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Home My WebLink About0498 SOUTH MAIN STREET - Health =A=2OS60-Ud'62 AIN STREET, CENTERVILLE 1 I UPC 17534 No.?-153COR KASTINGS.UN r X Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cG1M s 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is v required for every Centerville ✓ Ma. 02632 03/13/2017 page. City/Town State Zip Code Date of Inspection p. 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 v 7* /aa� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections rQ Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 03/14/2017 Inspector's Signa ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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: This 4 bedroom home has a H-20 1500 gallon septic tank with a D-Box feeding four cultec leaching chambers.At the time of the inspection there was appx. 6 inches of ponding water and no visible signs of past hydraulic failure. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville . Ma. 02632 03/13/2017 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 pumpingmore than 4 times a year due to broken or obstructedpipe(s). The Y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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 'h day flow t5ins•3/13 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 M 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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•3/13 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 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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? Y p El ® 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I " Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 0?D/16 `S 7 OW 6A/o _j ✓'ere L)S-e4—/ r20 15 L 7� 0✓f G re j2`e�. Sump pum ? ❑ Yes No p Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M50 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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: Barrows Septic Service 508-524-5129 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Drivers Est. Reason for pumping:. Owners request 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M s 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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: 1997 for the leaching and 2014 for the tank Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 19„feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard H-20 1500 gallon Sludge depth: 3" t5ins-3/13 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 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 page. Cityfrown 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 3" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 35" Distance from bottom of scum to bottom of outlet tee or baffle 5" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): would recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local septic pumping Co. 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 wM 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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): g g ( p p P ) ( p ) Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.). Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-Box had no visible signs of leakage. 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 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 Cultec ❑ 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.): At the time of the inspection there was appx. 6 " of ponding water and no visible signs of past hydraulic failure. 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 ^M 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 498 South Main Street Property Address P Y Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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 Li 371 Ua I T-1�:j t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 498 South Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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: 12 plus 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: I augered a hole to 12 feet to show five plus feet of seperation. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 498 h Sout Main Street Property Address Diane & Roham Saleh Owner Owner's Name information is required for every Centerville Ma. 02632 03/13/2017 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 P'JS F t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATIONAW14 r— SEWAGE# I VILLAGE SSESSOR'S MAP&/PARCEL t ' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Z! OG 62 LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: r 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 I �•� ,� � � �� d � : . � �� ,- No. 10 ( � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es Zipplitation for Vsposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon M ❑Complete System ❑Individual Components Location Address or Lot No. Q (lie Owner's Name,Address,and Tel.No. Assessor's Map/Parcel W yo /!7 J 1 �nditem Installer's Name,Address,and Tel.No. 0,7G y� Designer's