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0212 SKUNKNET ROAD - Health
[212 Skunknet Road Centerville A= 171-011 f Commonwealth of Massachusetts (� oI l ,i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 212 Skunknet Rd. Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms 51� IS( 2„2 on the computer, r use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. rae Company Address South Yarmouth Ma. 02664 City/Town State Zip Code ran 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes `��� \\%tuuliuuUiiii .```gyp LIH OF 2. ❑ Conditionally Passes ���,`` '' ''•• c'% 'g°:' MICHAEL ' 3. ❑ Needs Further Evaluation by the Local Approving Authority 'o SEARS * No.SI14430 c- 4. ❑ Fails * I a up0G�````\` 1-25-21 Inspector's Slowfure 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v!% 212 Skunknet Rd. Property Address x Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 212 Skunknet Rd. V Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts I� Title 5 Official Inspection Form '� I1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Rd. V Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 212 Skunknet Rd. Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or El ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts a Title 5 Official Inspection Form I1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 212 Skunknet Rd. u— Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. CityTTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 I Commonwealth of Massachusetts p Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Rd. Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No .Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2019-68000gal g ( y g (gp ))' 2020-67000gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 212 Skunknet Rd. Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow seats/ ersons/s .ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitarywaste discharged to the Title 5 system? Yes No 9 Y ❑ ❑ Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 212 Skunknet Rd. Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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: 3-27-18 #2018-077 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 30" Depth below grade: 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.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Rd. Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with in tee and out tee in place, both covers 6" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 212 Skunknet Rd. u Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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: F gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i c Commonwealth of Massachusetts �- Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Rd. Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is required for every Centerville Ma. 02632 1-25-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 with 2 outlet pipes, box is at 42"with cover at 24" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cM !% 212 Skunknet Rd. Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is Centerville Ma. 02632 1-25-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working rkin order: ElYes ❑ 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. System SAS locate on site Ian excavation not required): 11. Soil Absorptiony ( ) ( plan, If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 cPr�, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments « 212 Skunknet Rd. Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is Centerville Ma. 02632 1-25-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is a 2- 500 gal chambers chambers are clean and dry with no sign of failure 12. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 212 Skunknet Rd. u Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is Centerville Ma. 02632 1-25-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): 1 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 ,<f1\ Commonwealth of Massachusetts :. Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 212 Skunknet Rd. _ -- Property Address Larry Pennington & Kierstin Sample _ Owner Owner's,Name information is Centerville Ma. 02632 1-25-21 required for every -- - " page. Cltyfrown State Zip Code Date of In D. System Information (cont.) 14. 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 be low: ® hand-sketch in the area below ❑ drawing attached separately 11A BIN N A J -)Lq 3 q6.6 O Iq _ IIS OF�MAS����.,, y3, 3 �� .... . .. sgco,,� y„ t�6, 5 �'g M I C H A E L yN' SEARS No.SI14430 'N� �5mmmp ����`\`` t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 f cam, Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 212 Skunknet Rd. V Property Address Larry Pennington & Kierstin Sample Owner Owner's Name information is Centerville Ma. 02632 1-25-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high round water: p g g 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: 3-12-18 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: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Ins Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 212 Skunknet Rd. try .._. .._—.. Property Address La�Pennington & Kierstin_S_ample _ Owner Owner's Name information is Centerville Ma. 02632 1-25-21 required for every --- ----------- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included (�mole i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No.