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HomeMy WebLinkAbout0568 SKUNKNET ROAD - Health 568 SkLinknet Road Centerville A= 169—015 —009 5 M E A D No.H163OR UPC 10259 smead.com • Made In USA I / q Commonwealth of Massachusetts ! q—alb- 00/ - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,• 568 Skunknet Road Property Address �^ PQ Ken Babba 1`0 Owner Z- Owner's Name / r.s information is Centerville ✓ MA 02632 10-20-17 ,"� required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered itrany way. Please see completeness checklist at the end of the form. Important:When filling A. General Information 22 on forms the computer, �� �B(T \``�� �� .OF'A4gSS*/�i use only the tab 1. Inspector: key to move your cursor-do not JAMES N = James D Sears =�; use the return Name of Inspector ;Cokey. 'a Capewide Enterprises Company Name 153 Commercial Street Company Address Mashpee MA 02649 Citylrown State Zip Code 508-477-8877 S1623 • Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-23-17 spector'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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System`•Page 1 of 17 �OVV VS Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town State Zip Code Date of Inspection 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 (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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in UERM is less than 6" below invert or available volume is less than day flow p17- t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 . Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 568 Skunknet Road �M Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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 II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Skunknet Road �M Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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 maintenance of subsurface sewage disposal systems? proper 9 P Y 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r— Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. tank D Box and pit. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2015-39,000Gals 2016-40,000GaI s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is Centerville MA 02632 10-20-17 required for every page. City/Town 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: NA 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): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1981 Permit # 81 - 229. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): " Depth below grade: 31 feet Material of construction: ❑ cast iron ®40 PVC ® other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40&4" PVC SCH 20. Septic Tank(locate on site plan): Depth below grade: 23" 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 Gal. Precast H-10 Sludge depth: 1" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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 29" 0i. Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and cover's at 23" below grade w/outlet baffle. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. CitylTown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 568 Skunknet Road Property Address P Y Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x 16"-2' below grade w/cover at 4". Box is clean and solid w/one line out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G'M 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is Centerville MA 02632 10-20-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leaching is one 1000 Gal. precast pit w/1' stone. Pit at 38" below grade w/cover at 4". Water level at 18" below inlet. No sign of over loading or solid carry over. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. Cityrrown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection) Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•''r 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town 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 r 3 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 4 Estimated depth to high ground water: 14+ 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: 5-5-81 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: T.H.on Design plan 5-5-81 no G.W. at 14'. Bottom of pit at 9'. Bottom of pit at 5' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Skunknet Road Property Address Ken Babba Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 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:1 Fill in please: APPLICANT'S YOUR NAME/Si� K aXfi y1 ➢C,�. �L�r� bc.- ' BUSINESS YOUR HOME ADDRESS.: S(9 SV.--- QrA Ceo CoRMV9— Aa, 0Aa32 '! 