Name,Address,and Tel.No. Type of B lding: Dwelling No.of Bedrooms Lot Size / sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Ane.swer whe applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Si a Date c Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �U ( �—� � Date Issued ( t Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es ftpYication for Misposal 6pstetn Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon 0(6 ❑Complete System ❑Individual Components Location Address or Lot No. v -f A ('L1 Owner's Name,Address,and Tel.No. l Assessor's Map/Parcel sp N/9/h J f /G 6 ./qY�/ Le_ Installer's Name,Address,and Tel.No. dZG C�� Designer's Name,Address,and Tel.No. rot i D GYi•�`1�c3.S�/7� �J�`'�D Type of B ding: Dwelling No.of Bedrooms 'y" Lot Size / Z(0 sq.ft. Garbage Grinder( ) Other Type of Building r/�1A e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ~ \- Nature of Repairs or Alterations(Answer when pplicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health p r Si e _ Date p f! Application Approved by Date / t Application Disapproved by Date Q for the following reasons Permit No. U �(- 7 Date Issued ( / / ---------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ti r BARNSTABLE,MASSACHUSETTS Certificate of Compliance TVIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by (ILA 'C', piT-,)IiUt-�C� at / , S f` P . f t t p., n.• C has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. o% /'-��7 dated r Installer Designer #bedrooms' P"l Approved design flow gpd s.. The Issuan e ft is permit shall not be construed as a guarantee that the system wil nctio as des ig ed. Dated , 1. a �I II Inspector - - - - -- - --- --- ----- - No. )v d s y Fee�2_f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 33isposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) ! Upgrade( ) Abandon( (� System located at I�Ot 11, ) A/w.- f C and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within tAree years of the date of this permit. Date f Approved by i ToYfN or 2011 AUTI I AII ', {w # hh�'l�ltiS+'�r�CaF.NbiKM1:'�.{.yyp�.* No. v 1 _1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Q implication for Vsposal Opstem Construttion i3ermit 4qq Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. d/y� r �� S� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel J� a, Installer's Name,Address,and Tel.No. Desi er's Name,Address,and Tel.No. Type of B ilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re airs or Alterations(Answer when applic ) .�- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of t afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme Code and not to ace the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 7 Application Approved by Date � Application Disapproved by Date for the following reasons Permit No. d I `"t sZ Date Issued �'or No. ;-U l 4 _�i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ` 0 2ppliCation for ]Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address,or, No Owners Name,Address,and Tel.No. .. y , mow% s7 Assessor's Map/Parcel 14- 1 - µ j h Installer's Name,Address,and Tel No. Desi er's Name,Address,and Tel.No. �O Type of B ilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) I Other Fixtures Design Flow(min.required) 17 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re airs or Alterations(Answer when Date last inspected: •. Agreement: The undersigned agrees to ensure the construction and maintenance of t afore described on-site sewage-disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to •lace the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date t Application Disapproved by Date } for the following reasons Permit No. CJ j �- f Date Issued _ C THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,th the -site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by at (TalMksi ucted in accordance with the provisions of Ti the for Dis al 4'ystem Construction Permit No. vf�22 dated '��— /C( Installer (� /P Designer #bedrooms /v Approved design flow gp 49 The issuance of this pe it sh 1 no be construed as a guarantee that the system w` un ion designed. d Date rT Inspector - - -- ` � - - Fee i� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposat :&pste onstrUction Permit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. I Provided:Construction must be completed within three years of the date of this permit. Date (�' t-r Approved by i TOWN OF BARNSTABLE ant +11 n .5� SEWAGE # Vn::-,AGE . C gah-4& ASSESSOR'S MAP&LOT•R 06 INSTALLER'S NAME&PHONE NO. C.`��Jb,n� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) -'`� �(�I TeX (size) 10X -N al NO. OF BEDROOMS BUILDER OR OWNE,,1R /�I Z6a� PERMITDATE: /V -3-9 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 �w No. eel 7' Fee $5 0•0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppfication for �hgpogAr *p$tem Construction Permit Application for a Permit to Construct( )Repair(x,3 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 498 S Main St Owner's Name,Address and Tel.No. Thomas Henderson Assessor'sMap/Parcel Centerville, MA 771 -8701 o G- Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Sept Sry PO Box 1089 Centerville MA 0263 Type of Building: Dwelling No.of Bedrooms 3/4 Lot Size sq.ft. Garbage Grinder(nol 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 Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) T i 1 T, a .h i ng system r ran ci i c t i nq of four stonepacked h20 infiltrators. 