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Commonwealth of Massachusetts
Title 5 Official Inspection Form yy
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o o 7c� ra r✓'?at G d
Property Address 50
^
(NAV-PI or.0 Sty oiT 500d N-110 ,
Owner Owner's Name / /
information is C N am/`It „/ Oa�o-Tell f
required for every A
page. City/Town State Zip Code Date of nspe lion t
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Info ation / l , �l I3 a—
filling out forms I , G�Y'� I
on the computer,
use only the tab
key to move your Name of Inspector /` LL
cursor-do not
use the return Company Name ,op 1
key. 0 �O Ql
ICI Company Address f
CityrrowU653 A 0 State �40
;?C�— Zip Code
Telepho umberj License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
And.maintenanc f on-site sewage disposal systems.After conducting this inspection I have determined
that the s
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector V
ignature 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-Form
Subsurface Sewage Disposal System F o Not for Voluntary Assessments
wt A C- �C
Property Address /41 , i •
Owner Owners Name ry /i D/ /�A 3� g
information is
required for every 6e&i4i
page. Cityrrown State Zip Code Date WInspU
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) ;te sses:
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:
(Sur �v�.¢�� �ov�✓S (�
Sol/
2) 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):
t5insp.00c•rev.7252018 'ine 5 otlaal insperuon Fora:suosurace sewage Jisposa!system•Page 2 of 18
I
Commonwealth of Massachusetts
:. ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
141
Owner Owners Name
information is Ce,44,ro / t A,4 oa-`3a
required for every
page. CitylTown State Zip Code Date insp tion
C. Inspection Summary (cost.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc•rev.7/2612018 -itle 5 otficial;nsoecoon rom:SUDSLrfare sewage Disposal system•Page 3 of 18
Commonwealth of Massachusetts
�- Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Z00 Tare.wtaG
Property Address /J/
Owner Owners Name ��//''
information is required for every Ce✓i�y'/ A4 o ld'`3 L ✓- /9
required for every
page. City/Town IState Zip Code Date of ItApectidn
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ 2--� Backup of sewage into facility or system component due to overloaded or
lagged 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
Title 5 of`cia!!nspec5on-o�^SubsuYzce Sewage Disposal System•?age 4 0`18
t5insp.doc•rev.7252018
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/On 7re,
Property Address I ,.s F
Owner Owner's Name /�
information is i e�.�` e /� og4 3� � s � 9
required for every
page. CityfTown State Zip Code Date of Insf ectioif
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ❑ 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 1/2 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
tributary to a surface water supply.
❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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
indicates absent and the presence
laboratory,for fecal coliform bacteria i�
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 2000 gpd-
10,000 gpd.
❑ ❑ 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.
5) 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`yes3 or"no"to each of the following, in addition to the
questions in Section C.4.
Yes No
❑ �he system is within 400 feet of a surface drinking water supply
❑ he 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—IW PA)or a mapped Zone 11 of a public water supply
we Title 5 OfEdal Inspection corm. Subsurface Sewage Disposal system•Gage 5 of 18
t5insp.tloc•rev.7/262018
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/00 Taratme
Property Address F
zm&
Owner Owner's Name
information is Ce Ik A4
required for every �r,��Tii - /T Vd'
page. City/Town State Zip Code Date of Insp ction
C. Inspection Summary (cont.)
If you have answered "yes'to any question in Section C.5 the system is considered a significant
threat, or answered"yes'to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section GA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
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?
❑ Q/ s the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
❑ this inspection?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
/^ been determined based on:
(—✓'/ Existing information. For example; a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
-itle 5 Official inspection Form:subsurface sewage Disposal system•Page 6 of 18
t5insp.doc•rev.7/262018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/00 70 rcn w►a c Xci
Property Address !�
Owner Owner's Name (� ,`
information is
required for every
page. City/Town State Zip Code Date of Insp don
D. System Information Perm f f
.1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual).
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description: 0oo /' /rot, TG N if e L/
/ c
y
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection Yes No
information in this report.)
Laundry system inspected? ❑ Yes No
❑ No
Seasonal use? Yes
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ rYe�s No
Last date of occupancy: Date
isle 5 amaai inspecuor.Fcr-.Sucsu'ace Sewage Disposal System•Page 7 of 18
t5insp.doc-rev.7126/2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address /+
Owner Owners Name A4
information is Q 'e `
required for every N
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gaiions per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.).-
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
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 below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5irup.doc•rev.M82058 7ise 5 Oifdat insoeraor.=om:Subsurface Sewage Disposal System•?age 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
3 ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Zoo a rQ�"►Q ,�
Property Address
//y
W
Owner Owners Name ,/ �� / �� / 19
information is ,./ b
required for every v`
page. City/Town State Zip Code Date of Insp/con
D. System Information (cost.)
4. Type of Sy
Septic tank,a psoil 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):
Approximate age of all components, date installed (if known) and source of information:
QN �
Were sewage odors detected when arriving at the site?
❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron 40 PVC ❑ other(explain): l o f
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
'rtle 5„fcal inspection Form:suosurtace Sewage Disposal System•Page 9 of 78
t5insp.doc•rev.725/2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
/41 c✓s�
Owner Owner's Name /
information is �/�� n
required for every �w'"� "`Ile
T
page. City/Town State Zip Code Date of nspe on
D. System Information (cont.)
6. Septic Tank(locate on site plan): !/
i/
Depth below grade: feet
Material of suction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy or certificate) ❑ Yes ❑ No
Dimensions: `�
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 36
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
a
How were dimensions determined? -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
04e 111 010 7L 11"C-1- &-% 4. a#4C/
t✓1 00
t5insp.doc-rev.7126/2018 T ive 5 of iaai I-.specncn=o gin:suosurface sewage Disposai System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4�
Property Address 141 W
Owner Owner's Name
information is
required for every
page. City[rown State Zip Code Date of Ins ectio
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction.-
El 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.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
?rtle 5 ctt cla'inspecuon;:0—Subsurface sewage Disposai system•?age 11 of 18
t5insp.doc rev.712612018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I�) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/Q D a r/GWIG1 L /G
Property Address /—
Owner Owner's Name //,_� ,
information is �eol eyu//le �� ,'� S
required for every
page. CitylTown State Zip Code Date of Ins ctio
D. System Information (cons.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
n- sal S •?age 12 of to
�ca�:nspr.;uon pom. uos.:'ace Sewage Dispo stem y
t5insp.doc•rev.9R62018
Commonwealth of Massachusetts
r- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l"
/oo - 4 f-a
i.ty
Pro a Address
p
�s
Owner Owner's Name
information is •.f.�/f/ 6 /r' J �`'
required for every
page. City/Town State Zip Code Date oVInspe7ion
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required).
If SAS not located, explain why:
Type: `
leaching pits / number:
❑ lea ing chambers number:
I❑ leaching galleries number:
/� ?o � `f
I
trenches / number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativeialtemative system
Type/name of technology:
-itie 5 of iaai ins.Pe,-uon=cm:SUDSLITaCe sewage Disposal system•Page 13 of 18
tsinsp.doc•rev.7/2 6120 1 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Rii ktw` urface Sewage Disposal System Form Not for Voluntary Assessments
Subs g p y ry
100
Property Address
Owner Owners Name 6e94-1WVJ
D �information is `required for every Ci /Town State Zip Code Date of spe on
page. City[Town
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
o
ar-
4I)e 44 C- CG Qa v1 4�'►�C C/_
12. 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.):
Tore 5 Offcal inspeceen Fora:Sucsurtace Sewage Dtsposai System•?age 14 of 18
5insp.dOC•rev.726/2018
Commonwealth of Massachusetts
,i� Title- 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/00 TG ecavwi a c �
Property Address / / �' .