�/� tJ Fee 1� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS RppYicatiou for Misposal .pstem Coustrurtiou 3pPrmit Application for a Permit to Construct(/Repair( ) Up6a_ae(') Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 5Vvj^V_^Z— •'clb- Owner's Name,Address,and Tel.No. Wo.'N er--T-c%n %4% Lrib CCv, 21 L 54-mv-r .- 't_4At, Assessor's Map/Parcel `1 ly'� �� WIn InstgQer's Name,Address,and Tel.No: �,c (,�,;�g �� Designer's Name,Address,and Tel.No. hNk (Au— sce* c— .l��tJ��AntiS�/�:rV �$ `'T ,, Few PLC- 'Lf `iN f' I V,4- Type of Building: Dwelling No.of Bedrooms Lot Size *4 3 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided '3LJ4 gpd Plan Date oil A{)1A Number of sheets Revision Date Title c Size of Septic Tank �����'ri �r"a®® Type of S.A.S.I� ��� �flp `��1,,� CL_-01kq' Description of Soil 5Q I Ica Nature of Repairs or Alterations(Answer when applicable) \Cg Q W 1 ` 'l ��'_) K��A 0 6J C►�� T t.12 Ca. 1�a.eat— 9q! 0 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo ` ealth. igned Date 3 th 1 Application Approved by _ Date Application Disapproved by Date for the following reasons Permit No. �/ Date Issued �' � R �+ No-, 7"' &- Fee /O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS x T Application for Disposal 6pstem Construction Permit Application for a,Permit to Construct(�)/Repair( ) Vg—r d 9(�;) Abandon( ) ❑Complete System ❑Individual Components Location Addressor Lot No. -4\7- Owner's Name,Address,and Tel.No. Warn er! ^ a^ v.�,¢i �A 1 Z CAI, Assessor's ap/Parcel p ( ( 4) 2.3 - 2 Installer's Name,Address,and Tel.No.-rl �,� G Designer's Name,Address,and Tel.No. t%A C qt C 5��;C- 4ojc e.- :T lac— &tS tiny ZS W�br + c,�e��,,, ! •+n. P2b13 ! Type of Building: t Dwelling No.of Bedrooms Lot Size ♦ 3 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 A gpd Design flow provided 34 gpd Plan Date k\.41 IS Number of sheets Revision Date Title Size of Septic Tank {. A00 Type of S.A.S.�Z r�o COD [jrs�%A- rs Description of Soil 5" Nature of Repairs or Alterations(Answer when applicable) 11P._g\G x &L Ln' c \n/ t�, '2\ �k —\Qa e,., 6a CAA C, t r r in/4yk Lt �4- Date last inspected: Agreement: j The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of ` Compliance has been.issued by this Board o f ealth. sr igned Date 14 Application Approved by _ - Date jr Application Disapproved by Date 3' for the following reasons a d Permit No. 1 -0 22 Date Issued ---------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( yy--�Repaired( ) Upgraded Abandoned b I J at �.\Z �►�c =,( g rr L has been construed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. S'^CG _7 dated 73)D -7 f' XInstaller Designer #bedrooms `-Z, Approved design flow 3 C gpd The issuance of this permit shall not be construed as a guarantee that the system will lu ct o 1 e e t Date �� M/ 0 Inspector l — No. —1b -!�Cj Fee 0-C THE COMMONWEALTH 9F MASSACHUSETTS PUBLIC HEALTH DIVISION-PBRNSTABLE,MASSACHUSETTS Disposal .pSteonstruction Vprmit Permission is hereby granted to Construct( ) / Repair( Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed w thin three years of the date of this pe it. Date Approved by f TOWN OF BARNSTABLE LOCATION ��.ZIiCt��y�a��+� ``v�p SEWAGE# :POPE; VILLAGE ASSESSOR'S MAP&PARCEL 0 INSTALLER'S NAME&PHONE NO.Tony >>�C� o ' ,. an S i unlll SEPTIC TANK CAPACITY OOC. LEACHING FACILITY:(type Z) Ssx, 44kitn2, (size) NO.OF BEDROOMS OWNER t2t V PERMIT DATE: (33 1'L2 (9 COMPLIANCE DATE: 3 'c}--7//9' 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 6 .�rIArAC,� �►\ .._ 2-7"111 ® 3 -- 43 "7 6 Town of Barnstable Regulatory Services Richard V. Scali, Interim Director + HnxrtsraBce, s6;9. � Public Health Division " Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 5( Installer&Designer Certification Form Date: R,3A Sewage Permit# mil' -1�79 7 Assessor's Map\Parcel /7/ 1l Designer: 3�ctr ML(�A&rrj Installer: yoAtIpp— Address: 4t 'Dur-re-e. 'j)(' Address: i On ® ' %zwas issued a permit to install a (date) (installer septic system at ezi-AP- based on a design.drawn by (address) Scori MSC nn dated 3 141 1 b (designer) I certify that the septic system referenced above was installed substantially accordin the design, which may include minor approved changes such as lateral relocation of distribution box and/or septic tank. Strip out (if required) was inspected and the s were found satisfactory. 