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 by this,Bogd of Health. Signed � Date Application Approved by �U Z - Date Application Disapproved for the following reasons Permit No. �`'" 'f� Date Issued .� r No: J Fee $5 0.0 0/ THE COMMONWEALTH OF MASSACHUSETTS 5 Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migpogar *potem Construction Vermit . Application for a Permit to Construct( )Repair(X Upgrade( ')Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 498 S Main St Owner's Name,Address and Tel.No. 'Thomas Henderson Assessor'sMap/Parcel Centerville, MA 771 -8701 ,, Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Sept Sry t�- PO Box 1089, Centerville, Type of Building: Dwelling No.of Bedrooms 3.14 Lot Size'_ sq.ft. Garbage Grinder(nd Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures r Design Flow 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 Ana M , Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching system-cen- sis t of four stonepacked h20 infiltrators ng 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 by this Board of Health. Signed ` Date Application Approved by Date Application Disapproved for the following reasons 3 Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS Henderson BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( )Repaired(XX)Upgradl d( ) Abandoned( )by Wm E ROnbinson Sr_ Sent i r• Sry� x:_-- at 498 S Main St Centerville MA has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No 9_12__1i9 ated Z 47 Installer Wm E Robinson Sr Septic r_ Sry Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date ll - Inspector ---------------------------------------- No. � Fee$50_00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Henderson lwizpooal *pztem Con!5truction Permit : Permission is hereby ranted to Construct '�T y g ( )Repair(X)q Upgrade( )Abandon( ) ^ { System located at 498 S Main St,--contQ=A 3 1 e A Tnstn11ar• Ulm RGh1nsen Sr��e--Srg l 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 must be completed within three years of the date of th' rmit. Date: / _, �- Approved ^ ' a r NOTICE: This form is to be used for the repair of failed septic systems only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I,William E. Robinson, Sr.,hereby certify that the application for disposal works construction permit signed by me dated S '—? 7 , concerning the property located at 498 South Main St, Centerville,MA 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 obseved groundwater table is 14 feet or greater below the bottom of the leaching facility. * There is no increase in flow and/or change in use proposed. * There are no variances requested or needed. SIGNEDA G DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification plot plan,this plan should be submitted). 1 G l� f TOWN OF BARNSTABLE WWW SEWAGE# :?`VILLAGE ASSESSOR'S MAP& LOT'. O - ( � INSTALLER'S NAME&PHONE NO. CJ SEPTIC TANK CAPACITY E d %LEACHING FACILITY: (type) (size) NO.OFBEDROOMS w BUILDER OR OWNER j PERMITDATE: / V 3- `� :. COMPLIANCE DATE: %O 7 �� SeFaazation Distance Between the: ' Maximum Adjusted Groundwater Table and Bottom of LeachingFacility Private Water Supply Welland LeachingFacility ty __Feet on site or within 200 feet of leaching facility any wells exist Edge of Wetland and Leaching Facility(If any wetlands exist Feet ;within 300 feet of leaching facility) Furnished by Feet o �� r � TOWN OF BARNSTABLE BOARD OF HEALTH J'AY1.12� ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date /(g---q— /6 7�6t.6bA/ Time: In C� :3d Out �/�,, �7 i Owner I r�14 77W&-W V ��n Tenant Address 8 L0YMV1n l �'lct 1.Sf r(p�T s�1 Address `l"7 30 L4fl4 �1 Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities MD — 4. Water Supply 010 oR V 5. Hot Water Facilities � O C�O 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12, Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width S //t) zo 19. Number of Tenants Observed 0.— PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allow ax) Number of Persons Allowed (max) •ll .�_ Person(s) Interviewed(�N�� Inspector If Public Building such as Store or Hotel/Motel specify here COMMONWEALTH OF MASSACHUSETTS O� fa EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 498 South Main Street Centerville Owner's Name: Barbara Turner (Henderson) Owner's Address: �] Date of inspection: ` r13 7coo e 7 l� v` Name of Inspector.