Loading...
HomeMy WebLinkAbout0569 SKUNKNET ROAD - Health S 59 Skunknet Road Centerville A= 169 O11 004 ti R' F, F SMEADI No. H1630R UPC 10259 smead.com • Made in USA wvc� A °o i S Q� Commonwealth of Massachusetts �5 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection fors may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector. only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 �dOA City/Town State Zip Code 508-420-4534 S14297 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- 0 Passes ❑ Conditionally Passes ❑ Fails El Needs Further Evaluation by the Local Approving Authority 4-3-15 InspectorsjOignature 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'1 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 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: I ® 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 MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION. THERE WAS QUITE A BIT OF PINKISH SCUM IN THE TANK THAT LOOKED SIMILAR TO A PROPERTY WITH GARBAGE DISPOSAL. SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL 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•3/13 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 569 SKUNKNETT RD Property Address HUBLER Owner Owners Name information is required for CENTERVILLE MA 02632 4-3-15 every page. Citylrown 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•3/13 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 �M 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is CENTERVILLE MA 02632 4-3-15 required for every page. City/Town 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 cesspool is less than 6" below invert or available volume is less than Y day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every 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.3113 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 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Y ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ ® Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 - t5ins-3/13 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 wM 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 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)): Detail: 2013------237 2014----254GPD SYSTEM IS'NOT DESIGNED FOR DISPOSAL Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of.Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 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 569 SKUNKNETT RD Property Address HUBLER Owner Owners Name information is required for CENTERVILLE MA 02632 4-3-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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-3/13, 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 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every 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: S.A.S INSTALLED IN 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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.): Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: MODERATE t5ins-3/13 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 M 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness MODERATE WITH PINKISH GREASY LOOK Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING TANK AND LIMIT THE AMOUNT OF GREASY SUBSTANCES BEING FLUSHED DOWN THE DRAIN. THIS SYSTEM IS NOT DESIGNED FOR A DISPOSAL 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 569 SKUNKNETT RD Property Address HUBLER Owner Owners Name information is required for CENTERVILLE MA 02632 4-3-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): BOX LEVEL NO LEAKAGE • Pump Chamber(locate on si te plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: El Yes ❑ No* y 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 3113 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 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 3050 INFIL ❑ 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.): S.A.S WAS FUNCTIONING PROPERLY AT TIME OF INSPECTION 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every 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•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °,M z 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Surface water ® Check cellar ® Shallow wells . - Estimated depth to high groundwater: AT LEAST 5feet 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: MARCH 2O15 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 