/�h/ /—
Owner Owner's Name 1
information is /__ /A /�``/� /f� co 6 3� �-
required for every �'�'r'�/
page. CitylTown State Zip Code Date of Ins ction
D. System Information (cont.)
13. 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.):
I�
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/00 —Fa 0-0101 d—
Properly Address
Owner Owners Name
information is
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or chmarks. Locate all wells within 100 feet. Locate where public water supply enters
the build' Check one of the boxes below:
❑ and-sketch in the area below
drawing attached separately
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t5insp.doc•rev.7/26/2018 Title 5^C'Mcal inspecaor,Fon:subsurface Sewage Disposal System•Page 16 of 18
Assessing As-Built Cards Page 1 of 2
C . TOWN OF BARNSTABLE
LOCATION `00 .1� ,i/"S lj SEWAGE/ 9�=ass'
YILLAGE_ YU! ASSESSOR'S MAP C. LOT ; d$
INSTALLER'S NAME G PHONE NO:
SEPTIC TANK CAPACITY
•�„v 7�' St'l„lr'
LEACHING FACILITY:(type)
NO.OF BEDROOMS 3 PRIVATE WELL OR UUBLIC WATERI
BUILDER OR OWNER P.b"e 'Z' �v4..Sc� �I��"
DATE PERMIT ISSUED:-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
j
K LSPr T
o►
i
3i
3�
/-Z LS e v^
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=169088&seq=1 12/27/2018
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y ry t5
/00 a ✓ av�aG ,Q�l
Property Address
Owner Owner's Name
information is w• r-�v` / �� �� / Q
required for every
page. CftylTown State Zip Code Date of/nsp 'on
D. System Information (cons.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells �.�,1- ,y-
Estimated depth to high ground water: 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)
�hecked with ioc Board of Health - explain:
l"s - 4- Sf fah 4 s
i Checked with local excavators; installers - (attach documentation)
❑ Accessed USGS database-explain.-
You must des ibe how you stabli]hed the high ground water elevation:
Vl �r►cl AN /4 -e,(M C71—
/oC-4-lrl l
o Av,, o� !'` I' / Off✓
go
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
5insp.d=•rev.7126=8 `Je 6 075aai insoe=on=om:supsuface Sewage Disposal System•Page 17 of 78
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/00
Property Address
Owner Owners Name
information is
required for every
page. City/Town State Zip Code Date of In pecti
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
certification: Signed & Dated and 1, 2, 3, or 4 checked
C. inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (F ure (Criteria)and 6 (Checklist)completed
D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Tice 5 otfoai irspe=on Foy Suosurface Sewage D,sposai System•?age 18 of 18
t5insp.doc•rev.7/2612018
No. O 3 Z_ t Fee y
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: /
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
9ppliLation for VsposAY 6pstrm Cunstrurtiun Permit
Application for a Permit to Construct( ) Repair(Y) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. IA Mq MA t_ )?0 Owner's Name,Address,and Tel.No.
As sessor's Map/Parcel FILL t
ul
Installer's Name,Address,and Tel.No. Designer's Name, dress,and Tel.No.
elIS IFA rl1, 0�'63 -STq onijA- ,16)
Type of Building:
Dwelling No.of Bedrooms 11Lot Size sq.ft. Garbage Grinder( )
Other Type of Building f� C .l t1 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow min.required) d Design flow rovided �7G` gpd
g ( 9 ) �� gP g P
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 applicable)
P&4'r ° � P i v� ,' 'y✓ ,�Frt I c ^.z7�k 14 rcT,
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 Boar of ealth.
Signed r�--�"�"' Date '
Application Approved by Date Zlei, , ,j
Application Disapproved by Date
for the following reasons
Permit No. 001 h— 0 3Z Date Issued
t •. .,;•,{_ -gyp
-,,No. t�� 2 Fee - 5
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for 30ispoBal *pstem Construction Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No./ 7j4 Mq MA(• j: Owner's Name,Address,and Tel.No. �ft
Assessor's Map/Parcel 1r ►�' L' !C V�L l a_ Vh
it wtAf !?Il llfl 1�
Installer's Name,Address,and'Tel.No. Designer's N me,Address,and Tel.No }
n
I)eneiiS Oecct, 08,�3 Jgq
Type of Building: ' o f(4 fy� t ,�' !l U 6
Dwelling No.of Bedrooms / Lot Size sq..ft. Garbage Grinder( )
Other' Type of Building ~�� �- 1 d' Nol'of Persons Showers( ) Cafeteria( )
Other Fixtures y
Design Flow(min.required) 3 3 9 --"-" gpd Design flow provided J L' 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 applicable)
�6Tv,- ew e10 1�- �,�yv f fA�n
r , d,e r�..i� a
li
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. E
S•gned Date
Application Approved by _ ^ ------ Date Zlq
�.
Application Disapproved by Date
for the following reasons a;
Permit No. 7016 Date Issued ,���2/�
�- - --------- ------ ------ ----- ---
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
rep(A((- Or Certificate of Compliance
THIS IS TO Q RTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(>A Upgraded( )
Abandoned( )by -Ptpw:s rA*1<{.,e
- - -at~f� �&jgAA4.4C .b has been constructed in accordance /
with the provisions of Title 5 and the for Disposal System Construction Permit Noll;, D 3" dated 01q12,r
Installer ! Designer r
#bedrooms A /r Approved.desi flo• ^m , gpd
r
The issuance of this permit shall not be con t>ued as a guarantee that the stem will funct`bn esigi ed.
Date �� 1-7 7 I InsLjor
__---_-__ -------------- -
- ---------'------------__,___.____-__----.--------------------------------------------------- - J -- --_-----.-
'ZO
No. !g 032, Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *pstPta Construction Permit �.
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at �t AgAQ-A(' �._FJ�17fi2-✓�!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 three years of the date of this permit.
Date Approved by L_
VII(a). Informal Hearing:
A . Philip Boudreau, Attorney, representing Mr. and Mrs. Robert Johnson, 100
Taramac Road, Centerville —discrepancy on number of bedrooms.
