Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0052 STANLEY WAY - Health
52 Stanl.iy 4/a,- LA = e ' 228 157rville P No.42101/3 ORA � a 10% , 0 © 0 0 TOWN OF BARNSTABLE •LO CATION d*-X .!'Ti��� �Xy SEWAGE# -*A 013- VILLAGE ASSESSOR'S MAP.&PARCEL-7M INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type), 2MdtVGjy (size)/of X.X s°'X;L NO.OF BEDROOMS OWNER 41'dWI�-8'T4�t��T PERMIT DATE: fir' COMPLIANCE DATE: Separation Distance Between the: �s t� �✓��« Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /a 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 Geh i, � � . /9 7. a f _ , No. Fee U U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYitation for ]Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair A-11upgrade( ) Abandon( ) El Complete System Zidual Components Location Address or Lot No. 5—d �_PT/4,4 ld� Owner's-Name,Address,and Tel.No. Assessor's Map/Parcel c� ��S`7 eel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures gg Design Flow(min.required) gpd Design flow provided gpd Plan Date > m'.1 Number of sheets'-" Revision Date Title Size of Septic Tank Type of S.A.S.f mil" Description of Soil Nature of Repairs orAlterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ealth. Signed Date Application Approved by dy I ADate Application Disapproved by Date for the following reasons Permit No. — Date Issued -7 IYO i No. / § , ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes applicatioA for bisposal *- pstem Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System Vdiidual Components 'Location Address or Lot No. Sm? �T�w �`,y 6v Ow is ame,Address,and Tel.No. Assessor's Map/Parcel a,;�CP I r7 Installer's Name,Address,and Tel.No. Des* ner's Name,Address,and Tel.No. c�eocz�/ir 77:r'Q7O7 _PQ ti 3 6'_7 /6j, . . Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building - No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �� gpd Design flow provided O ' P J Plan Date ".T / Number of sheets--," Revision Date'- gp d Title ` 7 Size of Septic Tank 1o®4, f4 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �.,. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o ealth. Signed / Date Application Approved by j Date h Application Disapproved by Date for the following reasons c/ , Permit No. v Date Issued 7 - �{ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( v) Upgraded( ) Abandoned )by C;�-- 7 2' ��G/��'�`v /�l ,J' L C at ��- �� j?//�f Lr.�� has been constructed in accordance with the provisions of Title 5 and the for Dis osal System Construction Permit No. )6/1 `���ated Installer C 7� Designer4eA y/4 •6P fP;7oj r 11 4- 00?-p #bedrooms 3 Approved design flow gpd �1 The issuance of this permit sh not be stru as a guarantee that the system ction as designed y //�'Date p g Inspector l l% �- 1 i 1 /f --------------------— - � ------ - --------------------------------------------------------------------- -------- ------------------ r THE COMMONWEALTH OF MASSACHUSETTS Fee 'Ab PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Re air( � 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 comlpleted within three years of the date of this permit. Date �( � l/fi Approved b U �f N U' G r I JUI,/26/2013/FRI 10: 14 AM FAX No. P, 001 Town of Barnstable ; TKE Regulatory Services Thomas F. Geiler,Director MAMPublic Health Division den rn Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: � Sewage Permit-' ®_ � �`�Assessor's Map/ParcelC;,= 0 Installer &Desi ner Certification Form Designer: InstaIler: -4 1 it , Address: Address: v On !was issued a permit to insiall a (date) installer) 1 septic system at U2. � W based on a design drawn by ,,] {(�ad� ess) dated (designer) �— certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. 1 certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local R- '-fions. Plan revision or certified as-built by designer to follow. Stripout(if rP -pcted and the soils were found satisfactory, OF j DAVID B. C;1k (installer s Signature) MASON! cgr,I Na.1 goo SST esib er s Signature) PLEASE RETURN TO BARNSTABLE PUBI�,x_ OF COMPLIANCE WILL NOT BE ISSUED UN iiL bu i ri in1;� r ORNI AND AS- BUILT CARD ARE RECExV�ED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:lofftce Fonnsldesivnercedificadon fpmx,doc - Town of Barnstable, , P# cI, Department of Regulatory Services •�►• PubliicHealth Division 200 i639 �' rE0 J o Ya Date MA 02601 � • Date Scheduled t� ✓� Time Fee Pd. - 4 1• ,'t n e Soil Suitabili Asses ' '{ % ' '�' sm t for Sewage Disposal Performed ByI-�_-I�� ,� Witnessed.By: LOCATION&Location Address GENERAL FORMATION �`" �7f1/yL� y �y� Owner's Name -2xll�y • ---- Address sAl� Assessor's Map/Parcel: j / Engineer's Name+� �� NEW CONSTRUCTION REPAIR Land Use--------------- Slopes('Yo) Surface Stones Distances from: Open Water Body It Possible Wet Area — ft Drinking Water Well Drainage Way r , , e > . I ft •Property Line Other SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands. n roxi ' p ratty to holes) 77 J L �.r .N,, � I Parent ma terial(geologic) \ Depth to Bedrock �. Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: in. Depth to soil mottles: In. Index Well# Reading --rain• aroundwaterAdjustment ft. Date: Index Well level Adj.tdetor AdJ.Graundwater i evel, Observation PERCOLATION TEST bate ,gyp �j I Hole# �t — Time at 4" Depth of Pero 0 Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak ! Rate Min./Inch i Site Suitability Assessment: .',Site Passed SiteFailed. Additional Testing Needed(Y/N) Original:Public Health Division Observation Hole Data To Be Completed on Back---=------- �**If percolation test is•to be conducted within 100'of wetland you must first notifjY the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:ISEPTICIPERCFORM.DOC s i , r DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. sistency.%Gravel 1 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil 1, 1 Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. n istency,%Gravel) w DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling .(Structure,Stones,Boulders. Consistency,%Gravel 1 DEEP OBSERVATION HOLE LOG ' Hole# 6 Depth from Soil Horizon Soil Texture Soil Color Soil 'Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten Flood Insurance hate Mau: Above 500 year flood boundary No es ; Within 500 year boundary Ni Z, )� Within l00 year flood boundary No L, Yes Depth of Nat irally Occurrine Pervious Ma*erial ; Does at least four feet of naturally occurring pl exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring ial? .�' Certification ' I certify that on y (date)I have passed the soil evaluator examination approved by the Department of Envir men al Protection and that the above analysis was performed by me consistent with the r uired training,experti and ie ce ribed in 310 CMR 15.017. Signatu ;� Date b� Q NSEMIC�PERCFORM.DOC I I SEWAGE INSPECTIONS fi . EOtC tfON52 Stanley Way DATE 1 /22/03 VILLAGE Centerville,Mass. ASSESSOR'S MAP & LOT 2 28-1 57 -INSFkFCTORjo 5pt�h P_Ma��mher Jr_ s SEPTIC TANK CAPACITY 1000 cla 1 1 on s No box LEACHING FACILrN: (type) 1 -LP-1 000 (size)h 'X9 ' NO. OF BEDROOMS 3 BUILDER OR OWNER James McCarthy OWNER MAILING ADDRESS .112 Berkley Circle Basking Ridge New Jersey 07920 p LOCATIptQ : , SEWo.C,E PERMIT UO. VILLAGE ' �- - - - - IWST LL R'S U&tAF- ADDRESS BUILDER 5 ,Q &V AF- ADDRESS f Dl1,TE PERMIT ISSUED -2-� — — DATE COMPLI &MCE ISSUED : =2 1ol 1 C" F No..•.. .�'..... z�s... ..................._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEAL ..........................................OF............ ..............----.. . .----- --�-----_--_--------_--- , ppliration for Disposal Warks Cnonstrurfion Pprutit Application is hereby made for a Permit to Construct ( ) or Repair ( )man Individual Sewage Disposal �y G e.;.v -ati es o t No. W WK.96A.1 ------ �� ' '��... -------------------------- Installer Address `f /� , / 76C- )-S feet U Type of Buildi ,.- � Size Lot_,_ . f'______ ___ q. Dwellin —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (� `4 p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) PL Other fixtures -------------------------------- - W Design Flow.... per person per day. Total daily flow.._..._...._._✓.....................gallons. W tic Tan Se k i-Li uid caacit /b6D_ ..p q p y. _ gallons Length................ Width---------------- Diameter_____ ._____.._. Depth__.___: ..._.___ . x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.......J........... Diameter...Asin`gg _ h beloi Total leaching area_ _ I. q. ft. Other Distribution box ( ° ) tank ) fJ t Percolation Test Results Performed by._---_._sd/'_ .__a�_ ._��'¢_7 gate....-. __________________________ Test Pit No. 1............:...minutes per inch Depth of Test Pit.................... Depth to ground water._-__-_-__--........... w. Test Pit No. 2................minutes per inch Depth of Test P' ..... ____________ Depth to ground water___________-________.__. O Descript'on of Soil_. _ _. _ _. rs2� _ _., Q .. -----• r . x -----•••--•-----------------------------------=--------------------•••-••-•--•----------------------....--•---------------•••-•----------•--------•-------------------------•--------------------------- V Nature of Repairs-or Alterations—Answer when applicable._-____________________________________________________________________________________________. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned -agrees to install the- aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee is u y r o " 1 igne . -- .�..../ . . ----------------------------------------- ......................--------- Date Application Approved BY �� --�-�--...- --•---------- '' � ------ Date Application Disapproved for the following reasons------------------------- ....................................... -----------Dat.e------------- _ Date Permit No................................................