1 certify that the septic system referenced above was installed with major changes greater than 10' lateral relocation of the SAS or any vertical relocation of any compoi of the septic system) but in accordance with State& Local Regulations. Plan revisio: certified as-built by designer to follow. Strip out(if required)was inspected and the S were found satisfactory. I certify that the system referenced above was constructed in compliance with the to f the IAA approval letters(if applicable) 1] 11R I1lista Ier's Signature) (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICA OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISII THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc f ,e Town of Barnstable P __ Departinont of Regulatory Services s r�uwar,►nr� I Public Health Division Date MA89. fd3p. 200 Main Street,Hyannis MA 02601 rFu Mx+� Date Scheduled �� Time /2 4 Fee Pd._ r' Sail Suitability Assessment for Sewage Disposal Performed-By: 5e, Alr1l Witnessed By; LOCATION&.GENERAL INFORMATION Location Address ^Z I-Z_ Slc�Mn�N t� " Owner's Nam* :',d w W'OR v P'Y' n Address CQ Ilk L Assessor's Map/Parcel. • f 71 l/1 Beale Namo S� PAC-6�'.�oly" NEW CONSTRUCTION REPAIR `/ Tole hone# Land Uso 1-15f. ' S10 ae 96 p ( ) Surfhco Stones Distancoa from: Open Water Body ft Possible Wet,Aren ft Drinking Water Well ft Dralhago Way i ft Property Line ft Other ft SI i'TCHt(Stmot name,dimensions of lot,exact locations of teat holes&Para lasts,loeato wetlands-in proximity, to holes) LA LI Lor zt �60s E' pEZ4(, I o° Parent material(geologic) bV U-l-4-sh P Depth to Bedrock MA- Depth to Groundwater. Standing Water In Hole: n/ol" Q�� Weeping from Pit Fnoa Estimated Seasonal High Groundwater f I DETERMINATION FOR SEASON•AL'I[IGHWATER TABLIM Method Used: Do th Obsorvcd standing In obs,hole: _Al r 6 W In, Depth to still mottles. ,,0jam,,, Da�th to weeping from side of obs.hole: o'r 6^.g_ln, Groundwater Adjuatmont index Well-# Randing Dato;_ Index Wall Imval..:- Adj,fhetor-Adj.Groundwater•1.avel PERCOLATION TEST Date 3 Z Time ?'4 Observation j Hole# rip Time at Y" 1f7_ :2(v Depth of Pero Tima at 6' Start Pro-soak Time 0 :O 3 Timo(411•611) End Pro-soak Rate Mlir./Inch Site Suitability Assessment; Slid Passed 51tp Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Hack--- ' ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q;\SEPTIMERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# f Depth from Sall Horizon Soil Texture Shcl Color Soil. Other Surface(in.) , (USDA) ,(Muneell) Mottling (Stnucturo,Stonef;Boulders. • o talstancy.%'Oravell � _ IZrr COOL v� l o �(R:3 Z I-Z �3f3'► j �gu�^'� 1�YQ �& �� 3$�r' (eV, G ' fiat 0 ionn nn5 2rS`7' b'/ rf 6 30% �' S�il+�^LS (oln`� - 132' 2 t�ecQrJiv� x 2 S" i( -1 3 n/0 DEEP OESERVATION HOLE LOG Hole# Z- Depth from Sall Horizon Sol Texture Sall Color Soil Other Surface(in.) (USDA) (Muneell) Mottling (Structure,Stones,Boulders. d 12'` /�• tc�u 10Y2- 312 "D o 3oly (flb J3Z" Ci Aea— 2fr -, -3 DEEP OBSERVATION HOLE LOG Holm# Depth frond Soil Horizon Sall Texture Sall Color Sall Other Surface(In.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.. ConsintenoX. DEEP OBSERVATION HOLE LOG Hole# Depth from Sail Horizon Sall Texture Soil Color Boll Other Surface(in.) (USDA) (Muneell) M9ttling (Structure,Slopes'.Boulders. Co i Flood Insurance Rate Man: Above 500 year flood boundary No— Yes _ Within 500 ycir boundary No+ Yes Within 100 year flood boundary No. Yes peath of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious m itotial oxlst in all areas observed thrpughout the area proposed for the soil absorpdbn sylitem7 If not,what is the depth of naturally occurring pervious material?------ Ceftiflcation ' I certify that on (date)I have passed the soil eva]uator examination approved by the Cl;-Y �� Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 10 CMR 15.017. Signature Datts Q;\RHFrrl rBltCPORM.DOC TOWN OF BARNSTABLE Dater TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: �tb BUSINESS LOCATION: sm 5V Iti�A 9-A INVENTORY MAILING ADDRESS: 6&.AG✓Vi4 'k , aA o249*32 TOTAL AMOUNT: TELEPHONE NUMBER: liq Z-5i 19,4-0 CONTACT PERSON: la M (,l.I U-✓vt,c��/ EMERGENCY CONTACT TELEPHONE NUMBER: .S6LWte �-W7-5610gO MSDS ON SITE? TYPE OF BUSINESS: Ga,OcG 5640- Dec--JQd, INFORMATION / RECOMMENDATIONS: V Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals(Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers f Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) Any other products with "poison" labels ❑ NEW © USED (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes Laundry soil &stain removers (including bleach) �� Spot removers &cleaning fluids (dry cleaners) �" �(S . St . Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: ( '(�' 3 Fill in please: PON � �� ` R APPLICANT'S YOUR NAME/S. 4j""aw h BUSINESS YOUQ HqME A lVESS: ZI 5 k� nc v� c, 3Z vi TELEPHONE # Home Telephone Number 'Z NAME O�CORRCfRATION NAME+�F-NEW BUSINESS S c to _ TYRE OF BUSINESS K ca r' 1S TH1S A HOME OL�CUPATION� ACID.RESS:OF BUSIIVE�S ZLZ,S° w� `. -�.t.�> � :(� /��1'DZbjZ;IVIAp/PQgCEL NUMBER,=.I�.I `O(� .[.Assessing) , When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1, BUILDING CO ISSIO ER'S OF CE MUST COMPLY WITH HOME OCCUPATION This individ al h e n-infor e f on pe mi requir ments that pertain to this type of business. RULES AND REGULATIONS. FAILURE TO COMPLY MAY RESULT IN FINES. A riz i St O ENT 111_� k— i U CL�� :-T, ��. 