(please print) Sean Jones Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 _Centerville. MA Telephone Number: (SQ111 775-8776 CERTIFICATION STATEMENT I certify that 1 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 pursuant7passe's aa 153d0 of Title S(310 CbIR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Dute: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthw 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 seat to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments 0 5e,01h 6 �'tom cw 44 ifi CovLr ,Ivo f- G.Cc e,is 111� be- UA-cte.. &cc43s(4 by �`7 Sf�e( C ® SCP�G AnI-e -4S /Vo� Ge'atfVe d Jlp ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 �, 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 498 South Main Street Centerville Owner: Barbara Turner Date or Inspection: a a Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Systtee Passes: V i have not found an information. _. which indicates that any of the failure criteria described in 3I0 CMR 15.303 or in 310 CI4R 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: /t / 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"trot 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 exfaltration or tank failure is imminenL System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. `A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup'or break out or high static water level in the distribution box due to-broken or obstructed pipes)or due to a brokeq 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: 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 Wall): broken pipe(s)are replaced obstruction is rt wvcd ND explain: Papc i or it OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 498 South Main Street Centerville Owner,• Barbara Turner Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to deterin ne 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(I)(b)thai 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 Z. 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 l 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 front a private water supply well•• Method used to determine distance •'This system passes if the well water analyis,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: 3 Pagc 4 of I l V OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 498 South Main Street Centerville Owner: Barbara Turner Date of Inspection: a� D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for aU inspections_ Yes N 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.outict invert due to an overloaded or clogged SAS or cesspool " less than der flow than b below invert or.available volume s r Liquid depth to cesspool u less Y Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped U 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 I 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 systems passes it 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)hat facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria are triggered_A copy of the analysis must be attached to this form.) ,A J (Yes/No)The system ails.I have determined that one or more ofthe above failure criteria exist as described in 310 CMR 15.303.therefore the system fair 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 now of 10,000 gpd to 15,000 1;P d. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems its addition to the criteria above) 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 drinfang water supply __.. — the system is located in a nitrogen sensitive area(Interim Wellhead P otedion Area-11WPA)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 faded.The owner or operator of tiny 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. 4 Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ProperV Address: 498 South Main Street CentervIlle Owner% Barbara Turner We of iwpectlon: Cheek if the faliowla have been done.You must indicate "or'W as to each of tlu foltowing; Yes No., or Board of UcaM Pueapiud Informatloa was prom by the owner,fit, Wee any of the system,compo als pumped out In On ps hms two yaks? �Moa the system received mans!ffm in*t pmviaas two week Period Y -01 Have large vohmtes of water beat boodimed to the sWem men*or as pars of this bgmxdon 7 s Were as bulk pku of tlu system dabsed ad examIned?{ifdmy vmve not available um as NIA) Wax the fadWy or dweiting inspected for signs of sewage back up? Was the she ins steel far slaw of break out': Ware an ayBars ftmp=v^"do&&the SA.%kKaxed an she 2 7" Were the s t k M umma,qowd,wd to et*e tank fca the condition f tRe mottles��,tl ot� depdtofli�.dew�si�e and d�ofsemn? „� Was the facliigt tsvvt�{ate ate ifs Gam av�}pi+uv�ed veelh��the props Malntettattce of s disp�st s e To*mad tstatloa ottke San AIDS §A*an dw 3ift bto bees detenabod based am des � .Fer�sP�u►et�e t3eaedeft . �, eta► lb {Faft�ece�etiatsAutCati�se ot'ostalaoe itnm P14 CUR 03UP)(Q Page 6 of l t OFFICIAL INSPECTION FORM—RIOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddresr 498 South Main Street enterville Owner. Barbara Turner Date of Inspection: :2; a --7 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(anal): DESIGN flow based on 310 CMR 15.203(for exagtple: 110 ggd x it of bedrooms): 'i J �PD Number of current residents: 0 Does residence have a garbage grinder(yes 4r w):,A'9 Is laundry on a separate sewage