--------- Issued.__.,?, - -------------------------- Date " "" -.--.'-- - -----------__- - - --------------� No..... V •E Fnx:../.. .................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ._ ..... .... ...... ... ..........oF.......... �' ....... Appliratiou for Rnpviial 10orbi Tomitrurtiou lirrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at t .......... ._._ _____ _ ________...................... ............ ____.__ ___ _ __.__.___ -------------------------------- ion . - ocat d'ess� f ors I.ot No. . � Owner{� � ,r t �• •�'1 Installer 7 Address Type of Build Size Lot- :_. `- ` _Sq. feet - Dwelling—No. of Bedrooms...._..._'............................Expansion Attic ( ) Garbage Grinder ( 7- ay` Other—Type of uilding ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fi fAes ............................................................................................................ W Design Flow...................................1¢f_.gallons per person per day. Total daily flow----_----_-.._____-__`__-----•_____.__._---gallons. W Septic Tank—Liquid capacity_- -_-____gallons Length............... Width_-_--__-__.._-_ Diameter................ Depth................ x Disposal Trench—Nd. Widtl �t�tal Lena h Total leaching area sq. ft. Seepage Pit No..................... Diameter.................... epth belo ij y __ Toll le cuing area ,�/-- q. ft. Z Other Distribution box ( ) Dosing tank ) �z%��i'I` !�0 � - y ' /` y d a Percolation Test Results Performed by_______________ ____. _ !el_ ..___7Date_____.___.___.___.._._..__.___._.___.... Test Pit No.,1................minutes per inch Depth of Test Pit.................... Depth to ground water.-.___-___-_-_-•_-.-_._. 0;4 Test Pit No., 2................minutes per inch Depth of Test P•t . .. ..... Depth to ground water F __ __-___ a ?I.._...--- D � ! ' Descriptio of Soil- -�---------- �b � ----•---- cxj d►1 �.,,�- �- ._.. tre+..-----•-- ............ . •• - Q W - ---------------------'................................................................................................................................------------------ ---------.. U Nature of Repairs or Alterations—Answer when applicable._.__..;______________ _____•••: --- --- -- -------------- ---- .--• .......................... Agreement The-undersigned agrees to install the 'aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary C d e i� e t agrees not to place the system in ,F operation until a Certificate of Compliance tas be th ague -• . .. :•-=•••--------------•---------------•--------- ----• - Application Approved BY !1!� - ---! �c ��.;! ` •------- ------------........... Date Application Disapproved for=•-the'following reasons:--•---------------------- ------------•-------•------.....----.....-----------•-•-••.--•• -•••------•--...... ........ --•-------••......••-•-•--------•-- -••••••-••-------••--•••-••.....:••-•••••••-•-••-----••-----------------•=-------:---------------------.----•---------------••---••-----•------ ,• � ^� Date ; Permit No................................ tR$�•......------••. x � Issued. ((�fGJ -- Date ,THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��er#i�utt�r�`u �tDt�t�li��tr.� /Olw..a............. THIS IS TO C T , Th the Individual Sewage Disposal System constructed ( or Repaired ( ) Ely / ► ---•- - - - - ------ �. Ins ------------------ at......... _ - - has be ins a ec n a or ance wit t e pro ions of A;rticle" ,rof he ate ghnitary d as descri in the application for Disposal Works Construction-Termit No.___.-__-_-Alo I dated... . ..!z'_7 ._................ fHE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A-GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ; DATE Inspector.-, �- L?k-,.4& �__ ---------------- .H THE COMMONWEALTH OF MASSACHUSETTS #; BOARD OF HEALTH ` ................ ..... ! ,?,.t....OF............ �,,�•-7.....�;::::.. No.---�—""�----- FEE----/.-----•----- Permission is hereby granted'" _----- •. ------ to Construc ( r pair man dividual S Disp 1 Sy:to i atNo.. . ---- - --- ------------ --------------- -- as shownit-he application for Disposal orks Construction -P i• No. __r____ _ ated....f " .._.... ... •. • . oar o Health DATE....... += �K- - `7---------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • LOCAT N 5EW&6-4E PERMIT UO. IWST LL R5 ;U&ItAE ADDRESS 15UII.QER 5 tJ 11, E ADDRESS DINE PERNAVT — r 7 D ATE COMPLI b,t�10E ISSUED : 2—� 7 - .