7 i15viti Lj UX '7510 ;4 TELEPHONE # Home Telephone Number ;j — _ n E-MAIL: NAME OF CORPORATION: NAME OF-NEW BUSINESS`.�tanG(rZA� ' 0, C TYPE O BUSINESS; Cryl I hf IS THIS A HOME OCCUPATION. YES NO Co" vlt7� �F� ADDRESS OF BUSINESS Ho' . MAP/PARCEL NUMBER w� (Assessing) When starting anew 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"� business in this town. COMPLY wITH h. BUILDING COMMISSIONER' FFICE C RULES AND 13EGU(,AT�OOM� O�GU This individual h bee ormed f y permit m its that pertain to thisJ�eusiness. A4PL1 MAY,EXULT NS, 0CC1 �PATI©M IN Pl1 e1 , Tp Auto ' Si nat r�* COMMENTS: 2. BOARD OF HEALTH *' This individual ha�b /formed of•th rmit req that pei*tain to this type of business. Authorized Signature* COMMENTS: V 3. CONSUMER AFFAIRS (LICENSING AUTHORITY] This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: . No. 3C0 � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered mcomputer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for disposal 6pstrm ConetCurtion Vermit Application for a Permit to Construct( ) Repair(V�Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 5(o 9 S,kvv��e—hA I + Owner's Nate,address,end Tel.No. ga'7, Assessor's Map/Parcel W —O1,5 Installer's Name,Add ess,and Tel.No. 59, -V77'� Designer's Name,Address,and Tel.No. 3 co_P�w , 5}-(- rvks MIA Type of Building: 9 Dwelling No.of Bedrooms Lot Size r-3 ( sq--fi. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) IaGe —�jtYC 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He i e Date f�) aQ L Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ® Date Issued --- - — --------- No. , Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plication for Bisposaf 6pstem (Construction permit Application for a Permit to Construct( ) Repair(V� Upgrade( ) Abandon( ) ❑Complete System �ndiidual Components Location Address or Lot No. �j S kv��<<��'1Q Owner's Name,Address,and Tel.No. 92�_ !0 3 gr y979 Assessor's Map/Parcel _ Installer's Name,AddFe s,and Tel.No. �!�$-y71-gg7-7 Designer's Name,Address,and Tel.No. k N.x- �.��< f� C n Zq�k, P11 MA Type of Building: Dwelling No.of Bedrooms Lot Size sq--€t. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ` i Design Flow(min.required) gpd Design flow provided gpd y , Plan Date Number of sheets Revision Date Title 1 Size of Septic Tank Type of S.A.S. Description of Soil ' i + Nature of Repairs or Alterations(Answer when applicable)Qa )aca i r 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 Board of He tie Date L Application Approved by / ,�f Date Application Disapproved b ! Date for the following reasons," t � Permit No.r�v ®• Date Issued --,--.————- .—— -- »— „ —, r= ,. 77 r—: -. 7- . . —r — -.—c: Q�I11 THE COMMONWEALTH OF MASSACHUSETTS V BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V� _- Upgraded( ) Abandoned(,. )by 0 C-tty— -,c f 2S at 1K.,A2t> has been constructed in accoiadance with the provisions of Title pp 5 and the for Disposal System Construction Permit No dated Installer ��I2_w ode vtLr � � g Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date rZ 1 n J J *~ Inspector \, L �0161 I ----------------------—-----------------—--------------—-----—----------—----------—---------—---------—----------------—--—----------- No. 710, Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construction Vermit Permission is hereby granteQd�to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at 568 ,S k t"K,�,Zcf- � � C�.'��✓t�Q_ 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:Connstruc on m gt be completed within three years of the date of this permit. - Date / Approved by /r' c Sta,.IG��, ��1L� - 3�31=veac��K ;t� ', � L�.,,� , � _ � ',,.-•- "'".. . ' � _. '( I. , 410 GA28A<o� CRI�.t�ErL. I.{ • � '� � i rat Lam( Low _ 110 +�, _ ,33o 'G P-t 'i USE;I1 loo0 6AL. !G 939 , S(yGWALt A2E.A = 15D S.t=. t �j ' ISo Sr` Il,c /oe.Z 5o s5•. t •o = 6o C�.R Dk 1 peepToTAC -c;,esiew = d2S G.RD.4� Mid" i "(-oTo� va1 Lam( Few t 33D 6. iPD. • � tXP N 0=6 I fZGDt.QTlOU PATE � °�� 2�rtIU O¢ W9 y ,i •`F, \ r Afj Vi /• l% t V V f _ y 3 t 76 �a•� k i kN � LOAD -rem.. P-lq$ ' �� A� f Totem �i�ts a too.o r SvBSolt. � I coo . luv. � • �I INV. tj T-AWV. 1� i S' SAIJb•:� (000 9a•o ' Iwo 1W •, .t° �.. ; i p,T WITt.1 /� j, 't�/atfZ i WAS+dED � • F r i C6QTtFtED PLbT' '85 Id u o SGAL+�- t ,� d Chl Iry GliA�� r z CGtZT11=4 T1;(AT ' TNG 7oLjjJbAT V14 659400WQ PLAQ Rspp.zeI-j _a i P NF.1'i=a TWZ- AUt� SETI'_�AC1C �GQc�IRENtcuTy DF T1.1E �OT 1 f y -Tower pL �k. 33`� �� • 4 1 PA'TG la _ ,. RCGtS't-c_2�o La1.tG SU�v�Yur,:S TMl5 Vt-.AW I!, woT 01-4 AW OSTEZVtL_L.G o MASS„ i. . 4 TNC. UFO,' <<. 