system a(`y�es or noj: [if yes separate inspection,required) Laundry system inspected(yes or no):&14 Seasonal use:(yes or no): NJ 2006 — 61 ,000 Water meter readings,if available(last 2 years usage(ggd} Sump pump(yes or no):,.W — , 0 Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or nod Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if avaitable: Last date of occupancyluse: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the iaspution(yes or nor.,:!LD If yes,volume pumped:�gaflons—How was quantity pumped determified? Reason for pumping TYPE OF SYSTEM --'Septic tank,distribution box,soil absorption system _Single cesspool Overtiow cesspool --Privy . Shared system(yes or no)(if yes.attach previous inspection records,if any) _innovative/Altet the technology.Attach a copy of the eurrew operation and maintenance contract(to be ma obtained fiom system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date histalled(if known)and source of information: ; z 2 Were sewage odors detected when arriving at the site(yes or no): 6 i 1'aCc 7 t.l !3 OFFICIAL IN51'I;CI'I0N Font-mar FOR VOLUNTAltY ASSESSMENTS SUBSUR ACE SEWAGE DISPOSAL SYSTEM INSPECTION DORM VAIU C SiYSTEAI IN)}OIlMATION(conlinucd) Property Address: 498 South Main Street Centerville Qivncr:Barbara Turner Dale or lnspeetlon. V-23'&2z r - BUILDING 5LNYL 1(lucatc va site lstall) ;I Ucptll below grade:—� — � hlatcrials of construction:_cast irun ✓d(j I'VC_otltct(cxplaill). Distance Rein private sralcr supply ncll ar suction line:_ Cununcnts(oil cmldition of juints,vcitttstg,evidence of leakage,tics oi-a ti� j[ Gc�je bUTIC TANK:_(locale oil site plait) Depot below grade: Material of eonsiructiun. u,rcrctc metal fiberglass^pulyedrylene _vtlict(explain) — —" If tans:is meta)list age:_ Is age eurtCtrrreed-by a Certificate of Curtipliar,ee(ycs ur nu)__(attaclr a copy of ccnifrcatc) Dimensions:_ 'poe- ( IL Sludge depth: Distance Irons top of sludge tv bullutr►of outlet tee or Wile: Sctan lliickncss: 3`1 Distance front lull of scull,to lull of uullct ice of bailie: Distance 4ein buttuiit of stunt to bottuln ore tict tee or balllc: UP_ I loin sere dimensions determined: � i Cunuiicnts(vn pumping rccon►nicmfatiuns,inlet alai Dude,tee ut bailie currditli,n,structural intcbrity,IatuiS k.•rIc as related lv uullct blvett,evidence of leakage,etc .j: S 14 ia� In rl �� r�.,l� ,c .o�/17 S f1 r� GREASE TRA1'L/(ineatc oil site piari) Dclidi bclusv glade:— Material of eonstrucliun:_toliClctc tl,clai fiberglass 11vtyedly1eitc__ollicr (c).plaut): Dimensions: Scum tltickrtcss. Distance froul lull of sculls to lull of vullct tee or Wilk: _ Distance Gout buttom of scull,to buttul,,of vuticl icc of bafllc: Date of last pumping: Coilull€nts(on putl,ping rccuitilnciidations,ittict attd uullct ice tit bafllc cvndaw.-i,stluctuldl iiit% its•,liquid lei c 1; as Ic1a1cd to outlet invcit,cviticrl(c of lcaka&c.€ic_): 7 c . Page 8 of I I OFFICIAL INSPECTION DORM—NOT FOR VOLUNTARY ASSLSSil1L•'NTS SUBSUIWACE SEWACL DISPOSALSYSTL•M INSPECTION I;OI(NI VART C SYSTU l INI:ORAIATION tcontinutd) Proptriy Addrtss: 498 South Main Street Centerville Dwntr: Rarf]ara Turner 0111t of IbsptciloD: A114- 7 iG1lT or ElOLU1NG TANK: tle roust be pwa+iud at elate of inspectiott)(locate un site l+Ean) Dcplh WOW gtadc Material or construction_ —Colic[Cie_ruetal fiberglass_--polyctltylene othe+(explain): Dimensions: capacity: �allotts Design Flow; gallunstJay Alarm present(yes or no): Alum level: Alarm in working utdcr tycs or to). Dalt of last pumping: Conuncnis(condition of alarm and[Iva%switchcs,ctc.): UISTIUUUTION ll0\; (if ptcscnt lirasl be olscticd)(locate on site plan Dtpth or liquid level above uuticl utvers: Cotn+ncnts(note if box is Icvcl and distlibutiott to outtcts cquaf,any cvi&me of solids castyoVcr,any cvidcuce of It aka t into or out of box,ctc.): ►�:a I'Ui13!'CilAPIllGii: jItc oilsite}tia+r) 1'uotps to work'ing order(yes or no): Alanns in wotkittg order(yes or no): Conu►tcnts(note condition of pump thantirct,tooddiust of}warps and al-puttenantcs,ctc.): Page 9 of 11 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 498 South Main Street n ervi e Owner: Barbara Turner Date of Inspection: a 3 6d-7 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. Type _ leaching pits,number._ aching chambers,number. Y aching galleries,number: 5 leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number innovative/alternative system Typelttame of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 50 Pro 6r-,e , W G rib s /or,44 Na}- CESSPOOLS:�IP{cesspoot 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVI/41/is (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.): 9 Page 10 of l l a " OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 498 South Main Street Centerville Owner. Barbara Turner Date of Inspection: d ob? 