2. BOARD OF EALTH This individual he beE jnfo���ed of the permit requirements that pertain to this type of business. MUST XMPLY WITH ALL d Signature** 'HAZARDOUS MATERIALS REMj[.AT'r)N15 Authorized 1 COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature COMMENTS: i YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$40.00 for 4 years]. A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed-form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Ll Fill in please: APPLICANT'S YOUR NAME/S: l.Yy\dck 7,,�edald ,p BUSINESS YOUR HOME ADDRESS: Sal otTQ ! la,nP. Covwmgaj►d Mc� 02�o�'T 'A TELEPHONE # Home Telephone Number (e%-t-bc a.- 452A NAME OF CORPORATION: CaQe Col No,L . sanC'_ NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS ZA AAg, allyl MAP/PARCEL NUMBER r lQ G (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO j ER'S n6f MUST COMPLY WITH HOME OCCUPATION This indivi in rmn rmit req 'reme is that pertain to this type of busing ES AND REGULATIONS. FAILURE TO COMPLY MAY RESULT IN FINES. riz S4g n e** 'COMMENTS: (�"11_21/ ) (-"(W /W )U O tloS o _Si ►7rC w 6aL J 2. BOARD OF HEALTH This individual has been f'GC.1 of the permit requirements that pertain to this type of business. MUST XMPLY WITH ALL Authorized Signature** 'HAZARDOUS MATERIALS REG•aLA.TICj', COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Dater TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: BUSINESS LOCATION: 501 Z)-Me✓ lame c snu►naasLA , ✓ o- o-t-bZ,-i INVENTORY MAILING ADDRESS: Qo Fax a-I r,, ,,,,< a A r,���� TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: yts-ySa-Sc)-a4 MSDS ON SITE? TYPE OF BUSINESS: e INFORMATION / RECOMMENDA IONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals(Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes 1uc�n. ",6-,eck 0. 1ADry. 0,1\ gay Xke. , AmaeA ace Laundry soil &stain removers (including bleach) p , Der n (cdW /1a04, ,a. 4t e(b01)f' CynoS '10 b Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash JAI WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initia16 CA Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not_for Voluntary Assessments 212 Skunknet Road Property Address Estate of Elizabeth Tsan os Owner Owner's Name — information is Centerville required for MA 02632 July 23, 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. Important:When filling out A. General Information 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 — r� 189 Cammett Road - Company Address — Marstons Mills MA 02648 CitylFown — State Zip Code 5087428-1779 Sf 12855 t r s Telephone Number License Number 1 _ — B. Certification I certtfy that.l have personally inspected the sewage disposal system at this address a d that the- information reported below is true, accurate and complete as of the time of the inspecti n. The iNpect n was performed based on my training and experience in the proper function and mainte ance of do sites sewage disposal systems. I am a DEP approved system inspector pursuant to Sect on 15A46 of rn Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority July 23, 2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use. at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 08-197 Tsanggos.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is required for y Centerville MA 02632 Jul 23, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: Z 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, leachng pit was half full with a high stain line indicating fait had never been more than half full. 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 08-197 Tsanggos.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 July 23, 2008 required for 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 heallth, 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. - 08-197 Tsanggos.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 required for _ Y every page. Cityfrown 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_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 08-197 Tsanggos.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 required for Y 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. 08-197 Tsanggos.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 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 QI, 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)] 08-197 Tsanggos.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Road _ Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 required for Y every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 y DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 156,000 gal. = 213 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Vacant 3 Months. Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow (based on 310 CMR 15.203): — Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — Last date of occupancy/use: Date Other(describe): --- — 08-197 Tsanggos.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 required for y every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 4/3/91 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-197 Tsanggos.