�' ,A. ff I ri C ., t i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Stanley Way Property Address _ Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State." Zip Code. Date of.lnspection_ i Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 ermn City/Town State Zip Code (508)428-4028 S14454 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 ry Title,5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority f •., 3/05/2008 Inspector's Signature Date = ^ The system inspector shall submit a copy of this inspection report to the Appr Ning 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 slibmit thle report to the appropriate regional office of the DEP. The original should be sent o the system P,twner 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. 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 I - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name - information is required for Centerville Ma. 02632 3/05/2008 for every 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: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑' 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 Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 Y2 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 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 El tributary to a surface water supply. I 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. El ® 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 ❑ 0 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. 52 Stanley Way-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C4M ; 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? . ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? E ❑ 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? ® El information 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: ❑ Z 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)] 52 Stanley Way-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection D. System information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No ,000 :85 Water meter readings, if available (last 2 years usage (gpd)): 2002006:85,000 Sump pump? ❑ Yes ® No Last date of occupancy: 3/05/2008 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: Last date of occupancy/use: Date Other(describe): 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: i 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 52 Stanley Way M Property Address Peri Wentworth Owner Owner's Name information is required for Centerville M.a. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 10+ 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.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 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: 1000 Gallon Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 2 7" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured I 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Stanley Way GM Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 ' every.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.): Pump septic tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. 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 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): 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page,10 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No D-Box present. 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 9p leachin its number: 1-1000 Gallon ® ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Water to invert was 52" at time of inspection.Stain line is 36"to invert. 52 Stanley Way•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom MapIF Abutters Map Size 0 0 Zoom out J J'J J J'�J In _ ---------- i 07 0 20 Feet ' -PIPE — - Set Scale 1 = 20 �' I Aerial Photos " r ('—,rinhf T—A—of Rornefnhln MA All rinhrc rn—n, http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=228157&mapp... 3/5/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Stanley Way Property Address Peri Wentworth Owner Owner's Name information is required for Centerville Ma. 02632 3/05/2008 every 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: Bottom of LP 20' 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. 52 Stanley Way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable Regulatory Services . saxxsrnscE Thomas F. Geiler,Director 16 9. ��� Public Health .Division ,eT fD MA'S 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. DATE:1 /22/03 PROPERTY ADDRESS:52__$tanley Way---__—___ --Centerville,Mass_--_--- i:�� •J� 02632 On the above. date, I inspected the septic system at the above—atl,-d:-re�s=s,. This system consists of the following: ��=� � 1 . 1 -1 000 gallon septic tank.2. NO Box FEB 13 2003 3 . 1 —1 000 gallon precast leaching pit. (dry) TOWN OF BAPNSTABLE Based on my inspection, I certify the following conditions: HEALTH DEPT. 4 . This is a title five septic syst6m. (78 Code.) 5. The septic system is in proper working order - at the present time. 6. Pumped tank at time of inspection. 