569 SKUNKNETT RD Property Address HUBLER Owner Owner's Name information is required for CENTERVILLE MA 02632 4-3-15 every page. City/Town 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE U)CATION L'�@ -SEWAGE M VJ.LArE< ASSESSOR'S MAP&LOT G /� STALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 vyeor; LEACHING FACUZN:(type) iI (size)ff)X 30X NO.OF BEDROOMS_ BUIIAER OR OWNER 4 1.14 6 PERMTTDATE: / COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i. IL 0 0 for 1 �. I— `I H-A0 INU mAor Soso, Iro ck, 1Cl7c 30x a a(Eca, http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=169011004&seq=1 4/3/2015 -COMPLETE • . . . ■ Complete items 1,2,and 3.Also complete A. Signat item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X ' ❑Addressee so that we can return the card to you. B. Received by(Pr ed Name) C.Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No I _ � 31p e Richard Gallagher Hyannis Bn S Port, MA 026ox 514 4,7 ob9 Ndj y3. Service Type �� d ❑Certified Mail® ❑Priority Mail Express' ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (transfer from service iadep 7 014 -12A 0 Q�0 01. 0 3 5 8 05 ;4.:3 PS Form 3811,July 2013 Domestic Return Receipt r I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 a • Sender: Please print your name,address, and ZIP+4®in this box• I way I I ( Town of Barnstable I Public Health Division i 200 Main Street Hyannis, MA 02601 I i I � Town of Barnstable P# `5 Department of Regulatory Services a� Public Health Division Dated l/ 200 Main Street,Hyannis MA 02601 Ep M11t1� Date Scheduled, .. i�� Time Fee Pd. Soil Suitability Assessment for Sewage Dismal' Performed By: ��rt!!:L X cJ /7����^ R`-j' Witnessed By: oA LOCATION& GENERAL INFORMATION , Location Address �(�� S �; W Owner's Name �t� I AA C e"o k ero k Address Assessor's Map/Parcel: 3 Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(4'0) Surface Stones v Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) $(rJN/tNL7r X4 4l0 �-oast, -13eN TT— CD X ZA/- e -rp-� 42 cn - ;wa Parent material(geologic) lJJ�i^'A—I ff Depth to Bedrock r•� .v 8) Depth to Groundwater. Standing Water in Hole: �G Weeping from Pit Face Estimated Seasonal High Groundwater �- DETERMINATION FOR SEASONAL HIGH WATER TABLE Method.Used: Depth Observed standing in obs.hole: ___in. Depth to soil mottles: Depth to weeping from side of obs.hole: in, Groundwater Adjustment fe Index Well# Reading Date: Index Well level Adj,factor— Adj.Groundwater Level,,,e PERCOLATION TEST Daip ' 6 06 Thu a Observation Hole# TP -� Time at 9" 4 Y Depth of Pere Time at 6" Start Pre-soak Time @ !�:/6 _ 'lime(9"-6") End Pre-soak Rate MinJlnch Site Suitability Assessment: Site Passed Site Failed: _ Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***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# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. con istGravel) p -- 11" Al 0 y�4 �7 36` Bl y J Fi�v� �SytisM `iu,45Lc 62 p'' 2r/e �( 2 Ld�lz DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% C®A,—y VAwe 7.j'Jti5-/4 36 - Q,t �� o Ls� DEEP OBSERVATION HOLE LOG Hole# Depth from I Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA] (Munsell) Mottling (Structure,Stones,Boulders. 'Cnitec Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.j (USDA) (Munsell) Mottling (Structure,Stones;Boulders. ons' t n • E 1-�z<.•..w t Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No= Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio s m terial exist in all areas observed throughout the area proposed for the soil absorption system? � _— If not,what is the depth of naturally occurring pervious material? Certification I certify that on _u (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 3 10 MR.15.017. SignaturetA Date 61 c 06 Q.WEPTIC%PERCFORM.DOC No. � W r Fee ®� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppricatiou for Migo.5at *V.5tem Construction Permit Application for a Permit to Construct( ) Repair 90 Upgrade( ) Abandon( ) ❑ Complete System>4ndividual Components Location Address or Lqt No. nrel l- RJ Owner's Name,Address,and Tel.No. ,/ MA �r Assessor's Map/Parcel ���` j i�LEI is S 5 "tkN�C f t r ��► � �;� r;3 11 Installer's Name,Address,and Tel.No. ; ..rcf1..7��y Designer's Name,Address and Tel.No.f-D e �av Io; �s� ompsir Sc +ircasas�v o ��� I�u 5� 17 Y9� Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building 0ty No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) "I gpd Design flow