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 required for y every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 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): Depth below grade: 2'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: 2" — Distance from top of sludge to bottom of outlet tee or baffle 28" — Scum thickness 1 — 91, Distance from top of scum to top of outlet tee or baffle -----— — 8" Distance from bottom of scum to bottom of outlet tee or baffle — How were dimensions determined? Measured — 08.197 Tsanggos.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 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.): Liquid level was found 3" below outlet invert due to vacancy and evaporation, tees are intact and clear. 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, iniet 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): 08-197 Tsanggos.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is required for Centerville MA 02632 July 23, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 — Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.).- No solids or high stains present. Pump Chamber(locate on site plan): Pumps in.working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-197 Tsanggos.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 o'15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23 2008 required for Y every page. Cityfrown 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: One 6x6 pit. — ❑ leaching chambers number: — ❑ leaching galleries number: — ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: — ❑ overflow cesspool number: — innovative/alternative system Type/name of technology.- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit was found empty at time of inspection, observed a high stain line indicating pit had never been more than half full. 08.197 Tsanggos.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 o"15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 required for y every page. Citylrown 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.): 08-197 Tsanggos.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 o1 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 212 Skunknet Road Property Address Estate of Elizabeth Tsancigos — Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 required for --------------....-- ------- — — — y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Skunknet Road Water Service \ 15 25 2 40 40 32 t ,,; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M _ 212 Skunknet Road Property Address Estate of Elizabeth Tsanggos Owner Owner's Name information is Centerville MA 02632 Jul 23, 2008 required for Y every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 15 Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 35 and topo map shows property at el. 50. 08-197 Tsanggos.doc•08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 Df 15 C , THE Town of Barnstable CF 1p� Regulatory Services BARNSTPABLE, Thomas F. Geiler, Director sb3. � AT 139- 0110 Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIMisclaimer Private Septic inspections.DOC'. TOWN OF BARNSTABLE LOCATION SEWAGE# cP_0/-19 VILLAGE ASSESSOR'S MAP&PARCEL J 7 INSTALLER'S NAME&PHONE NO.+ f, T cIn �, i SEPTIC TANK CAPACITY '. �� 69J 44 -7) L LEACHING FACILITY:(type.) �IkQr (size) NO.OF BEDROOMS T �bC a-g OWNER Qi V PERMIT DATE: a) 1 COMPLIANCE DATE: 3 —7 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 0 e b� 2-7101 �3 � � 53 TOWN OF BAARNSTABLE _ LOCATION Unt � '`GeF' SEWAGE# .-�-+''S O VILLAGE Tt VAkk ASSESSOR'S MAP&PARCEL I146W 'S NAME&PHONE NO. SEPTIC TANK CAPACITY 10W LEACHING FACILITY:(type) PJ1T (size) aO NO. OF BEDROOMS J OWNER 'Sy PERMIT DATE: C E DATE:X, P Q� 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 Skunknet Road i Water Service i — 15 25 40 40 ' 32 ASSESSORS MAP N0:—e 171 JJ PARCEL NO:. 011 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH /1 TOWN OF BARNSTABLE AVV iration for 11ispoii ai Workii Tunstrnrtiun 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: cl = --------------------------------------------- L lion-Add,tess or Lo No. Owner Ad Installer Address � U Type of Building Size Lot... feet Dwelling—No. of Bedrooms...............>.3......................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) � Other fixtures ------------------------------------------------------•----------•......-----------------........................................................... W Design Flow..............�,�...._...____......._gallons per person per day. Total daily flow...L53 .._....._._........._._....gallons. WSeptic Tank—Liquid capacity.ICX..gallons Length''10._._.• Width�...)Q1/_. Diameter................ Depth.J_.` x Disposal Trench—No..................... Width....._-------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------1------------ Diameter......10........ Depth below inlet.....ID.._._..... Total leaching area.-,ID7....sq. ft. Z Other Distribution box ( ) Dosing tot*��( Q '-' Percolation Test Results Performed by_ rJl .. _ 2r._. 1' _:..