7. Leaching pit is presently dry. SIGNATUR Name:_ J__ P__Macomber_jr . ---- Company :joateh _p M�r4m�€r 8 Son, Inc . MAP PARCEL A0dr�ss :__�Qx _� ------------- LOT - -- - --C�fLC2LYLLLt~,_Jd-_QZ-632-0066 Pnone : 508- 775_ 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY IOSEPH P, MACOMBER & SON, INC. Tanks•Cesspools•Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632.0066 775.3338 775.6412 ' COMMONWEALTH OF MASSACHUSETTS 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: 52 Stanley Way Centerville,Mass. Owner's Name:,Tam _a M Lthh Owner's Address:1 12 Berk el y hrcie— Basking Ridge, New Jersey 07920 Date of Inspection:1 /2 2/0 3 Name of Inspector: (please print) Joseph P.Macomber Jr. Company Name: J.P.Macomber & son Inc. Mailing Address:Box 66 Centerville,Mass. 02632 Telephone Number: sos-77c;—i338 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 traiping 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: A/Passes ? Conditional) Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: V°f Date: The system inspector shal mit 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. f Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 �i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Add ress:52 Stanley Way Centerville,Mass. Owner:James McCaRTHY Date of Inspection:S / /p lnspection 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: tic system is in proper working order at the prPRPnt -tjme. B. System Conditionally Passes: 106 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. 4L 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. N'D explain: ItL# e- Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The s stem will pass inspection if(with approval of the Board of Health): y broken pipe(s)are replaced obstruction is removed ND explain: 2 i Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properc) Address: Centervil M Owner: James MrC'.arthy Date of lospectioo: 1 /22/03 C. Further Evaluation is Required by the Board of Health: ivy 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. I. S*stem will pass unless Board or Health determines In accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner wbich will protect public beaitb, safety and the environment: A,e Cesspool or privy is within 50 feet of a surface water Cesspool or privy is witbin 50 feet of a bordering vegetated wetland or a salt marsh 2. S.N stem 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 supple or Tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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. ItIb_ The system has a septic tart); and SAS and the SAS is less than 100 feet but 5 feet or more from a prt%ate eater supple well • Method used to determine distance 11--lzl e,(, "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are rriggered. A copy of the analysis must be anached to this form. 3. Other: 3 Page 4 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 52 Stanley Way Centerville,Mass. Owner: _.7amaG McCarthy Date of Inspection: 3 f 2 2/0 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 A, 'V t'- Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or %cesspool _ t/ Liquid depth in'eesspvuth less than 6"below invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped )- .�, �t' y 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. jkny yportion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 p d. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _- the system is within 400 feet of a surface drinking water supply f_l/the system is within 200 feet of a tributary.to a surface drinking water supply � the system is located in a nitrogen sensitive area(I.nterim 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. 4 c Page 5 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Add ress:52 Stanley Way Centerville,Mass. Owner:James McCarthy Date of Inspection: 1 /2 2/0 3 Check if the following have been done. Yod must indicate"yes"or"no"as to each of the following: Yes No ,,, y 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 ? r/ Have large volumes of water been introduced to the system recently or as part of this inspection ? _zWere as built plans of the system obtained and examined?(If they were not available note as N/A) 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,.eluding 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: Yes no / 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(3)(b)) S i Page 6 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 52 Stanley Way Centerville,Mass. Owner:James McCarthy Date of Inspection:L/2 2/0 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x N of bedrooms):54N Number of current residents: oc Does residence have a garbage grinder(yes or no): t'rs Is laundry on a separate sewage system_(yes or no):We) [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no):A20 Water meter readings, if available (last 2 years usage (gpd)):2001 —53, 000 gallons=1 45. 21 GPD Sump pump(yes or no):Ob °�" 2002-36, 000 gallons=98. 