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 feel Locate where public water supply enters the building. A ,d 3� c3�a 3� GArOA(06 10 Page 11 of V OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SUM INSPECTION FORM PART C SYSTEM 114FORMATION(continued) Property Address: 498 South Main Street Centerville Owner: Barbara Turner Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_2�eet Please indicate(check)all methods used to dcu amine the high grid water elevation: Obtained from system design plans on record-if checkal,slate of design plan reviewed: Observed site(abutting properVahservathm hole within 150 fed of SAS) Checked with local Board of Hralth--cxpllaiw Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain_ You must describe how you?established the high ground water elevation. 1 ll Town of Barnstable �pP 114E 1p� yP ti� Regulatory Services BA"STABLE Thomas F. Geiler,Director Mass. 9`b i639 Public Health Division AIFp�.(A Thomas McKean,Director. 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF ;� � I A x DEPARTMENT OF ENVIRONMENTAL P ECTION / ONE WINTER STREET, BOSTON. MA 02108 6117-29 ECEIVE9 V'V Play l WILLIAM F.WELD w O C 24 1997 ?TR DY CORE Governor �a T o,F O H RIvS 48LE ✓ Secretary r ARGEO PAUL CELLUCCI DAyV D B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F RM� Commissioner PART A L C3 CERTIFICATION Property Address: 498 S Main St, Centerville Address of Owner: Mary Henderson Date of Inspection:/� " (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: WM E Robinson Septic Service Mailing Address: PO Box 1089 , Centprvi 1 1 e., MA 02632 Telephone Number- 5 05 0 8�7 7 5_$7�77 5_$7 77 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: �Passes _ Conditionally Passes , Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: L ✓`--- Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should'be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 8, C, or D: A]SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] STEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon c om pletion of the replacement or repair, as approved by the Board of Health, will pass..Indi , no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 498 S Main St, Centerville Owner: Henderson Date of Inspection: 1 B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C] FU THEIR 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH WILL PROTECT THE PUBLIC HEALTH AND 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) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT E SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE NVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. 66 _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 498 S Main St, Centerville Owner: Henderson Date of Inspection: 16 D] TEM FAILS: You mu t indicate ei;,,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis or this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct e failure. Yes No Backup of sewage into facility or system component due to an 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 112 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a•surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] RGE SYSTEM FAILS: You ust indicate either "Yes" or "No" as to each of the following: The'following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The wner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requi ements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Hags 3 of 10 E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: . 498 S Main St, Centerville Owner: Henderson Date of Inspection: 16 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. e//. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 498 S Main St, Centerville Owner: Henderson Date of Inspection:/Q s-7—$ �7 FLOW CONDITIONS RESIDENTIAL: Design flow:,o g.p.d./bedroom for S.A.S. Number of bedrooms:`/ Number of current residents: Garbage grinder (yes or no): LO Laundry connected to system (yes or no) S Seasonal use (yes or no): A, Water meter readings, if available (last two (2) year usage (gpd): 1 9 9 5 — 9 0, 0 0 0 g Sump Pump (yes or no):_/L,O 1996 — 95, 000g Last date of occupancy: COMM CIAL/INDUSTRIAL: Type of es blishment: Design flo _gallons/day Grease trap resent: (yes or no)_ Industrial ste Holding Tank present: (yes or no)_ Non-sanita waste discharged to the Title 5 system: (yes or no)_ Water met r readings, if available:"Est date f occupancy: OTHER: ( escribe) Last date -occupancy: GENERAL INFORMATION PUMPING RECORDS and source of )nformat /on: /9 9 f System pumped as part of inspection: (yes or no)-&-S If yes, volume pumped: / F" Qallons Reason for pumping: i%t 5115 TYPE OF STEM 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Fags 5 of 10 II • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 498 S Main St, Centerville Owner: Henderson Date of Inspection: /a $— BUI L ING SEWER: (Locate on site plan) Depth low grade: Materi of construction: _cast iron _40 PVC_other (explain) Distanc from private water supply well or suction line Diamete Commen s: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: ✓ (locate on site plan) i Depth below grade: I Material of construction: _ oncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: r t� , -k- Sludge depth: n " / t, Distance from top of sludge to bottom of outlet tee or baffle 41 Scum thickness: 0 , . Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: 0 S-,0- l Comments: (recommendation for pumping, condition of inlet d outlet tees or baffles,,depth of liquid level in relation to outlet invert, structural integrity, evidence oJeakage, etc.) �✓ti. �' w %•- c: zO--Sr-�!f l-(5 /L m 1°2 O I;— S SK rP7A c z� o -- GREASE T P: (locate on sit plan) Depth below grade: Material of c nstruction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimension : Scum thi ness: Distanc from top of scum to top of outlet tee or baffle: Distance om bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommend ion for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evi ence of leakage, etc.) (revised 04/25/97) Page 6 of 10 i 498 SOUTH MAIN STREET LOw>*II-TION SEWAGE PERMIT NO. G`ENTERVILLE 78-724 VIkLAGE A & R- rVRgPQnL gVRVT(`.R I N S T A LLER'S NAME & ADDRESS r - l2A BISHOPS ME RACE, HYANNIS, -MA. 02601 , RODGER T. HENDERSON _ B UItDE R OR OWNER r 498. SOUTH MAIN STREET, CENTERVILLE'; ' MA 02632 DA T E P E R M I T I S S U E D 10/31/78 DAT E COMPLIANCE ISSUED 7/19/79 498 South Main St. Centerville, Ma. 02632 r ti -r4NK cp Sox �r f' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 498 S Main St, Centerville Owner: Henderson Date of Inspection: -7 TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locat on site plan) Depth low grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimen ions: Capa ty: gallons Desi flow: gallons/day Alarm vel: Alarm in working order_Yes; _ No Date of revious pumping: Commen (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:!/ (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) (5 PUMP C AMBER:_ (locate o site plan) Pumps in working order: (Yes or No) Alarms i working order (Yes or No) Comme ts: (note c ndition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 498 S Main St, Centerville Owner: Henderson Date of Inspection: )O 8'y-9 '7 SOIL ABSORPTION SYSTEM (SAS):3_,-" (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:*/ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: 1 (note condition of soil, signs of hydraulic failure, level of ponding, conditi n of vegetation, etc.) —� R -s's'y' CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY _ (locate on site plan) Mate ials of construction: Dimensions: De h of solids: Co ents: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 t ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 498 S Main St, Centerville Owner: Henderson Date of Inspection: f O T—may '7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ►P 01 Cl t O r .ems` t�6 8 e * 1'A b 1 � (sevieed 04/25/97) Page 9 of 10 II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 498 S Main St, Centerville Owner: Henderson Date of Inspection: dO—S^ �! ? X Depth to Groundwater /6 Feet I - Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record ZObservation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) 7 (revised 04/25/97) Page 10 of 10 4 F>, i...�.5..:.00......... • . 8 7 �f.... �, THE COMMONWEALTH OF MASSACHUSETTS BOARD -IOF- HEALTH - Town...............oF.....Bamstable Appliration for Uiipnaal Work.5 Ta imtrurfinn ami# Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: 498 South Main St. . Centerville -• ---------.__--------------------•--------. --------•-• •---•-•-•---.....---..........---•--••---------•--------------------------•------.............---- Location-Address or Lot No. Roger T. _Henderson 4 8 South Main St.*.& n s v , , ,e.,..-..... ............. ... Owner Address a A & B Cesspool Service 128 Bishops Terrace.,-_.Hy-anne. ----Mg... Installer Address Q Type of Building Size Lot..... ....................Sq. feet U Dwelling—No. of Bedrooms..............3------.._.--._ _Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Buildin ... No. of persons.........4................. Showers — Cafeteria Q' Other fixtures -----------------------------------•--- . W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) w, Percolation Test Results Performed by.......................................................................... Date--------------------------------------- aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------------------------------------------------------------------•--------.........---......................................................... 0 Description of Soil--------Sand--------------------------------------------------------------------------------------------------------------------------------------------------- x W --•-•-----------------------------------•-•---•---•---------....•----•-----------------•------•----------------------------------...-----------------------------------•-•-••---•-------------------•--- VNature of Repairs or Alterations—Answer when applicableinstallat-i.on....o.f...a...1,00.0...(-one---thousand gallon... eptin...tank--_and...a...1.tQQQ...4-ane...thousand)....gall_on...stone___ acked....leach Agreement: pit (overflow) The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i1TLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued y theUrdhea�h. Signed .....