-._. Date....._�.1I._/�.................. W Test Pit No. I..... ......minutes per inch Depth of Test Pit-----)._.65.1.1.... Depth to ground water....11d (i Test Pit No. 2......4�.....minutes per inch Depth of Test Pit----- Depth to ground water..... . C4 ........--•-------- -------•------------•-------•••-•••---------...•---------.......--------•---•••----•.....------------........------••.......---•--....... 0 Description of Soil........ .............................. .. x _-- -q -------------------- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------------------------------- •------------------ •---------- ------------- ...------------------------------------------------------------------------------- ---------------- 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 by the board of health. Signed ----- ....... /p j -/ . Application Approved By - ----- ten v> - <r�--------------------------------------------------------------------- ----- ` Date Application Disapproved for the following reasons- ......................................... �� Date Permit No- ......... --- --- ----------------------------- -------- Issued ----...------------------..:-------------------------------------- Date - -� -��s � R J7l ' �. >ng........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iration for Biipniia1 Works Tnnitrnrtion thrmit `-`�— Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_........ k I�n 1'rn p�- 1i�[ ----•-----------------•---•---------•--=--•-•.............................................. Location-Address / or Lot,No. .......... �1,�;,/✓nn__ i� � ! x! � t/( --- yn 7i n - Owner, Z Address Installer Address U Type of Building hs Size Lot_.=.�fj �9_______-Sq. feet Dwelling—No. of Bedrooms..............._.�_.._..._ ....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type,of Building ...........................• No.tof persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ......................................---'.."'.~.................................................................................................... Design Flow..•......_.........................gallons per persofi per day. Total daily flow_.._..53 ._...•....................gallons. W u �� s. WSeptic Tank—Liquid capacity__j>-!gallons Length_-.�n.___ Width. __.). .... Diameter________________ Depth:`?.__-! ... Disposal Trench—No..................... Width.................... Total Lenjith.................... Total leaching area.___________.__.....sq. ft. Seepage Pit No........ Diameter-._-___)'i _�..... Depth below inlet......!__ �......... Total leaching area___: ��7._.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by. _...?_` ,r;__. :1'X_:_____ Date........1__ hj................. 1 Test Pit No. I.......�.....minutes per inch Depth /of Test Pit------ .... Depth to ground water-----��A��:l ---_--- PLI Test Pit No. 2........ ____.minutes per inch Depth of Test Pit...... z' �___ Depth to ground water......./tomaf_z_ P4 ------------------------------------------------•-----------------------•-•-•-------__.------_-------------•---------------------....... 0 Description of Soil........................................--.............................................................................................................................. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ 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 has been issued by the board of health. Signed ....:-- f iyt... " " ' ........... yiI-.Date�--"-......... .. Application Approved BY -- -p.d..... Date Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------------- ...............'._...'--"--'---"--'-------------'-'---....---'--"---............. --'-----.....--'- ----- --''----...---..............------------------------------------------------- .--................................ ! Date PermitNo. ------...- . ` ' ........................ Issued .------. --'-- --'---'---'----'=n ---- --...--"- Dan, w THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 TOWN OF BARNSTABLE Ce>rtifiettte of Gra linurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) b ......................1�-�n- ... Y _ e :. <s pp Ins[aller at ......... �C :�M. t � ... r' c .�.. " .:................. ' 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 ED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--A-If--- '1-4 1 " " " ....... " Inspector :...... -�4, - 1�\ '"\------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No..... ��_��,7 TOWN OF BARNSTABLE / .-J FEE..._..... .. ....._ �i��la��t1 nrk� �nn��rilan rrnti� Permission is hereby granted........ "' ` ------------------••----..._.................... to Construct (0 or Repair ( ) an Individual Sewage?Disposal System qq at No.•--••• ............ _ �� ---------- - a7an =' '•' U Street as shown on the application for Disposal Works Construction Permit No..- \ .. Dated.......................................... .....................................f-!`!•..=;r-: ---•----•-•----•-^----•-•---U ------ DATE_ --------------------------- Board of Health FORM 36508 HOBBS&WARREN,INC..PUBLISHERS WN OF BARNSTABLE LOCATION f ,S (/ /I��C SEWAGE # I� VILLAGE C ef)-foA(/ i j,� -& ASSESSOR'S MAP &�LO �g INSTALLER'S NAME PHONE NO.