63 GPD Last date of occupancy: COM M E RCIAL/INDUSTRIA L Type of establishment: Design flow (based on 310 CMR 15.203): / gpd Basis of design flow(seats/persons/sqft,etc.): yA Grease trap present(yes or no): 40 Industrial waste holding tank present (yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):AO Water meter readings, if available: A?4 Last date of occupancy/use: X)A OTI4ER(describe): d2z± GENERAL INFORMATION Pumping Records Source of information:Maint. Tank Only. 1992, 1997 & 2001 Was system pumped as part of the inspection (yes or no): 5 If yes, volume pumped:/04[) gallons -- How wa quanttry pumped determined? Reason for pumping: 7, /ASS Z4w. S TYP F SYSTEM Septic tank, , soil absorption system -6 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 syst�eln owner) /1�Tight tank Ve Attach a copy of the DEP approval Xhther(describe): Apgroximate a of 11 components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 Stanley Way Cpntprvi 1 1 e,Mass. Owner: James McCarth Date of Inspection: 1 22 03 BUILDING SEWER(locate on site plan) Depth below grade:Y / � Lite Seh. 35 4" PVC Materials of construction: cast iron A v40 PVC_other�(explain):pipe & fittings Distance from private water supply well or suction line: /0 4- Comments (on condition of joints, venting, evidence of leakage,etc.): Joints appear tight.No evidence of leaka e.System is vented through the house vents. 01 SEPTIC TANK:/ (locate on site plan) d Depth below grade: -114_ Material of construction: concrete.440me 14l 0, fiberglasspolyethylene �C�other(explain) ,014 If tank is metal list age4AO is age confirmed by a Certificate of Compliance(yes or no • a (attach a copy of Certificate) t Dimensions: Sludge depth: Distance from top of udge to bonom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Q Distance from bottom of scum to bottom of outlet tee or baffle: 0 How.�vere dimensions determined: /rY)✓a i4Y' Comrf cnts(on pumping recommendation , inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of.leakage,etc.):- �.Pump the septic tank annually Garbage disposal is present ara-`; n T"nl of R r,,,t 1 ref tPPG nl iremhA tank i G ructurally sound and shows no evidence of leakage. GREASE TRA {locate on site plan) Depth below grade:,49 Material of construction:AO concrete, 4 metal f�A fiberglass,/�4 polyethylene other (explain): ,14J,9 Dimensions: A Scum thickness: 4141 Distance from top of scum to top of outlet tee or baffle:_1110 Distance from bottom of scum to bottom of outlet tee or baffle:_�� Date of last pumping: Comments(on pumping recornmendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GrPagr- trap is not present 7 Page 8 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:52 Stanley Way rPntarvi 1 1 Mass. Owner: James McCarthy Date of Inspection: 1 /2 2/0 3 TIGHT or HOLDING TANYA (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: 4M Material of construe: i Q_ t'concrete /r4 metal�fiberglass,�r/_ _polyethylene.e0 other(explain): Dimensions: Capacity: to allons Design Flow: Ado gallons/day, Alarm present(yes or no):_,J�t Alarm level: 40 Alarm in working order(yes or no):djR Date of last pumping: A),* Comments(condition of alarm and float switches, etc.): Tight or holding tanks are not present DISTRIBUTION BOx2 .t�.(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 4/. Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is not present PUMP CHAMBERe&&,(locate on site plan) Pumps in working order(yes or no): t),4 Alarms in working order(yes or no):o Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump chamber is not present. 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 Stanley Way Ceritervi l l _fMass. Owner: ,Tamar mccarty Date of Inspection: 112 2/1L- SOIL ABSORPTION SYSTEM (SAS):Zoocate on site plan,excavation not required) 1 =1000 gallon precast leaching pit Pit is presently dry If SAS not located explain why: Located: See page 10 y,/ leaching pits,number: )—'too/x L7 AID leaching chambers,number: 0 leaching galleries,number: 0 leaching trenches,number, length: [�j leaching fields,number,dimensions: Im overflow cesspool,number: dAZ c innovative technology:innovative/alternative system Type/name oftechnolo %T rfl y�(�e� Comments -- (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): L v iim fi na sand Nn si gnc of hydraulic failure or ponding soils are d�.` @-Q+-at+ nn i a nnrm� CESSPOOL_ (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Cesspools are not present PRIVX/14�&(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.): Pr1Vy 1S not present. 