Philip Boudreau and Mr. Johnson were present. The former owner had the house from
1973-1988 during which time they remodeled from a 3-bedroom to a 4-bedroom by
removing one on first floor and built two bedrooms in basement. The Septic system was
expanded in the mid 1990's when contractors were advising to expand before new rulings.
This system appears to have capacity far above any 4 bedroom and was done before the
330 rule went into effect. It was done at a time when,they were allowed to install as big a
system as desired. Craig Mederios had a septic permit on it in 1995. He tied a leaching pit
to the leaching trench.
The basement windows are "knockout windows", the house is in a zone 2. It should be
inspected to see whether the basement rooms qualify as bedrooms.
Dr. Miller explained the options are: (1) have a health inspector meet with Mr. Johnson to
verify whether the basement room can qualify as a bedroom, and if it can qualify as a
bedroom, then, (2) get a good septic inspection and see if it is built as a 4-bedroom
capacity and the building code allowed it, then the board can approve a 4-bedroom, or (3)
put a 3 bedroom restriction on it.
rKQE ray
Town of Barnstable klz Barnstable
° Regulatory Services. Department U-AmedcaC j
IARNSTA$M
"39. � Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7015 1730 0001 4987 6407
December 12, 2017
JOHNSON,ROBERT E&JANET L
3476 STATEVIEW
FORT MILL, SC 29715 ,
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 100 Taramac Road, Centerville, MA was inspected on
09/21/2016 by Sean M. Jones, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Need to replace compromised pipe between septic tank and leaching pit.
You were originally ordered to repair or replace the septic system within one (1) year
from deadline date of October 4, 2016. Please contact Health Division at 508-862-4644
within sixty (60) days from the date you receive this notification to rectify this issue.
Failure to repair/replace the septic system will result in a scheduled Board of Health
meeting.on February 27, 2018.
PER ORDER OF TH OARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditional ly Passes Letters\I00 Taramac Road Centerville SECOND
NOTICE.doc
1
VII(a). Informal Hearing:
A . Philip Boudreau, Attorney, representing Mr. and Mrs. Robert Johnson, 100
Taramac Road, Centerville — discrepancy on number of bedrooms..
Philip. Boudreau and Mr..Johnson were present. The.former owner had the house from
1973-1988 during which time they remodeled from a 3-bedroom to a 4-bedroom by
removing one on first floor and built two bedrooms in basement. The Septic system was
expanded in the mid 1990's when contractors.were advising to expand. before new rulings. .
This. system appears to. have capacity far above any.4 bedroom and.was.done before the.
330 rule went into effect. It was done at a time when.they were allowed.to. install as big a
system as desired. Craig Mederios. had a septic permit on it in 1995. He tied.a leaching pit
to the. leaching.trench.
The basement windows are "knockout windows", the house is. in a.zone 2. It should. be
inspected to see whether the basement rooms qualify as. bedrooms.
Dr. Miller explained the options.are: (1) have. a health inspector meet with Mr. Johnson to
verify whether the basement room can qualify as a bedroom, and if it can qualify as a `
bedroom, then, (2) get a good septic inspection and see if it is built as a 4-bedroom
capacity and the building code allowed it, then the board.can approve a.4-bedroom, or (3)
put a 3 bedroom restriction on it.
BOUDREAU AND BOUDREAU, LLP
Attorneys at Law
396 NORTH STREET
HYANNIS, MASSACHUSETTS 02601
Philip Michael Boudreau Telephone:(508)775-1085
Mark H. Boudreau Telefax:(508)771-0722
E-MAIL:philGboudreaulaw.net
June 14, 2006
Hand Delivered
Thomas A. McKeon
Town of Barnstable—Health Department
200 Main Street
Hyannis, MA 02601
Re: Mr. and Mrs. Robert E. Johnson
100 Tarmac Road, Centerville, Massachusetts
Dear Mr. McKeon:
Per our conversation this afternoon, I represent Mr. and Mrs. Robert Johnson relative to, s
their home located at the above-referenced address.
Recently, during the course of the Johnsons listing of their home for sale, they were
advised that it is described as a three bedroom home by the Barnstable Assessor's office. Upon
further examination, the Johnsons discovered that the Board of Health's records also indicate that
the home has only three bedrooms.
My clients purchased the home in question in 1988, at which time it contained four
bedrooms, two on the first floor and two in the basement. An Affidavit of Robert E. Johnson
attesting to these facts is enclosed herewith. Also enclosed is an Affidavit of George L. Norris,
the owner of the home from 1973 to 1988, setting forth the circumstances of his renovation of the
home from 1983 to 1985, at which time he converted one of the three bedrooms on the first floor
to a dining room and added two bedrooms, a family room, a laundry room and a half bath in the
basement.