provided `31/0,Li gpd Plan Date Number of sheets Revision Date Title . rr Size of Septic Tank 1C9 East 1N Type of S.A.S. (h ;z. i- d S• K 10 Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this rd of ealth. Signe Date , — Application•Approved,by Date D d :Application Disapproved by: Date for.the;following reasons Permit No. ® Date Issued Fee No. / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZfppYication for Migpgar �§pgtem Construction Permit Application for a Permit to Construct( ) Repair(IC) Upgrade( ) Abandon( ) ❑ Complete SystemAIndividual Components Location Addressor Lbt No. SC-7 51"vN K NC'/ /7 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel t,G/Ul 700"/ S-0 5 fC vv It N r f-t 1Z3 �to�){ (U I I e r Installer's Name,Address,and�Tel.No. �,0�3 6 o() 7/.7-� Designer's Name,Address and Tel.No. IDov�o 3 (�t�S r �� romps+�c Sc +;c 'Flk,5 v �,a$i177 yyo�' Type of Building:u Dwelling No.of Bedrooms `3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building I^Ins No.of Persons Showers( ) Cafeteria,.( Other Fixtures Design'Flow(min.required) �� gpd Design flow provided 3 410 `"1 gpd Plan Date Number of sheets Revision Date i Title % Size of Septic Tank 1000 f)Q S+ IN ` Type of S.A.S. I b9��r��u� 30 P (. �r 30 X /0 �2 Description of Soil Nature of Repairs or Alterations(Answer when applicable) NS�7c�I /�Cr.� < J 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 ealth. Signe Date lahloo Application Approved by Ti IC_2 Date 144 0 Application Disapproved by: �'�� Date for the following reasons Permit No. d�(n - L/ Date Issued /o b 0& THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On- ite Sewage Disposal System Constructed ( ) Repaired (x ) Upgraded ( ) i Abandoned( )by G c,J tJ at- S"Gcf S I,U 0 ^3' a k"-1 J ce j t,3- ) e has been constructed in accordance / with the provisionsof Title 5and the for Disposal System Construction Permit No."2 006- Y 3 y dated a (1 D Installer�l....r^ \C.C r'\ Designer-}—��MPSt NC_ #bedrooms a �, Approved design flow 330 gpd The issuance of this permit shall not be construed as a guarantee that the system will function as si ned. Date �0/ Inspector .�--�^ -- No. jQU "I 3,91 Fee �U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS =i5po!6a1 *psstem Cow9truction Permit Permission is hereby granted to Construct ( ) Rep it (X) Upgrade.`( ) Abandon ( ) System located at S-� S�v"i k for ft' Rd CP�J Pf 0 1'V and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with"Title S and the following local provisions or special conditions. Provided: Constru fion must be completed within three years of the date of his pe it. Date ° Approved by �M � , v 4' Town of Barnstable 4 �`"� ,� Regulatory Services �. Thomas F.Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: lollaIV6 Sewage Permit# Assessor's Map\Parcel Designer: A,+-t l eL J �'`'1�' Installer: j o J— G'tO � 1 Address: J. �7� �3/ Address: OS-r-e7�q 'LLe fWVI pot65`S (�Ctv7-0-VV, "Lr A-.%* 0.2,1(3,2 1 On jo JU- 6" f- was issued a permit to install a r (date) (installer) septic system at 5-6315�e-W A-'fe7 A-%CeA-TZ4�/(-based on a design drawn by (address) P-l"(Gz- J pt dated /0z6,10 6 I (designer) v I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. x { I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. 1 —qVif taller's Sig tore) esi 's Si ature) (Affix Designei's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc i �3 3 93 -. LOCATION PE RMIT `N.0. VILLAGE I N S T AYLL 'S NAME i ADDRESS 3 U I L D E 0 0 NER DATE PERMIT IS3UEO DATE COMPLIANCE ISSUED 61; no fompif)g -- nwssr'+.—n.Trr•rT^.e.►.—mr•r.'nrrrnrr a�rrre*r::�r•'!•t.►l+n-t*nn+ner+t�•s�'�rrvt ern �1 ft TOWN OP Barnstable BOARD OF HEALTH 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I `� �^•r^t^T••,••. '—r.itf.^.�rn1Tr.n•rtTn r•.lrtcsRaarrrr!•t+•'1Tr771RA�Te+fTR.1Of.Rf�.l�'R7 tin. -.-+rrr•r-•�.•—..^ -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 569 Skunknet Road Centerville ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # 3821-128 OWNER' s NAME Patricia Chartier PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. . COMPANY NAME J.P.Macomber & 34fn' Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 775 3338 FAX ( 508 790 1 578 CERTIFICATION STATEMENT ft I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: {CXXXXXXXXX'System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have con\___dUcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature /",4z Date 1 /9/97 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or..,o^operator shall u P pgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CHR 16 . 