-- J------------ 2Q,r!31/..7 ........ Dat ApplicationApproved By..............................----•---•----•---•--------•-•-•----•-•--••......................... --------10/3V78..------ Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------•--•-----.....•----- ..----•................••---------....•--••-••-------•-•----••-•-••-.........---•----------•--------•--•-•--------------•-•------......---•--------------.............................................. - Date PermitN ..7....•---------------------------------------- Issued_.......10I 1178---•-------..........--- Date zf Fizz..$5..09......... THE COMMONWEALTH OF MASSACHUSETTS "(4' BOARD OF HEALTH Town.....OF....Barnstable ------.....................................----- Appliratilan f nr i u gal nx ,Gnat rttr iun pruti Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at 49.8...S.Qkth...Main...at',..#...G.ente,tvjlla.....:. ............................. ..._.. - - ...........__ Location-Address or Lot No. Rover--- i.e 11maran............................................. 4.98... ......... Owner IA dress a A &. B- Cesspool `sArvice•-----------•••-•................ 12g_..5i±�b4 .Tex - �.. 3ta iis+s - .._. Installer ;Address QType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms..................._........._.__.._..._...Expansion Attic ( ) Garbage Grinder ( ) a4 Other—Type of Building ------------- _..-_____ No. of persons........4------------------ Showers ( ){ ,— Cafeteria ( ) Q' Other fixtures .........•-•-••-••-•-.... - -•-•------------------------------------ - ------------------------•-------------------......... W Design Flow..............................................gallons per person per day. Total daily flow......................._........._...._.._.._gallons. WSeptic Tank—Liquid capacity......_.....gallons Length................ Width----------------- Diameter__:.............. Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth-below inlet.................... Total leaching'area..................sq. ft. z Other Distribution box ( ) Dosing tank Percolation Test Results Performed b ......................................................... - Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to,ground water-------_---------------- ------------------------------------------------------------------•--••-•••---.._.:-...•--......................................................... ODescription of Soil......... and------------------------------------------------------------------------- ............. c., W U Nature of Repairs or Alterations—Answer when applicable -I-r St81le-tin e a__}jOW---. -Qne -thGUsand ) } gin septic---tsnk---ands:---a-•-}:'--GGG...(-One...thongand-)---gAllola---stone...�a�k 4 -leach Agreement: ` pit (overflow The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITiE 5 of the'State Sanitary Code=-The undersigned further,agrees not to place the system in operation until a Certificate of Compliance has been uea y the boa d of health. ...... ..................... ...►`..... Signed----••• - /3 / $ Date ApplicationApproved By................--•--•-------------..............-------------•---------...._....._...--•••-••-- •---••3-�.3-1/- 8•-•__-_. . Date Application Disapproved or the followingreasons:..................................... ______.____... `i.. ............................. h Date Permit N . { _ ' -------- :.. Issued ----_...1Q13-1/7e_.. ate THE COMMONWEALTH OF MASSACHUSETTS a BOARD OF HEALTH 016Wn......OF.......B arhs.table.............................................. Trdifirttte of To tplianrr THIS IS TO CERTIFY, ,That the Individual Sewage Disposal System constructed ( ) or Repaired by Ec E�s� gal- e�Y ., .12.8---B ships.-.Terrace.*...Hyann i a,...Ma. --QZ@i ....... Installer r Roger---Z,_He8 naeraon------. ................... ,has been installed in accordance with the provisions of TI;1Z.4 5 of The State Sanitary Code as described,in the ion " � Vorks ConstructionPermitt'No_ __ _ __________� �� dated_ ....-_.1 a�31/j78.aPPlicat for D>sPosa THE ISSUANCE OF{IRIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM' WILL FUNCTION SATISFACTORY. r { DATE._,*.-.... ................................................. Inspector.................................................................................... .,THE'COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. oi . ....i OF..... .....�rnata-b No.. ; FsE.. £�0 ...... t t l [ n1pal 1ops Ter, , Hyannis PerionS"bljed 0-& i@F' 'iF1 .Q =- 4geZ' '1'rBnfE401'1 to Construct ( ) or Repair. ( '") an Individual Sewage Disposal Sy 10/31/78 atNo.... = , 1_. ....................I--------- --------- ---------------•-----------------......-----•......••••--•-•-------- Street as shown on the application for Disposal Works Construction Permit No................�_,46ated........................................... I R !t ............................... :E_!J_R �_ `1 Board of Health DATE `-•--------------•-••-....i-----•---- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS` � t L _