�i/��� G�'j�} �� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) a^ (size) �� NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: .3 / VARIANCE GRANTED: Yes No c�I ti"\Y SEPTIC SYSTEM INVERT ELEVATIONS DESIGN CALCULATIONS REVISIONS BY CROSS- SECTION FOR A BEDROOM HOUSE WITH '`4(� PROPOSED TOP DIST. BOX IN GARBAGE DISPOSAL OF FOUNDATION j DIST. BOX OUT _ a)► SEPTIC TANK,' - X.15 0 :K = �� > A l_'�-U t1�, f - -'i o1 i _ -4" , LEACHING SYSTEM N.�_:=____ �•.A� ~�.•_.,• :__"... _ ! ;I - SEPTIC TANK I N �.,:.I ! , 6LIk Y LISE A y''L!�- GALLON TANK / r •_ �;� Lo�U i ;%� ,At LEACHING PIT% USING I -61X fP/T WX Z 'STONE 1 I 4 �i Ij SIDEWALL ; HEIGHT X 2 XETT X RADIUS l i y FLOW S.F X GPD/SF= `t 7( •G GPO LOCUS MAP EXIT 4 t. �v _-'' SEPTIC TANK OUT _ - . BOTTOM; TT(RAOIUS)2 LEACHING SYSTEM BOTTOM -- - 7__ -� 7�5` S.F. X , 'D _GPD/S.F. GPD 2 ! S.F = TOTAL = G 4 GPD DESIGN FLOW = ? L GPD Pitch 1/4" Per Foot (Min.)F Z RESERVE = 2(� • GPD 0 - 2 % GRADE (Min.) Q z r2_ 3"Min. " Mln 2 °f8 20 i n ° washed stone Q lb LEvEL ( j v r Q x 4-O" Liquid FOR 2 __ _ �� P or GS� moo.oo Level / DIST BOXLfl 1 L- Pitch 1 /8 Per Foot (n �' r j 4,_,, �dJy GALL.ON SEPTIC TANK (Min.) soIS U -_j LU 4 „ � � oa QQJ Z J 1t 4 Schedule 40 PVC 3/4 - ! �2 0 j W Washed Stone �'>--«� l._ �� �` Cr ��' III Or Equivalent NOT TO SCALE r^4J r � LEACHING PIT �' TYPICAL_ CROcS- SECTIOr. ZZ � �,tC Zc" , 18� 4� �W W �v `J r a i Q v �c 1' k1 wF � r �4� 11 NOTES rn r►�`� I a £LEvAT14NS SNc w/v r",HE /N FEET .4BOVE1 1 �, / z I V a. ACCESS COVERS of THE 5EP7-/C SYSTEM W � � Z ARE TO BE W/TH/N 12 OF PROPOSED GRADE. Q t THERE IS TO BE ONE FOOT OF GROUNDCOVER W ' OVER THE SEFi/C SYSTEM. O W - �� Cc / CONSTRUCTION OF THE SEPTIC SYSTEM /S ro V Lj z W \ CONFORM TO THE STATE SANITARY CODE , r ram- W \� �.- TITLE Y, AND THE TOWN OF Q Q v r BOARD OF HEALTH REGULATIONS. ' 8� . 3 0 d i b. DESIGN LOADING OF SEPTIC SYSTEM -i SEPTIC TANK s H - STRENGTH DIST. BOX = H - I= STRENGTH W � LEACHING P/TSH- STRENGTH W Li � J � Q _ SOIL TEST DATA rL �.M, DRAWN ,t A I F5 etc: � GLc--il,.A CHECKED KEY - - M•.Ts�r.'rf - DATE EXISTING ELEVATIONS X y,.ne.a,, ,4.M �` - `��'` � 9 4I,s sA,0P"id = I �� ►" ; NALL j � SCALE l EXISTING CONTOURS i✓ JO►4N ` S1 SicI '= rn,�L:; M �E D1 U µ JOB NO. PROPOSED CONTOURS — - ,,y,;•. rypA,� -At-Ta Tom. All �Gr4-j!(! ��AK ��.ARSE TE`'7PIT LOCATION fGrS1t% 7 err 5A,�.;p -- q ! SHEET A' �t th�d� 1 t(1�� !�`� ___12_7• �! (d .rila v Z CATCH BASIN 1N !-UTILITY POLE ��} '" - �'-�'--_ WATER FOUND t`� WATER FOUND I TEST MADE 1 ' 3 lff' TEST MADE = WITH F:n r,t�t<' ! WITH !=*' _ .__------ -DATE AGEr,T, LT PERC. RATE ' LESS THAN MINUTE PER INCH DROP +,:�ttiM-. ,Ar3l.E BOAF2D OF HEALTH OF J 0`J E SHEETS CENTERVILLE, MA CONSTRUCTION NOTES MINIMUM 20" DIAMETER CONCRETE MINIMUM 20" DIAMETER COVERS COVERS RAISED TO WITHIN 6" OF TOP OF FOUNDATION RAISED TO WITHIN 6" OF FINISH FINISH GRADE (OR AS NOTED) Race l°ne0o`�, 1.) ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE, TITLE 5 (310 CMR 15.000): EL=50.5± GRADE (OR AS NOTED) �ry 2 STANDARD REQUIREMENTS FOR THE SITING, CONSTRUCTION, INSPECTION, UPGRADE, AND EXPANSION OF ON-SITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT EL=50.0± El = 50.0± o �� AND DISPOSAL OF SEPTAGE, AND THE LOCAL BOARD OF HEALTH REGULATIONS. \\ \\ �/ X/ o \\�\\ 0 90 o 2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE IS POTENTIAL FOR AND /�/,/�j,/ /\\��\\� E /i./�/./ �o VEHICLES OR HEAVY EQUIPMENT TO PASS OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20 LOADING, IF UNDER AN IMPERVIOUS SURFACE, SYSTEM SHALL BE VENTED TO THE ATMOSPHERE. LOCUS Great Marsh F1 "' �� Rood 3.) TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS AND D-BOX SHALL BE INSTALLED ON A STABLE 48.3 47.0 GEOTEXTIILE FABRIC MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. E 1116 4.) COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK, THE DISTRIBUTION BOX, AND n THE SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN 6" OF FINAL GRADE. LEACHING t FIELDS, TRENCHES, AND OTHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL 47.6± 47.1 46.9 46.52 4t46. > SITE LOCUS HAVE AT LEAST ONE (1) INSPECTION PORT CONSISTING OF PERFORATED 4" PVC PIPE PLACED o 1 N 2 (V 3/4" to NOT TO SCALE VERTICALLY TO THE BOTTOM OF THE SOIL ABSORPTION SYSTEM WITH A CAP, TIED WITH MAGNETIC 0 DB-3 1-1/2 STONE (Double wash) MARKING TAPE, ACCESSIBLE TO WITHIN 3" OF FINAL GRADE. GAS BAFFLE H-20 Rated 5.) PIPING SHALL CONSIST OF 4" SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A D- BOX 44.2 /CONCRETETWO LEAOCH CHAMBERS WITH 4' OF MINIMUM CONTINUOUS GRADE OF NOT LESS THAN 2% FROM THE BUILDING TO THE SEPTIC TANK, STONE ON ENDS AND 4' ON SIDES AND NOT LESS THAN 1% OTHERWISE. 6.) DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4" DIAMETER SCHEDULE 40 EXISTING 1,000 GALLON Longest Run 5.1 PVC (OR EQUIVALENT) LAID AT 0.005 FT/FT, UNLESS OTHERWISE NOTED. LINES SHALL BE CAPPED LEACH CHAMBERS SEPTIC TANK (END VIEW) AT END OR AS NOTED. 