305 . partd .doc V 7� b S�j'If 3��1 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the 'ion of Water Pollution Control f DATE: ' 7 e6l) PROPERTY ADDRESS: •569 -Skunknet Road c� o Centerville ,Mass . � � d A*d 02632 ' �4 On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1-1000 .gallon septic tank. 2. 1-Distribution box. 3. 1-1000 gallon precast leaching pit. 81x7' Based bn my InRvection, I certify the following conditions: 1 . This is a-. title five septic system. ( 78 Code ) 2. The septic system is in proper working order., 3. We pumped septic tank. Heavy Scum & solids layer. . 4. The leach pit water level is 4161, 5.. No pumping history available. SIGNATURFF: Name:_J_P M_acomber Jr________ Company: J. P_Macomber & Son-_Inc , Address:_-Beac-bb------1---,-- Centerville LMass__0.2.632 Phone: _S0.&_7_733a------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • LE P. MACOMBER & SON, INC. Tanks-Cesapoola-Leaohf lelds . Pumped & Installed Town Sewer Connections x 66' Centerville, MA 02632-0066 775-3338 775-6412 Commonwealth of Massachusetts Executive Office of Environmental Affairs department of environmental Protection Trudy Cox* s.u.c.ry David B. Struhs U. • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION Property Address: 569 Skunknet Road Centerville,MaSWddr.,,f0wner 78 Dow Avenue Date of Inspection: 1 /9/97 (If different) Arlington Mass . Name of Inspector Joseph P.Macomber Jr. 02174 Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site"wage disposal systems. The system: .,Passes _ Conditionally Passes -_ Needs Further Evaluation By the Local Approving Authority _ Fails �3/J Inspector's Signet •c� Date: J—�" 7 ` The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner.-u,d copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check B. C,or D: A) SYSTEM PASSES: —�—/I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: kV One or more system components used to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yed go, or not determined(Y, N,or ND). Describe basis of determination in all instances. U'bot determined•,explain why not) The septic tank is metal, cra:ked,structurally unsound,shows substantial infiltration or exilltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by tL. Board of Health. (revised 11/03/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617) 556-10-49 • Telephone (617)292-55W t� PM10d on RKYckd papa V• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ProPertyAedresa 569 Skunknet Road Centerville,Mass . 02632 Owner. Patricia Chartier Data of Inspection', 119/9 7 B)SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or 40 static water level observed in the distribution boa is due to broken or obstructed pipe(.) or due to a broken,settled or uneven distribution bee. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year duo 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _A10 Conditions oust which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DET71 MINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT•. Cesspool or privy is within 50 feet of a surface water _WA Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER.IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: iyQ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. �Q The system has a septic tank and soil absorption system and is within a Zone I of a public water supply wen. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. �J The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. S) ,,OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART A CERTIFICATION (oontinued) Property Address: 569 Skunknet Road Centerville,Mass . Owner. Patricia Chartier Date of Inspection:1 /9/97 D) SYSTEM FAILS: • &Vb I have determined that the system violates ow or more of the following failure criteria as defined in 310 CME 15.303. The basis for this determination is identified below. The Board of Health should be contacted to detarmins what will be neoessary to correct the failure. Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of chs ground or surface waters due to an overloaded or clogged SAS or oesspool. 