511awtD A�PI_1'GA►-.IT A 1M i 1 +JIiT• t'C'_ U'�G(71 Tu 1.0_C' l_11.1E,� M� �• Cj "�- ,� Town of Barnstable Barnstable °+ Regulatory Services Department AAFAnwdcaCilyy 11 BARNSTABM Public Health Division ' I s6;9 ♦� fDN1"`a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2843 2034 February 21, 2013 Mr. & Mrs. Alan'Merando 1103 Glenn Lane Safety Harbor, FL 34695 'ORDER TO COMPLY WITH STATE.ENVIRONMENTAL CODE, TITLE 5 The septic system located at 568 Skunknet Road , Centerville, MA was last j inspected on 2/05/2013, by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • The Distribution Box needs to be replaced. You are ordered to repair or replace the septic system within two (2) years 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 as McKean, R.S. CHO • Agent of the Board of Health Q:\SEPTIC\conditionally passed\568"Skunknet Road Cent 2013.doc l r ` r , I Parcel Detail http:Hissgl2/intranet/propdata/ParcelDetail.aspx?ID=11087 -)pt Y'it y to Logged in As: Parcel Detail Wednesday, February 20 2013 Parcel Lookup Parcel Info Parcel ID 169-015-009 Developer � Lot LOT 9 I Location 5 88 SKUNKNET ROAD I Pri Frontage D09 Sec Road I Sec Frontage i Village LCENTERVILLE I Fire District C-O-MM Town sewer exists at this address�NO Road Index 1494 Asbuilt Septic Scan Interactive 169015009_1 Map Owner Info owner IMERANDO,ALAN J & DIANE H � Co-Owner I streets 1103 GLENN LN I Street2 i City ISAFETY HARBOR ( State FL zip 34695 Country Land Info _ Acres 10.39 use Single Fam MDL-01 ( zoning IRC Nghbd 0105 Topography Road_ I Road{Paved Utilities Public Water,Gas,Septic _ + Location �I Construction Info Building 1 of 1 Year 1981 � Roof Gable/Hip Ext jVertical Sidin Built Struct Wall Living 912 Roof As h/F GIs/Cm ac None Area .._ ,_ _�... Cover�.._P P � Type �D Style Ranch � Wall l Int Bed 12 Bedrooms gyp' RoomsBath 11'a ; Model Residential Floor 1^ardwood ( Rooms 11 Full + 1 H �) Heat Total, Grade jAverage Hot Water 4 Rooms z 0 Type Rooms _ Heat Found Stories 1 Story Fuel �l) ationTypical Gross 12232 Area Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=11087 2/20/2013 Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 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 ng out forms A. General Information. on l the computer, , o��o<�jH OF'M,qSS use only the tab 1. Inspector: key to move your cursor-do not JAMES James D.Sears = :� use the return Name of Inspector key. CapewideEnterprises,LLC � � rho Company Name ��F ..TT..• O�`\��. 153 Commercial St. ��Oq�rrst IN SPtEAlf \a`��� Company Address ��--- I Mashpee MA 02649 City/Town State Zip Code 505-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is-true,,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails; ❑ Needs Further Evaluation by the Local Approving Authority y ,3 2-6-13 P,3 spector's Signature Date 11.J .,.� 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. ZI 1� ►3 t5ins•11/10 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. Citylrown 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: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is Centerville MA 02632 2-5-13 required for every page. City/Town 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): Need to replace D Box ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in zmapaw is less than 6" below invert or available volume is less than Y2 day flow 64ch(iy1; t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Skunknet Rd. Property Address All Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. City/Town 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 II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. City(rown 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): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal precast tank D Box and pit. System is 30 years old. 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 ears usage 2011-31,000Gals g ( y g (gPd)) 2012-29,000GaI s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 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 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. Cityfrown 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: 1-7-13 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Skunknet Rd. Property Address All Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1981 Permit#81 -229 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 31"feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing tank to D Box and D Box to pit 4" PVC SCH 20 Septic Tank(locate on site plan): Depth below grade: 23"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 Gal precast Sludge depth: 1 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments uM 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. Cityrrown 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 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level, Tank and cover's at 23" below grade w/outlet baffle. No sign of leakage or over loading.. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Skunknet Rd. Property Address All Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. City[rown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): . , Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 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 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x 21"-28" below grade w/one line out. Note: Pipeing into and out of box 4" PVC SCH 20, Wall's are gone on box, Need to replace D Box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11110 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 M 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leaching is one 1000 Gal precast pit w/ 1'stone. Pit at 38" below grade w/cover at 4". 6"water in pit w/stain line at 40". No sign of over loading or solid carry over. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.). t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 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 A - o t 134 �a A 3-7 31 O3 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,. 568 Skunknet Rd. Property Address All Merando Owner Owner's Name information is required for every Centerville MA 02632 2-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells NO Estimated depth t high ground water: 1 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: 5-5-81 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: T.H. on Design Plan 5-5-81 No G.W. At 14'. Bottom of pit at 9' Bottom of pit at 5'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Skunknet Rd. Property Address Al Merando Owner Owner's Name information is Centerville MA 02632 2-5-13 required for every I 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-11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 17 of 17 L O CAT ION S G E P�RMIT NO. Z oL"P4 L vA KE,.�r7- '1264 .VILLAGE (S7- �a � INSTA LLER'S NAME i ADDRESS '6/M T^ e 14 IZA- d U I L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED ppp� �� 6 �G �� No.. Fps.... .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �Liw.n..............OF....... fls.: ..................................................... Applira#ion for Disposal Works Tonstrurtiun Permit Application is hereby made for a Permit to Construct (w� or Repair ( ) an Individual Sewage Disposal System at: L ation- dress. LotNo. M. ............. •••---.. `,3-�-•...... 1 n.................................. W ner A ess ---------� n s ........................ ------�... . �. _s -1 ........................................... Installer Address U Type of Building Size Lot_1U S. ......Sq. feet a Dwelling—No. of Bedrooms............. _.__..______.._----------Expansion Attic ((\0) Garbage Grinder (0) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )' d Other fixtures ._._..... •---------------------------------------------••-- W Design Flow...........l►-\.0........................gallons per person per day. Total daily flow.._...._.3�®__..___..............gallons. WSeptic Tank—Liquid*capacity00P.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Widt .................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No......../.......... D ............ Depth below inlet.....(0_........... Total leaching area..r�O.0...sq..ft. Z Other Distribution box ( ) Dosing-tank ( ) '~ Percolation Test Results Performed by.... �. e-A.... ____________________ Date.....;.—�_�................ ,4 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........................ P4 .....•..--•-•------------------••---••..... ...........---.....--------••----------•-----•--- ® Description of Soil------.0_="-:4n--------\3�U.M.......... -.0 ., _ 1 x ......................... ........ .e ......SSg dN-0-•-............................. 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 iITI U 5 of the State Sanitary 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. igned... _1Y�9i.rs.....Y,2_.---�f_`r1.��..----- -----••------------- .......................... at; Application Approved By. ..... .....__.., '� '� o f--------•------ Date Application Disapproved for the following reasons:------•---------------------•-------------------------•---------------------•----------........................ -•-------•-•--•-----.....-•---------------------•-----------•------.....--------•---------••---....-----------------•--...