9 Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:52 Stanley Way Centerville,Mass. Owner. ,Tames McCarthy Date of Inspection] /22,/0 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �a 5 an1�1. U40Y I.. . Cxn en I 10 Page 11 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: 52 Stanley Say Centerville Mass. Owner:, James McCarthy Date of Inspection: 1 /2 2/0-1 SITE EXAM Slope Surface water Check cellar. Shallow wells y ' Estimated depth to ground water Q feet Please indicate (check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-if checked,date of design plan reviewed: NA YES Observed site(abutting property/observation hole within 150 feet of SAS) rLQ_Checked with local Board of Health-explain: NA yFS Checked with local excavators, installers-(attach documentation) yFC Accessed USGS database-explairthttp: //town.barns table.ma.us. You must describe how you established the high ground water elevation: sed: Gahrety & Miller Model 12/16/94 Ground water elevations above Sea level. sed: US�i-q-'--nhsRrvAti nn wPl 1 r7ata _ J i i n P 1 99 sed: USA-S_' Tecbni real hill 1 et in Q 131 ;4i-e { 9 Anniial rangaa of grnunt'3 tame Leaching Pit 9 .eet _ Groundwatep/ Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is � feet. 11 >•w►.TlTw.—R.1•Ir�.T-1rn�Ja1a•Menarltrt+7rRrRmr.�'rr+nrrTrRe'An fsrin7t 11s7rtartlrn .�, TOWN OF Barnstable BOARD OF HEALTH 1 SUDSURFACF SEHAGF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••T'1^T'•. ::f�T.1If.^.�TT.11T.111'af.'TSt TIlr7lleI7R1IT7'Tt'trRtRR:q 7ne4T-1'�eAAf iR/wlCet}tf7f►7 runt :TrPT•T-1.�.. -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 52 Stanley Way Centerville,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # 228/157 OWNER' s NAME James McCatthy PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. ---------------- COMPANY NAMEJ.P.Macomber & Son�,Inc.r'O" COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 •. 1 578 fate LIP CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at lathis address and that the information reported is true , accurate , and omplete as of the time of -inspection . The inspection was performed and any ecommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . i, i Ilt{ 1 Check one; �—_Zt_/Syste6 PASSED J The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or' the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con acted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date rue copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTII. * If the inspection FAILED, the owner or."operator shall upgrade ' ayste within one year of the date of the inspection, unless allowed orthe requiredm otherwise as provided in 3.10 Ch1R 16 . 305 . partd .doc x DSO v� I \Jt �p7ppf2 w WE M/WW" i ®R NO WN/W/M NO -4, Li t4l 1 4 ?J - 1 1 a r41 .mow Y. ° ....rw.Mrr.r�.b,MMSnwiw�aM.rMwrw.s+r�+ .x..v,.,..:.c,..,.y'cr.,wn....e+,.w>nw,a+..r,.rn+,,.��1�YMM:�M�;W".<sl'•.ryMr�.n'N� ,... ••: 1 's Lsf 4 h. ASSESSORS MAP : 2� TEST HOLE LOGS NOTES: 6T. PARCEL : -- -� �� --_ _ - I�,(� /jQ,�,V'U SOIL EVALUATOR : D v1 l) The installation shall comply witli Title V and 'town AgWA oard of FLOOD ZONE: I►�-�C� �'\�' l�"�-t��✓� --_ WITNESS :- 1 p Health Regulations. REFERENCE: `7 DATE: �uO 11,62t2 PAM 2) The installer shall verify the location of utilities, sewer inverts and septic PERCOLATION RA E:,-,C 2. WH I 1 components prior to installation and setting base elevations. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first v T11- I 4� TN-2 two feet out of the d-box to the leaching shall be level. 4) This plan is not to be utilized for property line determination nor any other -119»s_1kA()w1_ purpose other than the proposed system installation. c�1�1 I- 5) All septic components must meet Title V specifications. ! r1""�`Jt '�' _ _ 6) Parking shall not be constructed over 1110 septic components. V / 7) The property is bounded by property corners and property lines. LOCATION MAP Gv kip 8) The property owner shall review design considerations to approve of total V"y Aq,�'J design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed 1 approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall A be removed along with contaminated soil and replaced with clean sand per Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the / water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if - applicable. The proposed SAS is being installed below the water service SEPTIC SYSTEM DESIGN j line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such exists. -� _f�__ ___ � BEDROOMS AT GAL/DAY/BEDROOiA -3�GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer _ lines exiting the dwelling'prior to the installation. A14 4 SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting Title V requirements. GAL/DAY x 2 DAYS GAL USE IUD( GALLON SEPTIC TANK �t✓�C1�'�'lv4 ( X-ItA OF 'SOIL ABSORPTION SYSTEM 9 cis U 2 OU Clo(c" �j' 1�,�� ,J�j� I 1 IL , L� v NO.1o66 Y . �+ 1 �V4V PODU�� H2Z V►mot�✓ �G�STE��cO SIDE .'?REA: Z " [�jZx ' —�G/"� /TA ---� t� z� N � BOTTOM AREA: 1 Ot"1, A Z� S SYSTEM SECTION f� L� �Mr X t z'"ate �7v oGL Ml et d GAL D 7 Z - /C� �/ s SEPTIC TAt IC - 5`3 31TE AND SEWAGE PLAN ----- L OCAT I ON : PRl=PARED FOR : ::VIM P M l ti4-�-•.�c�1�} , SCALE : ( � U DAV I D Q . MASONIC DATE : 4� Z DBC ENVIRONMENTAL DESIGNS >, (_AST SANDWICH . MA w DATE HEALTH AGENT ( 508 ) 833— 2 I I7 Z