440 Static liquid level in the�ribution box above outlet invert due to an overloaded or clogged SAS or owpooL L& L fq� to Liquid depth in oeaspooWs less than 6"below invert or available volume is Is"than U2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. %Z p4je-09 Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is leas than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety Lad the environment because one or more of the following conditions•list: 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) The owner or operator of any such system shall bring the system and facility into full oompliance with the groundwater treatment program requimmenu of 314 CMR 6.00 and 6.00. Plea"consult the local regional office of the Department for Authsr information.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddresa: 569 Skunknet Road Centerville,Mass . owner. Patricia Chartier Date of Inspection:1 /9/9 7 e Check if the following have been dons: Pumping information was requested of the owner,occupant,and Board of Health. 1 Noes of the system compona4ts have been pumped for at least two weeks and the system has been reosiviag normal flow:alas A'�, that period. Large volumes of water have not been introduced into the system recently or as past of this inspsetiom s built plans have been obtained and a mmined. Note if are not availab le b with N/A. zTha ty or dwelling was inspected for signs of sewage back-up. system does riot receive non-sanitary or industrial waste slow ZTh'site was inspected for signs of breakout. , All.system oomponsntsAiduding the Soil Absorption System, have been located on the site. XThs septic tank manholes were unoovered,opened,and the interior of the septic tank was inspected for=uHtion of bafaes or tree,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. size and location of the Soil Absorption System on the site has been determined based on dstiag information or rip ted by non•intrusivt methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSUIU'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAJtl(c.a 569 Skunknet Road Centerville,Mass . owner. Patricia Chartier Datc of Inapowiw.: 1 /9/97 FLOW CONDITIONS RPBI D ENTIAL- Detign now: �Ow`d Number of bedroomi: .r1f Number of current residents: r/ Carbas^e grinder (yes; or no):_&A2 Laundry connactad w sysum (yes or no): � Saaro--.A) use (yea or no): o Water meter roadiap, it available: IV Last date of occupancy:-`" COMMERCLAL/INDUSTRIAL- Type of srublishment: Aix Desie-m now: j&Lona/day Cream trap pr%A eot: (yes or no)Arl ladustrial Wasu Holding Tank present: (yes or no)AI-14 Non•aaaitary waau dischnrgad to the Title 5 rymm: ryes or no)" Rater meur reading, U available: AJA Lan daw of o=pancy: OTEER: (Dwribe) Lars date of occupancy: - GENERAL INFORMATION PUMPING REPORDS d ao of rtration: AleVg IAIUM Syrtam pumped as part of ins ion. dyes or uol 1f yea, volume pumped: Reason for pumping: 5 y�11�r$ SYSTEM Septic uu.kJdistribution boz/soil absorption r)rtem Sr.;wa l Overnow etr:epwl Privy Shared rpum (yea or no) (if yea, attach praviour inrperctioo recordr, if any) Other (ezpl in) 7 e AP P O�X] TE GE of ill componegs date u:.w.Wt.l (if krtown) aad source of information: SOWaVe odors (4.Rtwtxl vlran umv.nn nr r1.n .. .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 569 Skunknet Road Centerville,Mass . Owner: Patricia Chartier Date of Inspection: 1 /9/9 7 SEPTIC TANK: 4,Qa 9A41jv &joTc e (locate on site plan) �r Depth below grade;_ Material of construction: Zoncrete _metal _FRP —other(explain) Dimensions:-7 Sludge depth;_ Distance from top of 3 dge to bottom of outlet tee or baffle: 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. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid IPvel in relation to outlet invert, structural •rity, evideMce of leakage, etc.) pump se'ptic. tank _every 2—� -veags ;1�nlet& outlet tees are in lace Se tic tosound GREASE TRAP.AIPVf, (locate on site p(an) Depth below grade:..A/-14 Material of consin�ni6n�/)/-oncrete _metal _FRP _other(explain) Dimensions Scum thickness:.) Distance from top wi scum to top of outlet tee or bahle:,4l, Distance from bottom nt srom to bonnm o) outlet tee or 6a, ie: 40 Comments: (recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, ei0- Grease trap is not present t— s (revised 0/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) PropertyAddroaw 569 Skunknet Road Centerville ,Mass . Owaer. Patricia Chartier Data of Inspection: 1 /9/97 TIGHT OR HOLDING TANXA kft (10094 on sits PILO e Depth below Nader Material of aonstruceSon:�, ooacsete_metal_FRP_other(expl&W - zu.. Dimanaicas: Capacity ns Deems aow naldsy Alarm Iewl: co (ooadi of t tee,oo of alarm and t swi u,etc.) ig or FYI Ing tank no present DISTRIBUTION BOX _/ (1out•on site plan) Depth of liquid level above outlet invert:_ Commaata: ( if level}nd dy�trsbuU is,�qual, aygwe of solids?