-•--•---••-----•---------•-----------------------•----------------•----._..._. w Date PermitNo....................................................... Issued....................................................... Date Fiz$...�3-().............. THE COMMONWEALTH OF MASSACHUSETTS • BOARD OF HEALTH c�w.n oF......b-c�cns ...\o\cam ..................................................... ApplirFatfon for Ili-qVus al 10orks Tomitrnrtfou Vantit Application is hereby made for a Permit to Construct (1j or Repair ( ) an Individual Sewage Disposal System at: ........S .v���nc S\CoA•-- ..... ----- ................................................ -- cation• ress Lot No ernes \ m ,�� - - ....._.»---_-, ------ .....�.........---•-••-...------•-•-•------• .......�� \ .-- ..._�..._ u n n Owner dress a � e e C 'e l S G C . Installer Addr---•------...--•-•----•----...----•---.....__. ess Type of Building Size Lot AU�.3�.......Sq. feet a, Dwelling—No. of Bedrooms.______......_ Expansion Attic (AO) Garbage Grinder (\O) ,.-I Other—Type of Building ____________________________ No. of persons............................ ( ) Cafeteria ( ) _____.____ Showers — Otherfixtures -----------•--••--•---------•--•---------------•------.-----------•----------------•-•---------------- W Design Flow___________0__r0.........................gallons per person per day. Total daily flow........... .................................gallons. WSeptic Tank—Liquid capacityX9.9()_gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........./.......... Diameter_.__.8............ Depth below inlet...... _.......... Total leaching area... _-sq. ft. Z Other Distribution box ( ) Dosing tank ( ) d�d� ~' Percolation Test Results Performed by.._v.�:_.Q_1..__.�_.___P_� ..................... Date...2... .--Y-�............... Test.Pit No. 1________________minutes per>nch Depth of Test a............ Depth to ground water........................ (� Test Pit No. 2................minutes per inch Depth of-Test Pit.................... Depth to ground water........................ --•--•--•----------------------------------- •-----------..-----------•••------•----...••-•----•--•......................................................... ® Description of Soil........U--�--`-......... ............ -----------------•----•--------------------------------•----...__---------••----- U .......................................a" 1.............. _ ..... ----------...-------------...--•------------------•-------•---•-•-----..._._..____ \` r `•n sc�na VW ------------- -•-----•-----------------------•---•--•----------------------------------------------------••-..-. 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 TITLi:, 5 of the State'°Sanita't 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 � ......... .---- .=..__s.?L4! ..................... .......................... C'1 Date Application Approved�By......... _________ __ _ _ _ _ o rll ate Application Disapproved for the f ol&ng reasons-----------------------------------------------•--•---•------------------------•------------•-------------•_.... ........... -----•---......---•--•------------------------= Date PermitNo......................................................... Issued....................................................... Date THE-COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L).W.n................0F...�. n..SA..c'`,....................._......................._._. ...t �� b� TrrtifirFatle of TuutlifiFattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4-" ) or Repaired ( ) by.......... ............................................................. Insrler\ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...V _____ZZ__9_____________ dated_............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL ROT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �,o DATE......................... ��• ��_--•--.........._ ._ Inspector...........�_� ----•--••----------------------------------•-••••-----••--•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N ,e! - .: .�. 1,.O .n..............OF........... `°_C1�1.11. . . tire-._.........._._....... FEE.... ' Disposal Workii T.latutrttrtion rrmft Permission is hereby granted........ ..... ................................................................. to Construct ( L or Repair ( ) an Individual Sewage Disposal System _ at No. t3�•------ •-•--------c= 1.a. 2_�F-. C.'x.-----_.tom 1�. £ 11) -C_ _V._ -- - .............................. Street as shown on the application for Disposal Works Construction -t No..................... Dated.......................................... 00004, DATE................................................................................ D9ea FORM 1255 HOBBS & WARREN. INC., PUBLISHERS