7.) LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO (2) FEET BEFORE (To Remain) FLOW PROFILE PITCHING TO THE SOIL ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATER TESTED TO NOT TO SCALE EL=39.1 Bottom Test Hole ASSURE EVEN DISTRIBUTION. 8.) GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES IN ORDER TO PROVIDE A WATERTIGHT SEAL. 1•) Assessor's Map 171 Parcel 11 9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE 3.) Plan Book 224 Page 127 .) Book 28088 Page 19 DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. 4.) This property is in the Resource Protection Zone 10.) IN ACCORDANCE WITH 310 CMR 15.221, ALL SYSTEM COMPONENTS SHALL BE MARKED WITH 5.) This property is not in a Flood Zone MAGNETIC MARKING TAPE. 11.) THERE ARE NO KNOWN WELLS WITHIN 100' OF THE PROPOSED SOIL ABSORPTION SYSTEM. 12.) FROM THE DATE OF THE INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL RECEIPT OF SYSTEM DESIGN CALCULATIONS THE CERTIFICATE OF COMPLIANCE, THE PERIMETER SHALL BE STAKED AND FLAGGED TO PREVENT USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. SEWAGE DESIGN FLOW REQUIRED: 3 BEDROOM DWELLING 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UNLESS N 20'05'25" E 110 GPD / BEDROOM = 330 GPD REQUIRED CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE 15.27' SEWAGE DESIGN FLOW PROVIDED: TWO (2) 500 GALLON LEACH CHAMBERS DESIGNER. / WITH 4' STONE ON THE ENDS AND 4' STONE ON THE SIDES 14.) THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE a 1-'__`�.�I5542p„ Vt = [(25.0 x 12.83) + 2(25.0 + 12,83) (2) x .74 = 349 GPD PROVIDED BOARD OF HEALTH AND THE DESIGNER. THE DESIGNER SHALL CERTIFY IN WRITING THAT THE 0 / I86.43• E 349 GPD PROVIDED > 330 GPD REQUIRED SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE PERMIT o ! 49.8 TBM EL = 50.0_ Top Corner c ncrete SfJ AND THE APPROVED PLANS. 48 HOURS ADVANCE NOTICE IS REQUESTED. 3 (A� .- I �� 50.2 SEPTIC TANK CAPACITY REQUIRED: 330 GPD X 200 15.) LOCATION OF UTILITIES IS APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR / ' z _ SEPTIC TANK CAPACITY PROVIDED: EXISTING 1,000 GALLON SEPIC TANK TO REMAIN DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO �. House #212 -� A GARBAGE DISPOSAL IS NOT PERMITTED WITH THIS DESIGN FLOW COMMENCEMENT OF ANY WORK. THIS INCLUDES, BUT IS NOT LIMITED TO, REQUESTS TO DIGSAFE, C Q / in Co 3 Bedroom _ SAS 6 50.2 / ANY PRIVATE UTILITY COMPANIES, AND THE LOCAL WATER DEPARTMENT. o / TOF = 50.5 rr v w`r 4e.z / / 25.0' 16.) CONTRACTOR SHALL VERIFY THAT ALL WASTELINES ARE CONNECTED BY WATER TESTING Z �!l sT o o / WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. / 0e I , t 17.) CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY i w�,L'° / SEPTIC SYSTEM COMPONENTS. f E�eo Ltn - / k/ O "" -_ - 117 - 18.) TEST HOLES COMPLETED PER STATE ENVIRONMENTAL CODE, TITLE 5. SOILS CAN BE - / ' �- ° �J �-_ , a VARIABLE AND TEST HOLE DATA IS NO GUARANTEE OF SOIL CONDITIONS IN OTHER AREAS. IF / 7/soySee sos o o SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS, DESIGN ENGINEER IS TO INSPECT THE Gos Line �j /t9 o c� SOILS PRIOR TO PROCEEDING WITH INSTALLATION OF ANY SEPTIC COMPONENTS. r' 40 <<` I 19.) EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND _ p0"Bf'0/w 11 Lot 21 ABANDONED IN PLACE OR REMOVED AS REQUIRED. AREA TO BE COMPACTED TO MINIMIZE SETTLING. J150.11 0. 42± Sq. Ftr I =50.1±) TEST HOLE LOGS N 'S:S- Test Hole #1 (EL 49.3 / 20» W l rDepth Elev. Layer Soil Class Soil Color Comments / so.z / D-Box 50 __J "-12" 49.1 A Loom 1OYR 3/2 "-38" 46.9 B Sandy Loom 10YR 5/6 Note: 38"-66" 44.6 C1 Medium Coarse 2.5Y 6/3 30% Gravel This plan is only valid for current regulations and may Sand and Stones Stones not be suitable for future regulation changes that may occur. 66"-132" 39.1 C2 Medium Sand 2.5Y 7/3 Test Hole #2 (EL=50.1±) Layer Soil Class Soil Color Bed2 Bedroom a Depth Elev. Comments # GRAPHIC SCALE #3 0"-12" 49.1 A Loom 10YR 3/2 30 0 15 30 60 150 Bedroom _ 12"-38" 46.9 B Sandy Loam 10YR 5/6 #1 38"-66" 44.6 C1 Medium Coarse 30% Gravel ° Sand and Stones 2.5Y 6/3 Stones ( ) 66"-132" 39.1 C2 Medium Sand 2,5Y 7/3 IN FEET Dining 1 inch = 30 ft. DATE OF TESTING: 03/12/18 Family SOIL EVALUATOR: SCOTT MCGANN Living BOARD OF HEALTH AGENT: DON DEMARIS Proposed Sewage Disposal System PERCOLATION RATE: LESS THAN 4 MIN/INCH IN "C" LAYER AT 54" Kitchen '" """`='°d - NO GROUNDWATER ENCOUNTERED 212 Skunknet Road Centerville, MA I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF Floor Plan Prepared b ENVIRONMENTAL PROTECTION PURSUAMT TO 310 CMR 15.017 TO CONDUCT ;�i� ..' Prepared for: p y SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED N.T.S. All Cape Septic LLC BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE Ian Warner 618 Route 28 DESCRIBED IN 310 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY Y 212 Skunknet Road West Yarmouth, MA 02673 SOIL EVALUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, �'�� -- Centerville, MA (508) 771-4200 ARE ACCURATE .AN I ACCORDANCE WITH 310 CMR 15,100 THROUGH 15.107. allca ese ticQ mail.com r / P p 9 r Dote: 3/14/18 Sheet 1 of 1 By: MA Check: SM Project No. AC-125 SCOTT MCGANN, CERTIFIED SOIL EVALUATOR