="v�,sv�dance of laakap into or of boat gtC,) D box is leyel;lVo evidence oI so ids carry over ell o 1AA1gAgR In nr nut, of the hox. No remits needed at the present time. PUMP CHAMBER: �if/�- (locate on site plan) Pumps in working ordar.(yes or no) NA Comments: (note condition of pump c),ambar,condition of pumps and appurtenaaow, etc.) NA Pump chamber is not present (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Propertymdresa: 569 SkunknBt Road Centerville,Mass. owner. Patricia Chartier Date of Inspection: 1 /9/9 7 SOIL ABSORPTION SYSTEM(8A9xLe8 �fu►�to�/U�'eU'4�P ��r• Uocate cn site Plan,if possible;excavation not required,but may be appro duuLted by non-intrvsive methods) If not determined to be present,explain: e Type: laac pits,number. number Lachi"g galleries,number: laaching trenches,number,length: leaching fields,number,dime no: overflow cesspool,number.CAmments - See :8 can idof soil,signs of hydraulic failure level of "ding,condition of vegeta,4on,ou.) nee P g ;No signs ns Of H drau� ic failure or ondin vauatatinn is normal - Na repairs needed at he Aresen ime 0 CESSPOOLS: (locate on site plan) Number and configuration: AJl¢ DoPth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of owspooL•_ A Materials of construction: I"dication of groundwater inflow(cesspool must be pumped as part of inspection) .�1�t esspoo s are not, present Comments:(note condition of soil,signs of hydraulic failure,level of pondi"g,condition of vegetation,etc.) Uess-"ols are not present Pww.�v (loco"on site plan) Materials of construction: NA Dimensions: NA Depth of solids: NA Cammants:(note condition of 64 signs of hydraulic failure,level of ponding,condition of vogrtation,itc.) Privy no . present (revised 11/03/95)• g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Centerville Osterville Marstons Mills Water Company 428-6691 ou DEPTH TO GROUNDWATER depth to r ^n dvJ�� oli r+pthod of determini n' or Sapp .v -- J P I G A,)= R � 1 14411 K n6�E.t VAT/o�t/ 0 osoa�rA7'1045 SY= crH s�'titr \ 100 . 0 \\ �Y Y ` ` � .. + '•' Mai �� _ NJ!o �+d 60 x ; �,\ t SCOT G IS r yti r AA •:� — �. era `� `` a TOWN OF BARNSTABLE LG;£ATION SCE b,Jet t \ SEWAGE # aOC`�Co'y VILLAGE ASSESSOR'S MAP & LOT//,. 6 iATALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY OCR 2 /N LEACHING FACILITY: (type) /1 (size) 4X InX:L NO. OF BEDROOMS BUILDER OR OWNER Gt PERMrrDATE: G G COMPLIANCE DATE: Separation Distance Between the: +� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility (-,Ce?LN 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 LJ Li 3- y� H-�© �N�+Itr�zror 3osoS ck n 3o x a alec t c� 3 93 ' L 0 CATION _ S G PERMIT NO. 13 V4LLAGE INSTA LL R'S NAME i ADDRESS ozn M e U I L 0 E 0 OWNER DATE PERMIT ISSUED U DAT E COMPLIANCE ISSUED Z . t Nc .3 3........... FRs... ................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .........................._..............O F....................................... Applua#ion for Disposal Works Toustrnrtwi n Pumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: T/ e C�� .......... _....... ........................ .... 1= :....._....... ------.......------......----------------------.............---............---- Location Address r or t No. .... @� -- - 'f r �/i✓)---------------------------------- -------- _ �c.�L�. ..... ...... !Q........................... Owner Address .......................................... ......... � _ --------_---........--------------------.... Installer Address Q Type of Building Size Lot...�5�.Eg.'_ __.._..Sq. feet U Dwelling—No. of Bedrooms.............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building 1 _._x2! °_. No. of persons......._3 Showers e- — Cafeteria _ Other f�ures ---------------------------- -------•-••---...--------.----------------------•-------------------------------------------.....--•------•--..........-- W Design Flow............._. .........................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.1 .-gallons Length.-i............. Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. i Seepage Pit No-------�............. Diameter......110......... Depth below inlet......6.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...................... ----------•-----------------------••--•••----- Date........................................ t . Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._..................._. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' --•••-------•••------------••••••••••-••••••••--•••--••--••••---•......................•------------------------...._...................-•-•----------....•. ODescription of Soil........................................................................................................................................................................ x U --••-------------------•--•---------------•---------•------------------•---------•------------------••----------------------------------•---------------....-•--------....-••------..._................. W •-••--••--- ----------------------------- -----------------------------------------•--------------------------------------------------------------------•------••------•............-•...---------•- VNature of Repairs or Alterations—Answer when applicable............................................................................................... --------•------------------------•-••------------------------------•---•---------------------------------------------------------------------------------------------------------------------------..... Agreement: The undersigned agrees to install the aforedescribed Indivicf. al age Disposal System in accordance with the provisions of 2ITIE 5 of the State Sanitary Code— ntp un r_ ed further agrees not to place the system in operation until a Certificate of Compliance has been issu �y,t b rd of health. ne............. v;...._...._._.._.............._....__..._._..........._........_...._. ....... ...Y................ ApplicationApproved By. ......__ ..... ...........................................••-••......-•••••---•-••---- y-. j•--........ Date Application Disapproved f t e following reasons: _.....----•--•••••-----------•••--...•-•••---•••-•-•••••••••••---•••••••••-•--••-----••---•--•-••--------••••••----------•-••••-••••------•--•-••--------------•--•-----••-----••----•••••••--•----..... Date PermitNo-------------------------------------------------------- Issued_....................................................... Date I z / .No:_:_ Fizz............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -•----....................................OF...............--•----•----•--.......-----------------•---....---------.................. Appliration for Disposal Works Tonstrnrttnn rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ..............jt1 l,€f ................. ............................ ................ ..... ........-- Lo�a��on Address or ✓' o � � � • ++ (f Owner /5 p Address a •--.#'•^r�J1.f' �_ {""^' �`+ �:. 1`y l'"7 �i�� ............................................................. Installer Address Type of Building Size Lot.. ��S _C�_ r.........Sq. feet �-, Dwelling—No. of Bedrooms...........................................Expansion Attic ( '� Garbage Grinder ( ) aOther—Type, of Building No. of persons--------;----------------- Showers (. ) — Cafeteria ( ) Otherfi:f tures ..................•-•••--•-----••---•-•••--••---•----...-----•-•----•--••-•---------------------...•-•-••-••••----•-•••-••-....---•-••................ w Design Flow............*s3..10 .....................•..._..gallons per person per day. Total daily flow............................................gallons. n. W Septic Tank—Liquid capacity.11...gallons Length..:............. Width_.............. Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......i............. Diameter.._..;CJ..t....... Depth below inlet......?........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 40 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -------------------- -•--••--- .... ....-••••--•••••-•••--•-------------- •----------------- -------------...--------------------------••----•--••--•- x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------••---•••••---•-----•-•---•----•---•••••-•-••--------••-•----•-----....----•--•--••-•---•-•-•-----•-----•••----------••--•-•-••-----•----•--•-•----•------•-•••----•-•-••----•.......-- Agreement: The undersigned agrees to install the aforedescribed Indivi I wage Disposal System in accordance with the provisions of i_l 5 of the State Sanitary Code— er ned further agrees not to place the system in operation until a Certificate of Compliance has been issud y rd of,,healtlh. f l ^4 I Application Approved By. 1 .. _...---•--••--....... _c " •-------••-•--• Application Disapproved r tie.following reasons----------------•-----------------------•--------------------••---------------�------....Date.....--------- ---------••----------•----------------•-•-------------------•------------•-------.....-----------...----'--•-----•-----•--••---- --•-••--•------------•----•-•--•-••-----•-......-•••-•---••--"•' Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... -Errtif iratr of Toutpliattrr THISIIS CE RI?Tllf'F -- hat the Individual Sewage Disposal System constructed ( or Repaired ( ) y :: er at r - -----•---•----•---------------------------------•--•------------••------••------------••------------•- has been installed in acco `ance with the provisions of m o The State Sanitary Cod s c ibed in the application for Disposal Works Construction Permit No.. _.�--------!-_{... ............. dated...sV!`r._Y'� .................... THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 16N FUNCTION SATISFACTORY. DATE....2.1..P•-••........................................................... Inspector--- ..............._.......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ..................OF...........--------...--- /. `.P FEE ............ ..... i � � n trilan rrntit Permission is e y granted - f ` L r _ d m d to ConstructF or e it ( °at{1Xnc j g "� pgsal System at No r ............................................. -- �° f street r as shown on the application for Disposal Works Construction Permit No..___......a-•,: '� )ate �r_= Z, .:`✓:_ '.................»._ / r Board of Health DATE............................................................................... r FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS -�-�---- — --Air EcE.J'. 94ow,,1 AQrr MrcA.w! SEA 1...rmvtEL ---- - - ------� 9Ag�D o«.t �.� �5 S71►Tt�v! Pr, ,.,.I+E / ZQ- 9rlc&4 ALL LiWES A Mlk4,MuqA oP t/C../rc.x,T UNt_ES- CFTNF�t�E 3PECa�1ED. PIPW-5 To .aAWD ,d T44E SYS(EM S►+pu 2d' -� AE C/►ST IitbM.l Cir- 5C-*1,C0UL..E A(> P U c C` AFL SEPCK K S�J TAIJS� �,ST2� Tit>., t'Sox , A lU A G L.EAcN,.JEa PtT� SHALL 8E DESKa►.,IEO T=c� 1- O O J N - Y.O �c1+4EE>✓ �n.D+.JGiS WNE►-1 ►JG `J�hl�' N ` +rJ!°1 _--- - - ----.-� 2ENto✓E Au �.Jsv+rA3L� MATEi�IAL ®E.�E:.�"TL1 -- O 00 (0) O 'TVW- Vv) 0 A 1'nauS of 10 s,.>o BoLICFtL. wtTN Cu+.y 00 PT t ^, �^�) yn/ THE $ I 1S'TAgfr.� E3r�p o ,1E�s ITN r u5T 00 C) O " � � tJCSTt� E� WNEi..3 Tµ� �y�TEn•1 1S NEAf� O 00 O �' � C F' -- zG ��. \ .f 1 J `� �— vc7►.s�EIS oTNEQWSSE �soTEU, A� SYSTT ►'� C L $A...)ETA Cy O O �\ CQMPOI►.1 tic,.yTS �J►-1+l►l-L- h � � �E 1..►ST o.��...cC� IwJ TEC ` cc T"E. i4.1 T\/PIGAL SDI STV-1bUT10nJ E50K 4 i O co O C (O C �cJ�N�1N ►wAti AP« / o e,�y �.0 L �i�� ES T- ►.l T F ,c^L ,orb G+��- SEPTec. ��•lr; _LEfscta l� -`P,T 0B5E,E VA 770 A.1 o/75 >el'c+►1FC?QED �E»r+� T r. �.� e y -Q!) SCAM Nlor•To SC AL CA: EQUAL 1st� : TP.y K S R�4 C FcaCGE G T ipG+u4 M ou T ",e CoL A ria Av 4 aT� = 211-V"7 /..lc h win-1 �L-F�TV-ki:- �.cJE�-DCa 083��YAT/o�15 6y- 2,4 - Z" EM8EOOED S�f�L YOZ>S ,� fJOT�= r^i-" MAn�Ho�L TO •SepT,G T/+tJr[ /AND IE�N,Y.lb• rflg g 'h4�7T . {_C ao,4t0 �F f ALTH �1 �ono► 1. coa,C. ,6 4oco P9.1 Tf,T To V.E OvILT UP To ItfKJc"C% �JC�RMA'1-i C,P��MA�.. R� Tor FOc�De.Ttaw� 8e�c�n.J t r�►,y�+ 6,t��� pA7d r[L J � L�.v._ F,f.,15µ CtAo,i. F ,w,,►St► ,AIIS►1 6 c¢,�.uE F e^ vE /FaP►aSH GC^m-f [JJE2 13k"K t itl I�cn IE,wGH ►,G 7z r ---_-- - v - -- re .� M► ;Y NIdTQ O . O . ® .O � ► • 'e�br�D sTo..1t 1oOo cs.� O ee uJ Focce v cp•alc• p�ST psor[ •,aL Q ® O m ' • S�EQr ' l TyPIc.�.L �cvr�F SYSTEM �f',LIE 70!.C�LE Ida GEG EAIP PROPOSED DWELL I KIG LOCATION -? Aaron cavrduc ��` �J� P R o o s S wA.G M DISPOSAL.. S Y-5-r E.M �t/vMeEle OF dEO•e�Ms wx Q -ear Env ftOBEfti '��� s Zu /',roe. �c.�i , . 11 \c-� �E,CSON/S AeX QED eOa M RAYmoND ,l 6T f4 .:++ (,,Q 3 - ] _ #-Do '" GALLGUNS f il<L'xiM PEe a4 Y .�'�_ A=%r ! 9p►o a�a7 �, CA//N6 AZ64 ,E'EQ u1.eev :t Oa3E�[ Trow P T. �c,�crsTt ��• , . Z vw L6AL fir/A16 AtF...I PROPpSED LE,,gGHINa p,T + .4.?P�-1iG�uT � Ea.t6,r-►�: - l / �>�Pam,� f*'I�w,,,wi�J ► {Z.Og Eer.TC QAWM O"L7 100 x NA Kt 510 rt , � � --- ' ��4�,.._. "�`t E, FAI.4MU�J1'Ff ROSERI SIDE vC1�•L.L A�E1L r(�.2e�( )� �2,5) _ CAP C� SCAUE: owrE sr►w¢tt °Y�iS Do AS OOT Z <5E\4J 1;;�2 APPt_iGA.T► O►..! �O,��' 1 "�p L. J Tz�t 4Pp T���� D*AVIN BY: c «:wD BY-. Aho ay: ft." no.