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0645 SKUNKNET ROAD - Health
645 Skunknet Road, Centerville P A = 169 011 UIAXTOrd, NO. 1521/3 ORA AM� � Y No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zfpprication for ni5po5a1 *pftem Con5truction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. A.,IQ, Owner's Narue,Address and Tel.No. /r 1Oi I t K Assessor's Map/Parcel ad M 15 _oil �---o> 9- P-1- w�Kne+ 6, Ce���v,Ilc,07f o In aller' N e,Addfess,and Tel.No. 6g 54'0,q 017 q' Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms -� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow [7 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re 'rs or Alterati ns(Answer when applic ble) Date last inspected: Agreement: The undersigned agrees to ensure the construction.and'iiranten ce of the afore described on-site sewage disposal system in,accordance with the provisions of Title 5 of the E`A nmental ode and not to place-the system in operation until a Certifi- cate of Compliance has n issued by thi _ o f lth. Sign Date Application Approved,by - Date Application Disapproved for the following reasons Permit No. /1 _ Date Issued r No. 0 / Fee 160 . 2--�,E_COMMONWEALTH OF MASSACHUSETTS, f Entered in computer: Yes PUBLIC HEALTH DIVISION-TOWN+OF BARN,STABLES MASSACHUSETTS 2pplication for 33igpoOal bpft* GowAruction Per'mnt 1 Application for a Permit to Construct( . Repair( )Upgrade( 1 Abandon( )- O C mple�System'"0 Individual Components Location Address or Lot No. 6q 5 S L�Vll knc ¢— V-? Owner's Name,Address and TeL No. Assessor's Map/Parcel C v j tP ��((� {�001M 1,5 _ o o f 2- ��� kunrrne4 QJ, Cep cr�!:I��, o Installer's NRe,,;;,A and Tel No. �( � 0 q D'� Designer's Name,Address and Tel.No. X Toe, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow _ 6 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. s Description of Soil Nature of Rep or terati ns(Answer when applicable) p� K AA61 a ron or of a Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainten ce of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the End' nmental ode and not to place the system in operation until a Certifi 4 pate of Compliance has b en issued by this oar d��f e th Slgn , . s t t 1'Ar _ Date G Application'lpproved Date ' Application Disapproved for the following reasons Permit No Date Issued V 1 r �.. .. THE COMMONWEALTH OF MASSACHUSETTS Dk 11 1BARNSTABLE,_MASSACHUSETTS Certificate of Compliance THIS IS TO CE_R_ Oat the On�si Sewa a Disposal System Constructed( )Repaired,( �, pgradedAbandoned( )by � �� �v Ij otc) -7ni c at his been constructed ac ordance with the provisio s o-Title 5 d the f r Disposal System Construction Permit No. e�O/`�— dated Installer- f,. ,r "e , AM) L ,e- Designer ��l �� t�. The issuance of this permit shall not.bre construed as a guarantee that the system will.funcjti/o`n asydesigned � / Date �7 `� 1 � Inspector � !function as No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ]Digpooal &pztem Con.5truct on Permit Permission is hereby granted to Construct( )Repair( t-`Upgr de( )Abandon( ) System located at Vs 5411 t, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ` Provided:Construction mu t—b7e Jcompleted within three years of the date of thi7permi t. Date: <1 / / Approved by � r TOWN OF BARNSTABLE' LgCATION �� � �.��:�: SEWAGE # ®/ VILLAGE �e���c vt���— ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /11//D (fir 4 PC" C,PY,L SEPTIC TANK CAPACITY 10C CJ 4' LEACHING FACILITY: (type) 11,7 76/2,C (size) y S NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: /, Z& 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 { E-13 f li o F http:llissgl2lintranetipropdata(ParcelDetail.a5px?ID=11067 4 Lure Search j P Application Center(2) ®http--www.town.barnstable.,. ff]Application Center ®5uggested Sites Web Slice Gallery ' Favorites Parcel Detail RtMA55�'°TED���+A.:, �• !��/�/ `u(//Gerlli7 Ul/"-ram/ � `A� � JRa.-� � ry Logged Parcel Dietail 2G14 Parcel Looku Parcel Info I Parcel ( Developer I 1 ID 169 011-D12 lot LOT 42 Location 1645SKUNKNET ROAD Frontage 104 Sec I Sec I - Road Frontage Village I CENTERVILLE I Fire C-0-h9M District I {' Town sewer exists at this address No I Road Index F1494 Asbuilt Septic Scan: Interactive ' r — ' 169011012_1 Map Owner Info Owner LOOMIS,LUCY E I Co-Owner Streets 1645 SKUNKNET RD I Street2 I ' City CENTERVILLE State h1A Zip 22632 Country I � T Land Info Done -- ��I,..JJI_.JI�.J,�I�I'1.�1i�_4�Local Intranet _ j,f`8'��! j Io0/_ f ---- --- --- r�,,Start I� �®V �► �i a�'� 11 29 AM I1 Parcel Detail-Windows I. (;, Navigation Canceled Wi..I �, Tuesday Commonwealth of (Massachusetts Title 5 Official Inspection Fora =_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 645 SK_UNKNET ROAD Property Address LU_CY LOOMIS _ Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Informationfilling out forms I O on the computer, use only the tab 1. Inspector: (�J key to move your cursor-do not JOHNGRACI use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS, LLC rQ Company Name PO BOX 2119 Company Address eum TEATICKET MA 02536 CitylTown State Zip Code 508-641-6694 S 1468 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 Evaluatio , by he Local Approving Authority A^; 08/05/2014 Inspector's Signature ` Date The system inspector shall bmit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 ays 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 th6 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•3/13 Title 5 Official Inspection o m Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 ®fficial Inspection Form _ — -- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 1M ; 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: NA 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): 0 NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts _ = W, Tile 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 645 SK_UNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 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): DISTRIBUTION BOX DETERIORATED NEEDS TO BE REPLACED. LEACHING FIELD#1 ( LEACH PIT) AND LEACH FIELD#2 ( INFILTRATORS) NEED TO BE PIPED PROPERLY TO NEW DISTRIBUTION BOX IN ORDER FOR SYSTEM TO FUNCTION PROPERLY. ❑ 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): NA 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 Title 5 Official Inspection Form -- _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is CENTERVILLE MA 02632 08/05/2014 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: NA **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: NA 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 '/z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 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 M 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts -__ 6'itle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 page. CityrFown State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK, DISTRIBUTION BOX( NEEDS TO BE REPLACED), 1000 GALLON 6X6 LEACHPIT AND 4 LEACH INFILTRATORS WITH FOUR FEET OF STONE. Number of current residents: 3 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 ears usage d TOWN 9 ( Y 9 (gP ))� Detail: 2012 55,000 2013 45,000 2014 18,000 Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NAGallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): NA 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: NA _ 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 M 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 - - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: NA Date Other(describe below): NA General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA 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 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 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: 1984, NEW LEACH FIELD ADDED IN 1997 PERMIT NUMBER 97-465 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: (3)THREE FEET feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: GREATER THAN 10+ FEET feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO COMMENT Septic Tank (locate on site plan): (2)TWO FEET (6) SIX INCHES Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: (8) EIGHT INCHES t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form =� _= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 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 (26) TWENTY SIX INCHES Scum thickness (1) ONE INCH Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? MEASURED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SYSTEM APPEARS TO BE STRUCTUARLLY SOUND AND FUCTIONING PROPERLY AT TIME OF INSPECTION RECOMMEND PUMPING EVERY TWO YEARS RECOMMEND RAISING COVERS. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date t5ins•3/13 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 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NA gallons per day Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments (condition of alarm and float switches, etc.): NA *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 753 -- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' —, 645 SKUNK_NET ROAD Property Address LUCY LOOMIS _ Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 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 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.): DISTRIBUTION BOX NEEDS TO BE REPLACED DUE TO BOX IS DETERIORATING. PIPES NEED TO PROPERLY PIPED IN ORDER FOR SYSTEM TO FUNCTION PROPERLY. 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.): NA * 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: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts -_ r� `title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments %� 0'V 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 4 ❑ 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.): LEACH PIT#1 1000 GALLON 6X6 LEACH PIT EMPTY AT TIME OF INSPECTION APPEARS TO BE STRUCTUARLLY SOUND. LEACH PIT#2 (4) FOUR INFILTRATORS ARE PLACED UNDER THE DRIVE WAY. VIDEO INSPECTION WAS PREFORMED AND FOUND INFILTRATORS WERE FULL AT TIME OF INSPECTION. DISTRIBUTION BOX NEEDS TO BE REPLACED AND PIPES NEED TO BE PROPERLY INSTALLED FOR SYSTEM TO FUNCTION PROPERLY. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth —top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA 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 �i Eli Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 page. City/Town 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.): NA Privy (locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I� Commonwealth of Massachusetts W Title 5 Official Inspection Form — f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 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 FRONT A e .A alai _j q rah l�-taI�CS AA 144 AB is o c /+C 11 / DRivEYvAY AD 32 1000 Gallon (PAO Leaich p%4- OA 41 lip B13 6S8 eC 284 r 38 t5ins-3/13 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 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: GREATER THE 12+ FEET feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 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 645 SKUNKNET ROAD Property Address LUCY LOOMIS Owner Owner's Name information is required for every CENTERVILLE MA 02632 08/05/2014 page. City/Town State Zip Code Date of Inspection Ea Report Completeness Checklist Z Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed �]C 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 f ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS COP DEPARTMENT OF ENVIRONMENTAL PROTECTL N 1 d C e� MAY 0 6 2003 M sy° TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 645 SKUNK-NET RD. CENTERVILLE,MA 02632 M169 PI L42 Owner's Name: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Owner's Address: 645 SKUNKNET RD.CENTERVILLE,MA 02632 Date of Inspection: 4/7/03 n� Name of Inspector: (please print) JOHN GRACI,INC. K Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02�3� Telephone Number: 508-564-6813 FAX 508-564-7270 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 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: X Passes _ Conditionally ses J _ Needs Furthei valuation by the Local Approving Authority Fails Inspector's Signature: Date: 4/7/03 The system inspector shall submit lo py of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectiIf 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. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. LEACH FIELD WAS UNDER ASPHALT AND WAS EMPTY AT TIME OF INSPECTION. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. i` Page 2 of 11 Par OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 645 SKUNKNET RD. CENTERVILLE,MA 02632 M169 P11 L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.LEACH FIELD WAS UNDER ASPHALT AND WAS EMPTY AT TIME OF INSPECTION. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a i Page 3 of 11 ak OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 645 SKUNKNET RD.CENTERVILLE,MA 02632 M169 Pll L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a IPage4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 645 SKUNKNET RD.CENTERVILLE,MA 02632 M169 P11 L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped SYSTEM WAS PUMPED TWO YEARS AGO.. X Any portion of the SAS, cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 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, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. A `Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 645 SKUNKNET RD.CENTERVILLE,MA 02632 M169 P11 L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up`? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site X _ 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? X _ 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: Yes no X _ Existing information.For example, a plan at the Board of Health. X _ 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(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 645 SKUNKNET RD. CENTERVILLE,MA 02632 M169 P11 L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd))1J ; Q - (CbC) Sump pump(yes or no): NO ------' ` Last date of occupancy: n/a 1 - 0 p0-Q) COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: SYSTEM WAS PUMPED TWO YEARS AGO. Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1984,NEW SYSTEM IN 1997 PER PERMIT#97-465 'Were sewage odors detected when arriving at the site(yes or no): NO F Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 645 SKUNKNET RD.CENTERVILLE,MA 02632 M169 P11 L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 BUILDING SEWER(locate on site plan) Depth below grade: 42" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:36" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed b a Certificate of Compliance es or no : NO attach a co of certificate ( ) ( PY ) g g Y P Y Dimensions: 1000 GALLONS" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. SYSTEM WAS EMPTY AT TIME OF INSPECTION. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 645 SKUNKNET RD. CENTERVILLE,MA 02632 M169 PI I L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): NO BOX TO NEW FIELD/THERE IS pa..64TO PIT PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 645 SKUNKNET RD.CENTERVILLE,MA 02632 M169 P11 L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 INFILTRATORS leaching chambers, number: 4 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH FIELD WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND. SYSTEM WAS EMPTY AT TIME OF INSPECTION. OUTLET TO LEACH FIELD COMES IN ON INLET SIDE OF TANK.THE PIT WAS EMPTY AT TIME OF INSPECTION CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 I page,10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYST EM INFORMATION(continued) Property Address: 645 SKUNKNET RD.CENTERVILLE, MA 02632 M169 P11 L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. r G<<sz C ° O .. 0 AA 144 A613 AC A0 3) U 41 f 3S y ( C- a� in Page 1 1 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 645 SKUNKNET RD.CENTERVILLE,MA 02632 M169 PI I L42 Owner: ENGELOS CONSTANTINE C/O CHARLES CONSTANTINE Date of Inspection: 4/7/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. I 4 l COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS v DEPARTMENT OF ENVIRONMENTAL PROTECTION vo A 4 ti �t rG TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 645 SKUNKNET ROAD CENTERVILLE, MA 02632 MI69 P011,012 L42 Owner's Name: CHARLES CONSTANTINE Owner's Address: 645 SKUNKNET ROAD CENTERVILLE,MA 02632 Date of Inspection: 7/23/01 Name of Inspector: (please print) ~: JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O;`BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes ` _ Conditionally Passes _ Needs Furthe aluation by the Local Approving Authority Fails Inspector's Signature: Date: 7/23/01 The system inspector shall submit 1copy 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. Notes and Comments SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM. ****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. F.'1 C 1,1000 I Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 645 SKUNKNET ROAD CENTERVILLE,MA 02632 M169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 Inspection Summary: Check A,B,C,D or El ALWAYS complete all of Section D A. System Passes: X I have not found any informationtwhich 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 PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair„as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by-the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a 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*uneven'-distribution box. System will pass inspection if(with approval of Board of Health): 1° ` " _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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 pipes)are replaced _obstruction is removed ND @rplain; n/n ra� ,J Page 3 of l 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 645 SKUNKNET ROAD CENTERVILLE,MA 02632 M169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning m 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution frorn that facility 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: n/a , Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 645 SKUNK-NET ROAD.CENTERVILLE,MA 02632 M 169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 D. System Failure Criteria applicable to all systems: You muss indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding.of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X 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 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, provided that.no other failure criteria are triggered. A copy of the analysis must be attached to this form.) (Yes/No)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. i 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. You must indicate either"yes"or"no:"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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§y§teal lifli failed:Thy owner or opt3rator of any large system considered a§ignifcant thr-cat 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. n Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:`SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 645 SKUNKNET ROAD CENTERVILLE,MA 02632 M169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ` X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection '? X .; Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling,inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site'? X _ 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 ? X _ 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: Yes no X Existing information. For example,a plan at the Board of Health. X _ 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(3)(b)] 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 645 SKUNKNET ROAD CENTERVILLE,MA 02632 M169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for,example: 110 gpd x#of bedrooms):330 Number of current residents:3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no):;NO , Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203):•n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records ,_ Source of information: n/a Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,spil`absorption system _Single cesspool _Overflow cesspool _Privy E , _Shared system(yes or no)(if yes,attach,previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: INFILTRATORS IN 1997.TANK IN 1985 Were sewage odors detected when arriving at.the site(yes or no): NO 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 645 SKUNKNET ROAD CENTERVILLE,MA 02632 M169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 BUILDING SEWER(locate on site plan) Depth below grade: 42" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:36" Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 51711 W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet lee or baffle: 32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE MAIN SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE SYSTEM GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a .Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a iY4 Fe .r - 1' Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 645 SKUNKNET ROAD CENTERVILLE,MA 02632 M169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): n/a PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no):NO Alarms in working order(yes or no):NO ' Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 645 SKUNKNET ROAD CENTERVILLE,MA 02632 M169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a INFILTRATORS leaching chambers, number: 4 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): THE INFILTRATORS APPEAR TO BE FUNCTIONING NORMALLY CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a , Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a .. a Q V Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 645 SKUNKNET ROAD CENTERVILLE, MA 02632 M169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. C a O D �I M AA 14 y M A-C l� AA 3a` M 4( 1 � 35N 31 Page 1 l of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 645 SKUNKNET ROAD CENTERVILLE,MA 02632 M169 P011,012 L42 Owner: CHARLES CONSTANTINE Date of Inspection: 7/23/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12 FEET ,y PP 4. C TOWN OF BARNSTABLE 1 LOCATION SEWAGE # `/ VII LAZE rAmAnPJk ASSESSOR'S MAP & LOT /6 ?-Off b f INSTALLER'S NAME&PHONE NO. C�r�� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) �T i5 1-n-i'a� NO.OF BEDROOMS 3 BUILDER OR OWNER 5 PERMIT DATE: -2 � COMPLIANCE DATE: — 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 r � �� �3 3�� s No. t Fee THE COMMONWEALTH O ASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for Zi$ponl bp$tem Construction Permit Application for a Permit to Construct( )Repair(V115,Pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.1a`-I S)Ku n,lCl-=r Owner's Name,Address and Tel.No. � Assessor'sMap/Pazcel ry®,�vv 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ry�1 Ci Type of S.A.S. LET D`aG"C- Description of Soil °cr D.S b—, Nature of Repairs or Alterations(Answer when applicable) :970—q-444 1 ''4 41D 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 d not to place the system in operation until a Certifi- •sate of Compliance h fea� Signed Date �9, 17 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued • M No. i:+/ �Jw Fee s Von " -» THE COMMONWEALTH OF ASSACHUSETTS Entered in computer: Yes .PUBLIC HEALTH DIVISION -TOWN'�OF BARNSTABLE., MASSACHUSETTS 01pprication for Migonl 6potem Construction Permit Application for a Permit to Construct( )Repair(V,Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.tQ t-L S S v Owner's Name,Address and Tel.No. C�P1�-Tcvv�t Assessor's Map/Parcel ' _o`I O`� N q\_"a VU Ins is Name,Address,and Tel.No. ! Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms_� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �y�c.'S't�C 16M 564 c--- Type of S.A.S. �L- ' Description of Soil WI N 0,S Nature of Repairs or Alterations(Answer when applicable) .='y`Sl'�a( � y (-��0 J�t,S h Cc PL a 1�-vLt`--T��,Z�rIS OIL e�cr5tl- 7'UrS�. wl�/rSt7� 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 Cod d not to place the system in operation until a Certifi cate of Compliance ha en issue of Hea t Signed Date a<)`f1 7 Application Approved by Date Application Disapproved for the following reasons Permit No. 7 - Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS certificate of Compliance THIS IS TO�at t e On,%tL31wage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )by a e `--/��e S at Ca `-r S S�vr�.1�►� e Tf& (f�eA'r`crvi) 'e has been constructed in accordance_, with the provisions of Title 5 and the for Disposal System Construction Permit NoY ��ated ,�' 1L a Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed:- Date C) ~/ Inspector !r \ --------------------------------------- ,. No. �/ Fee�,E� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ;Mis;poal *pgtem Congtrurtton Permit Permission is hereby granted to Construct( )Repair( Upw grade )Abando ) System located at & �� L ter. C,V and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to P Y PP g Y comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thi it. Date:�'" !� Approved b �%� jl NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCII AND APPLICATION FOR A DISPOSAL NVOKKS CONS'IRUCI'ION PERI191'I'(WI'I'IIUU'I' DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated "�� 7 . concerning the property located at �o `��s���-��� C2 meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in(low and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: -1 -27 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. 1 / 11 TOWN OF BARNSTABLE LOCATION y C S SEWAGE # Ya VILLAGE �,"Ai-1) ASSESSOR'S mmMA//P�� & LOT 16 ?.6ff• 61 X INSTALLER'S NAME&PHONE NO. �� _��� ✓�IfTK_ SEPTIC TANK CAPACITY o0 o ep(,,+� LEACHING FACILITY: (type) Le--Zt (size) �S � 1 NO'.*OF BEDROOMS BUILDER OR OWNER S PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 � Gr � � I i 4 6`f5 ` %6 %®//-o/.Z LOCATION SEWAGE PERMIT NO. T LAGE •INSTA LIER'S NAME A ADDRESS B U I L D E R OR OWN ER �. AJAJe DATE PERMIT ISSUED dDAT E C 0 M P L I A N C E ISSUED 1 c 3s 06 Li d � ` I � i fa r L �I t _ r No.... . ........ ` / THE COMMONWEALTH OF MASSACHUSETTS )BOARD OF HEALTH iP,CJ®U................OF....c ,lEf /lZ 'L��-------------••-----.-..--------•--- 1 Appliration for Uiipniial Works Tnnitrnrtinn Vantit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ............................ r.. ................ ----...................... z.....-----......--------------......------......-- c ion-Address J or Lot o. W Owner Ltss a .....................................................---.........-............................. ------------••-•--•------•----............................................................... Installer Address d Type of Building Size Lot....157.72-------Sq. feet U+ Dwelling—No. of Bedrooms..................3--•--•-••-------•---- ExP nsionAttic ( ) Garbage Grinder ( ) aOther—Type of Building --_----------------------• No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ................... ----------------------------- ---•-----------------•-•-----------•-----_--------------•---•----•........ ••-------..... ------- Design Flow................�r,J....................gallons per person per day. Total da}ly flow_._......._..___-.3a..._..........�.. �Ions WSeptic Tank—Liquid capacity./. /gallons Length_ '. . Width.4r.�el.-. Diameter-------------_. Deptl�!.'I�.� Disposal Trench—Np..................... Width.................... Total Length.............. Total leaching area....................sq. ft. Seepage Pit N........ Diameter.-- �d��--- Depth below inlet... ........ Total leaching area.&-v.�....W4V Other Distribution box ( Dosing tank ( ) dPercolation Test Results Performed by.-; ...... r�/'� C. Date_ _���t._1 _.. a Test Pit No. 1....�,-------minutes per inch Depth of Test Pit_.l "..___. Depth to ground water..R14%11v�.. �fi'CGIO:Cf?�ZZ� -.---• �. � (i, Test Pit No. 2..._� minutes per inch Depth of Test Pit.__... .��.____ Depth to ground water.____>!............... W -•-•-•--••---•--••---•------•----•---•---•-••-••--- ...................................................-._........---------•------------...--------...... o Description of Soil 1 .�-. 2�� �IGC . 301 ' v -�Xi'e�,——�?------ ----------- ---- W UNature of Repairs or Alterations Answer when applicable.-___--......................................................................................... Agreement The undersigned- agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLI- 5 of the State Sanitary Code— h rsigned further agrees not to place the system in operation until a Certificate of Compliance has been is t oard of health. Ksigned.......... -- -•-------•--.....•-•---......--•••-------•-------------••----------- ................................ "aL Application Approved By. �. _'�.. Date Application Disapproved for th f llowi reasons:--------••--•-•-•-••----•---------------•-----------....