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �OJ /" '' FEE........................ Disposal Works Tonstrnrtion Prrmit Permission is hereby granted............. 41677`7-_--_-__(f'O 1�sT. ---------------••••-•...--••-•••----••--•---••-•-•-••----•••-••-•-•--............. to Construct ( ) or Repair�><) an Individual Sewage Di s a�jal System atNo................. ........ 52<,Iee 7.-....... ...... --------- .................................... Street •� // as shown on the application for Disposal Works Construction Permit __ .............•-• •---- s _ ....._ ..+ �.-- Board of Health DATE • / -- •----•-----------.-G---------------------------------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS