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HomeMy WebLinkAbout0152 SKUNKNET ROAD - Health (2) 152 SKUNKNETT RD., LOT 15 CENT. A=171-005 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville V/ MA 02633 November 1, 2015 3; 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 filling out forms A. General Information 5 I� 1 I' z- - on the computer, I `y�z; use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Rapid Response kCompany Name 155 George Ryder Road South Company Address Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority P--S November 1, 2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �a ed V5 t5ins•3/13 //�%/ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1, 2015 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: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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 ;M 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1, 2015 page. Cityrrown 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 Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1, 2015 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1 2015 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 W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1, 2015 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd 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 �,M ,•°'F 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is Centerville MA 02633 November 1 2015 required for every , page. City/Town State Zip Code Date of Inspection D. System Information. Description: A system sized for three bedrooms was installed by Bortolotti Construction in 1996. Number of current residents: 0 i 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 79 gpd Detail: 2013: 32,000 gallons 2014: 26,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: not determinedDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner's agent 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 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1 2015 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: Age:19 years. Disposal Works Permit for a new system was issued 10/22/1996 (Permit#96-532 at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1feet 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: 10.5 x 5 x 6-1500 gallon Sludge depth: 6 in t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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-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 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last um in p p 9: Date Comments (condition of alarm and float switches, etc.): I *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 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1, 2015 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 at 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.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 12 inches below the top of the stone layer. 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 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1, 2015 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.): 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 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is Centerville MA 02633 November 1 2015 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System' Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately F T§OonNlS COMPONENTS IN DECIMAL FEET A 8 NOT TO v 8.5 22 SCALE Q 12 30 O 6.5 34 /43j DISTRIBUTION BOX SCREEN A 2 PORCH O 1500 GALLON Oo��o I SEPTIC TANK 8 \ \ �QV THIS SKETCH IS \ �p� BEST VIEWED IN 508 364-0894 COLOR FORMAT 0 O I 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 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1, 2015 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: 10+ 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: 10/22/1996 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: Town of Barnstable GIS Department records indicate that the property is over 10 feet above groundwater table. Approved design plan on file with the Board of Health shows bottom of system is 5 feet above the adjusted high groundwater elevation. 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 M 152 Skunknet Road -Assessor's Map 171 Parcel 5 Property Address Lisa R. Aprea Owner Owner's Name information is required for every Centerville MA 02633 November 1, 2015 page. Citylrown 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 GEOHYDROLOGICAL PROFILE — NOT TO SCALE � f BOTTOM 10--+ OF LEACHING GALLERY LEACHING IS ABOVE HIGH GROUNDWATER GROUNDWATER ELEVATION PER GIS MAPS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 it TOWN OF BARNSTABLE t�/ a� ��� LOCATION /5� !�+o_Le K-"� i t SEWAGE # VILLAGE C tE�N, E:2t/I t_L_L- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.�',Cp-tZiBT—�( SEPTIC TANK CAPACITY 6 S-Cerr) C A-L- LEACHING FACILITY: (type) 'tom�t f G I-�-�g e t 0 L�2f�i _• ( 7 of ' NO. OF BEDROOMS / BUILDER OR OWNER C LLb -t2&hk1 3z. l L- Q1 TJ PERMTTDATE: 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 !A Ll Al Oa 4,3 J41 Ar4 '-W ' 70 ° s\ i '_ ASMSORS MAP N0 No. '° PARCEL IA FeeJd- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Digool *pgtem Congtruction Permit Application is hereby made for a Permit to Construct(/r Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. l�Z G p� Owner' Name,Address and Tel No Assessor's Map/Parcel 61,27 Installer's Name,Address,and Tel.No. Desi�g fis Name,Address and Tel.No. f '7/-- ��— yrill- Type of Building: A� Dwelling No.of Bedrooms_ Garbage Grinder( OfO Other Type of Building Xf6MIM664o. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �'�O gallons. Plan Date & � A`i Number of sheets Revision Date Title v i"-?, 947 5-el7�/s�i%' Description of Soil 1,fe joleo 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 Certifi- cate of Compliance has been issued this Bo of th. Signed Date l Application Approved by Date �1.�'`� .� Application Disapproved for the following reasons Permit No. 9eri / _74*7 Date Issued V, ZaK— y Fee `r-=:_ THE'COMMONW"OF MASSACHUSETTS V k 'f PUBLIC HEALTH DIVISION,-TOW OF BARNSTABLE., MASSACHUSETTS 0ppYication for ;Bigogal bpztem Con.5truction Vermit Application is hereby made for a Permit to Construct(/r Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. "� � S' Owner' Name,Address and Tel No. Assessor'sMap/parcel G .17 r'of Jk-t" Installer's Name,Address,and Tel.No. Desig r s Name,Addres's and Tel.No. ✓for 1`� G d�� G��s7` - �pw 77Z— • �� 1 Type of Building: Dwelling No.of Bedrooms"" Garbage Grinder Other Type of Building e o.of Persons Showers( ) Cafeteria( ) j Other Fixtures ' Design Flow gallons per day. Calculated daily flow 30 gallons. 1 Plan Date rt /Z Number of sheets Revision Date Title Description of Soil � 3 Nature of Repairs or Alterations(Answer when applicable) �G �fY'd,�� r P , Date last inspected: y 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 Certifi- cate of Compliance has been issued by this Bo of H lth. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 494gr� - Date Issued "V +�` r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( or repaired/replaced( )on by Installer A zi® at J _ 1 N i` �' has been constructed in accordance with the provisions of Title 5 and the for.Disposal System Construction Permit No. dated Date Inspector THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. No. A!;— ——— -- --- ^---------------Fee d`=�j� 7 07 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE., MASSACHUSETTS Miopozal *pgtem Construction Vernift Permission is her by granted to 9_A1WZe#1 to construct(Lj ( )an On-site Sewage System located at No.# /,S"7_ �" meet and as described in the above Application for Disposal System Construction Permit. {, .. No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. Date: / a—— �]'� Approved by vx__� Board of Health �-CHAMPION P.0 I�{LDE '=-.r �(�(�[ E-1 � _2•� L1l_iL_0 P. 02 t./ l,[ .c�•l�,-!' �I 1iF, to" 1-S� � �,{ai nJr .t/r r� rt �,' u e a7L 'i .1♦Vl� i H i l� y {r y• r '� kG- .� "� "QW1Q�V, 'i}f!.a f•.r r dt r 1 y`"S` 1 e la 4A�y t�, A �µ�,,. 1� �, ,�,f }"a�i'T' �t zkr•�' 1�i4 1,� a�. ` pi i } ) r •r oop a 6P •`t. ��, ��Q•• � rrn4r M a� + i1�� tdja ?R i Y ���t°�.�.. p t t' Sri i I ���� >r.. s' •�' 'r' � Sr ` t'� .1 :L7�ir P P. � Cr y !4.• I� rr x r, ip' �r,� �'"(.�i� r t "±. ;;�i��.t�.r � � rq, r � � Lr`plt l y�y i��Ti ''F' 'Y� � �� �:J r•�t�-t tr :. '''�'C'r , a ���. 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',•+ itr r 4�??Irk,� 'i tyr. ��,, t rrT 4 i . aM "• fr i A" �r. .,,; � �. � �. •, '�"���•1�`r,:�MIK � f*.i.,-�..,.�—�A' BOx-.•_r____-__—„ ''LpE,ArC''H�INrG f:• s 15E A kj"IN VI s, _ 5n'r7'c�N�o✓p.� of �4'c3.d r C4 P hQo.-1.— pA 4a.iQ r -- — - O T- I Z // 9; S 1 , TOWN OF BARNSTABLE C/ i LOCATION :3^� K'o SEWAGE # VILLAGE GN't%2t/I -C.t_� ASSESSOR'S MAP &LOT INSTALLER'S NAME&.PHONE NO.�,',n-ty SEPTIC TANK CAPACITY. I- LEACHING FAM17Y: (type ' of t G 1-�— tic ;tz�4'(�11 1 7 rf��- NO.OF BEDROOMS BUU DER OR OWNER I&LI XL&I r--� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maumum 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 'b' - - --day I - + /� i O ; ti Hfir1F I C�Fa E:�I_I LDcH E.1 8 29 04100 F . 0 -, 1 > Y 5t5Y�� 'Y 4. •Lu M1, t 1 + +L;,�TS' +� � S '�", ��y$.5 �'yi di �r•�,;� v { .� 1 e 1 e } 3r r P y 4T ¢• , \R1,IH�J�Fif�{y P 5.� >A v e J ^1a� y� A c �r�^' J.iV 1n "•r:.i,r 4 �r. 9. 7 °i �+ tir$1�� v �Ilk dui h. , `P 7JI�N r 1..1 �}`,y'�i,.n �� "4r�` r*tr �t i� �3 t yt � 7 {l, �\ �u.'iat _a. - �;rl°� I,� .h �� t,r • v 4� 4i M �.. }< <. �: r Yyp��rH,��"�i C�,#�1� '� 4 +� � it.� � �n Y �Z ,� �• y ,� �y } { f�i >i✓ ,, ( � M, f t �' rq `_^�;.! +�.r-r,: r,,� 1 + 1 ii �1� AK d.�. .� i �.� S r i' r 1M• ���k � tl,�i� f.. t f, �.` _v�.� . ,� �4�� �..,C`�r + `�i � `73.k ty f �d d- r • � t' '.L.�..,� 4 1+-- rl.�,'�'f o � ` ry,Y ' >t ,� v , ti ."e i� � Y t, 7 { Yi , r e , r � � \ s .�� � w r s,�:j�5 i� :' A i � i y r � L ' ! u -�y�+�°• 7 r 'A y :y F {. ti 1� r r, r J5, �'a ' q�j'{r •'` y L ,. 4 j 4; t h �r ` ' , ..,1 r ; 1�4,% T -7 q Fia��a•5�0►!`,14 j n 'r ( � er 4 r .J � S r'c J l}tii �� `M1 f•f - - A1� AP CCH(fJG + <,w t t ,E•r/y� 5..e. :• + SS 9 r , ';\ 7 ♦ Tt�f C.a. 7o. rf`1h{�''.Y#�-TEA-`',+42 t �t.�wp►� r ��' ft.00D IC11'��.,,�:..,.'� "�''r,s� ll�i"�';q� `". r1 SE"►B►+GK�'; F 2dNT `�U j IDE PLAN REFERENCE: l4. i I ! NOT I, DATUM IS _ C✓_ate"yf�P fir.. i G?,y D . 1 EPTIC DESIGN; ( ( gyps" Is .r+•S r+ynleo ) 2, MUNICIPAL WATER IS t'"�•11AQL4, _ -- DESIGN FLOW: BEDROOMS We .GPD)' L11 GPO 3. MINIMUM PIPE {'ITCH Td BE 1/tr PER, OOT. USE ��GPD: DESIGN PLOW DESIGN LOADING FOR ki PRECAST UNI S TO BE Aa5H0=N 1 . PTIC AkK'Jj vv o GALLONS S..PIPE JOINTS TO BE MADE WATERTIGHT. USE A. S�°O GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCC IOANC€ WITH MASS, EM-1IRONMENTAL .CODE TITLE V. HIN 7. THIS PLAN IS FOR PROPOSED WORK ON r AND NOT Tp BE �,ta.s GPC USED FOR LOT LINE STARING. . 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40- i PVC" CPO Tp'AL. S.F. �s�.5 riPC 9. COMPONENTS NOT TO BE SACKFILLED 0 ! CONCEALED WrTHOUT INSPECTION By BOARD OF HEALTH ANG 'ERMISSION OBTAINED R4. L•. �L-G~ !_T7LltJ. ✓f '� chi Lr� 2' -ROM BOARD OF i-4EALTH. SITE AND SEWAGE PI AN OF if IN THE TOWN OF: �iirpRovm PREPARED FOR: DA7E p&0%, l,jz Y rvo Pet J SCAU: ?-o`_ DATE: i down cape engineering, inc. r �r a CIVIL 15 ENGINEERS HLOT LAND SURVtYOI2S • PHONE SOE-362-4'S41 P1p ! oryw FAX n st,a_Aaa_9a 039 ma yarmouth, ma AR JALA," ti ----- APB TOWN OF BARNSTABLE '® LOCATION SEWAGE # �� VILLAGE LhI-DIQ t I -.t. k ASSESSOR'S+ MAP & LOTS�f' ®� INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY �, t-- LEACHING FACILITY: (type) E I� (size) 1A e 3 NO.OF BEDROOMS (:B:U:ILDEj OR OWNER 4,A—✓q P(&M 1 t PERMIT DATE: / 0 6? :y , OMPLIANCE DATE: Separation Distance Between the: e 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 F:i is LIS r i L i iZk-1��5 SEPTIC PROFILE TEST HOLE Lots -----------_______ , 7.O.F A? El_ —_ f= _ (NOT TO 9aNX) ACCESS "OVEP TO W',HIN r OF FAN. GRADE ) 4 _ ACCESS COVER (OVA-EF'lG�-r"` T� ENG;NEER. __ �SP-►-t> �E___ _ r� / W"t Ilh r OF qN. GRADE _MINIML40 .75' OF COVED OVER GRE1S' f �jL 2% SLOPE REOQIRE� 0Vv_R SS-EW WT^J�SS V -- -- - -- .r v" _ s�. DA - l i RUN PIPE :EVr' , �T.:....i y T�• —..Pt�e q� 1 1 (Da—) i I i `OR FIRS' 2' t r' -.7=7Z ~ �� '��ON S£ MC -��- - ---t � � _ - PER". RATE I -yak ,'►: >�2��!L --�l�i`. -- 1 - -- i ti Y _ �"N••K.E �5 _So_'n� 5O L—'' 1 SEW _ - - — — = = CLASS S _ __— SOILS P I r - x SLOP!� CRLSHE2 ,^.ONE OR ME7-r,A.NICA_ OE°T}• OF =10M COMaACT10%. 5 22' i 2]) ---- - - r31 1f� TEE SIZES �;It SLOPE. Uy. SLOP `- L ,14 y It- 00 _I n L-E- t..tA.t..rA Q.f? - NLf' DEP'I^ a 10 ---o,----- A - --- -- - _--——- ---- ----- 30`rL.L7 DEP-M _ la " LOCATION MAP ,• _ ,o 4 i V ASS�»ORS MAP -1 rARCE G20 !; LEACHING ,4 1. YA 0•l. l._.__ �c� =OUNDaTiON-- �� -___ SEP7'C TANK - ---_ ? ___ _ D• BOX `} r I ___ _. 1 _�_. \o<rQ. sly FACILITY _ - G u,' 4b , wA 3 v i���7 R,I G ZONE. O't V !'b r1VOAVV1 — --- '�'�'' 1 0 SE_r:sQ.CKS =RONT - .a . l G a.. f�•t c_S --- I SIDE - 2 S`T O AN DEFERENCE: 1 � � � -- . ,�_ __-• -..... ..._. + t ���_ �_ � : . DATUM `S *�cx`�'' ,�`.�`,��'►'liF.✓-� i�•.,-ti.Z..tzl t� Ci3..ir-/ -- I w ;� � _ • I - y1� ' S : 'T:IC � c } L. MUNCIPAL NATER ISDESIGN: (GARBAGE O+SPOSER IS �T h: — --- i - 3. MIMMiJM PIPE PfTCH ?0 BE ' '8" PER FOOT 17, oo3 'i-5.f. 7! SIGN ;:-'-OW' 2 BEDRJGMS �'U GPD '' v GPC 4 DESIGN LOADING =OR ALL PRECAST �Nlrc BE AASi-+C,__ I , a si; u A GPC DESIGN ^w I _ w A ` ' 14-1 ,,. POPE JOINTS T BE MA E +NATERT!GHT. r C%DTI TANK' -/ / n L l fipLa I^ O D } C SPA GALLONS ET T� E NSTRUCT10�1 DETAILS BE IN ACCORDANCE W!TH MASS. ' -- - - ENVIRONMENTAL .ODE T'TLE V. �E a t5r�r> ',A.L:.ON SEPTIC TANK T>•i!S PLAN IS FOR PROPOSED WORK 3NLl aruC NOT TO 8E I L� two - - "" ' f2�cMOJh-✓ l�ACH!N -IISED FOR _OT LINE STAKING. 4 -OR S[PTIC SYS 7 EM Tv^ SCH. 40-4" PVC, 1 . prr.1 . .�.. ---�G c O _,.x��� , 5 ? P NEti - �0 BE BACKFI OR . 0'v I✓A W!Th0 I � �x�- ;� t EG � - :� ``�` - ..�''�� -'� ,� S - �sP� 5 Apr ":S?=C'ivN B" BCARD OF HEALTH-I ANC PERM!SSIO OA'Ai►vEI_ I � ' - - '___ ~- t - '. _ _t�' J ;� >-t • %au tT ► P 'ol. 2t =KOM BCARD OF HEALTH. O 1 ►� r 0� , j tee. ---~ ---- ------ _--_ -__ - -� I T E AND SEWAGE PLAN OF IN THE TOWN OF: HOARD OF HEALTH - ----- - -- --------- MA PREPARED FOR '5 Ii� ;✓a-:. p F nJx!'- v-t3 .E APPROVED DATE I ( t�✓ 2 Ih ,.Jt°r� c'3 ;,.•c':�:4- "' __—_— +-=ate SCALE: _�_ '_ DATE: F down cape engineering, Inc. 9% OF A CIVIL ENGINEERS = NOJALA QUA �s���, LAND SURVEYORS iea,is xLA � PHONE 508-362-4541Ift FAX SC8-362-988C Ytti � .. 939 main st. yarmouth, ma 4R JALA �� JOB# =� z t 1. n E.