--------------------------------...---•------••--•---. ----------------•-••-...-------------------••---------•--•---------- -:--------...•------•------•-•- ------ Date Permit No.........Y m �7 Issued_--...._..�---_-- Date , a. No.._.. .:` T FEs..... THE COM^MONNWEALTH OF HEALTH MASSACHUSETTS RD OF Z ' ` OF..... :. ... . ` App irFatiowfor `Dispos al Works Toaastrurtioaa ramit Application is hereby:made for a Permit to Construct (4--1 or Repair ( ) an Individual Sewage Disposal System at . L c ion-Address p W Owner Address a ....---••--•---••-••..........................•-•.......----•------_..__........._._...._______.._ ........................... -----•------•.......------___.......-- Installer Address UType of Building Size Lot....... : 772-------Sq. feet Dwelling No. of Bedrooms................. ._...Ex Expansion Attic � g— ------------------- p ( ) Garbage Grinder ( ') �4 Other—Type e of Building ............... No. of persons............................ Showers� YP g ------------- --------------------P ( ) — Cafeteria ( ) P4 Other fixtures .---•••......•------•••••... ••.••--••...... W. Design Flow................-5...................gallons per person per day. Total da}ly flow................-'_.�`-.__: ..........__ lons. .`l.___ Width_4:� Diameter________________ Depthf W Septic Tank—Liquid capacity_. a g Ilons Length_. x Disposal Trench—Ng- --------------•_-. Width.................... Total Length.................... Total leaching area.............=......sq. ft. Seepage Pit No._____-_..1-.--_--_--_ Diameter___- Depth below inlet...6-_'0.11______ Total leaching area.-15�.�__._�c%±� Z Other Distribution box ( 4� Dosing tank ( ) ram. Percolation Test Results Performed by._;j14? •_Q .-_.'+'`!Jk. ":� AX ,. Date-T-_ �-�_:f�,------- .:. Test Pit No. 1----- .......minutes per inch Depth of Test Pit- _ ...... Depth to ground water__ .. "✓ � > '' 44 Test Pit No. 2.___,2.......minutes per inch Depth of Test Pit...... p g____.___.. Depth to round water------°°............... ------------------ ----------------------------------..-------------•---•----•--_____-_____-----•------------_____--_--------------------------•- Description of Soil------ 5; --`�Z '' ' C �f 0</4J /G ' `'�--= /,0 l�'�i/�'� `G ----•-•- U + ` ----- U Nature of Repairs or Alterations—Answer when applicable.--_--_......................................................................................... ----------------------------•---•----------•------------.•...------------------------.......-•-----•----•----------......----------------------------------------------------------......_.....•-•••---• Agreement: The undersigned agrees to install the aforedescribed Ind* lad al Sewage Disposal System in accordance with the.provisions of TITL% 5 of the State Sanitary Code— h rsigned further agrees not to place the system in operation until a Certificate of Compliance has been is t oard of health. Fllow7i-ng igned---------- -- -----------------•--------•-..--------••------•-------•----------•. 'Application Approved By........... +_ Date Application Disapproved for th reasons:.. -•-•-•• =' -----_.. .• --••---••-•-•-• ••••---•----•-•- ••---•-•--- •-----•-•--•••----.._.._ Date Permit No.- .-31-5 Issued = ?. . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r� Currtifirttr of TourpliFaatre � � TH IS T CERTIF That the Individual Sewage Disposal System constructed (t/) or Repaired ( ) L( 4hJ...r.�............ at. ------------- has been installed in accordance with the provisions of TI 'r j of The State Sanitary Code as des c bea in the application for Disposal Works Construction Permit No.___ �r'_ .-__3_'"T: dated_ -.-. .." ______________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRIBE® AS A GUARANTEE THAT THE SYSTEM WILL F N TION SATISFACTORY. 195 DATE ro Inspector....... ec THE COMMONWEALTH OF MASSACH ETTS BOARD OF HEALTH • c7 � �!f!f1`............oF.---------. i !!.:✓,� '` ....:.......I........_.. No....B5 -11-7 � FEE..._�Q: - �i��o��al r����aa��raar�ioaT rraati� aPermission is ereby granted................ �- ---�--------------------- �A.!`V-1==--................................................... to Construct (%o air an I dividual wage is osal Syst r at No. ------._. '! P .... w I - ' - Street as shown on the application for Disposal Works Construction Permit No ........ Dated.._...:4_..-�...�'�.-�_�........ j ------------------------------ .................................................... C oard of Health PATE------,� / J-------------------------------•-•-• i FORM 125'5 HOSES & WARREN, INC., PUBLISHERS . GENERA 4, NO I'ES ��tl• -2��co .-�:��':t_ --_ ...,� -;.-,. _ /. ,4r;.. . EkE"Y.9TfON5 SNOdVN ARE :57ry A2 Z. PITCH A41. L IN4`S A M:N;MUM OF %8'f FT. _. f 1 k c Q�(D � ; ) ® U,N�ESS OTHER�YISE �PECIF/�'P.r ► .2a"1 ��'`'f I (D ()(D '`1 J. 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