From all of the information presented, it would appear clear that the home contained four
bedrooms before the so-called"330 Rule" was introduced to this area by the Town and that it has
remained in that configuration to the present.
I understand that the Board of Health has requested that this information be presented at
one of its meetings. Accordingly, I hereby request that this matter be placed on the Board's
agenda for discussion at its July 18, 2006 meeting. I have a hearing in Boston earlier that day
and would appreciate it if you could schedule me towards the end of the meeting.
Thank you for your assistance in this matter. If you have any questions or need anything
further, please let me know.
Sincerely,.,w.,.3 ry,. ....... ..
Philip Michael Boudreau
PMB/hcg
Enclosures
I
I
AFFIDAVIT
I,Robert E. Johnson, of Centerville,Massachusetts, after being duly sworn,do depose
and say as follows:
1. That my wife and I live at 100 Taramac Road,Centerville,Massachusetts,having
purchased said property from George L.Norris and Sharon M.Norris on November 30,
1988. When we purchased said property, it had two bedrooms on the first floor and a
finished basement, which included a family room,two bedrooms, a laundry and mudroom
and a %2 bathroom.
2. That the real estate broker's listing sheet for the property at the time of our purchase
indicated that the home had four bedrooms and a true and correct copy of that listing
sheet is annexed hereto.
3. That we have occupied said property as our home continuously since 1988 to the present
and the home is still in substantially the same configuration as when we purchase it and it
still has a total of four bedrooms.
SUBSCRIBED AND SWORN TO under the pains and penalties of perjury this day
of April, 2006.
Robirt E. Johnson
COMMONWEALTH OF MASSACHUSETTS
Barnstable, ss.
On this)�day of April,2006,before me,the undersigned notary public, personally
appeared Robert E. Johnson,proved to me through satisfactory evidence of identification to be
the person whose name is signed on the preceding or attached document,and who swore or
affirmed to me that the contents of the document are truthful and accurate to the best of his
knowledge and belief.
Notary Public
My Commission Expires:
DAWN L.CORCORAN -
' Notary Public - -
Commormedh of Massachusetts
My Commission Expires 6/2/2011
*RE'' E PLOT PLAN ON REVERSE
C4PE COD �
BOARD OF REALTO S
REALTOR" b a
Listing ' orn. ❑
NoUnfurn
1Q8:............... $
Village ..........Cent f:eol...................................
Type House....K�Fh................................. Age ......U.
No. Rms. ......a.......Bed Rms. .....4.......Baths.........-1 z.... :
Lot ....47.1.. ....x........ ... ....... Area ....:....45:... .........
.e
•Landscaped .yes-new,.Garage....none... ........_.......`:.Fireplaces ....LR.........Porch..aePX.....:.Breezeway..............
Basement.w<Full (N Partial ❑ Cape Cod ❑ I�!undation .....PAtr:ed..cancrete..............
Heating,System FHA ...... .............. ................. .....�uel Used _..gas....-Hot Water By :....gas._.... ....... .....
Roof ... Phal.t............... Siding shingles/T1.1.1::.. ..Cc31idition: (Ext.) ............... (Int.) exc.
Insulation: Cap Walls U .... Screens D*-s Windows ® Storm: Doors ® Windows
- st Far __weer..island.ea n..kitchen•4 formal—dining{9 13), �P mina
P1R(12xi�
full bath,...f itepiaced.-Liv..ng..room 12xl5. ,...bjdr'oom.. 9x12
R .I,E1/EI,..-..F T.y.:raam w/wood/cDa1:..stoV,e, .bedroom(.9xl7�,...bedroom(11xl3.).,....-
_LQWZ2..bath►..lawny raom� W ]� i�t baszn�:nt. ..... .....
Cess. 0 Building Dimensions . . . x .. .... Title Reference Book .....3358. .
Town ❑ Tank ❑ Town ; Street
Scxver: Septic } Gas: Piped [ Water: Well [D Mee..' .. . .. _ Paved ...Ye,5.........Zoning ...........
Grade
DiAnce from: Beacl-tes.... .3..M......... Stores .... .Drive.._.:.Churches .......Drive.............Schools: High.........Bus
Assessed Value TT Taxes Assessors 169/088
Land Buildings Total General N Fire Water Other Total
School
S 20,100 $ 52,90,2____ $ 72.1 — v - - _ _t 9.;1
S $ $ $ 74 2
s �.
LE MIDE 1 —
Orig. Mortgage C ;::- ........... Unpaid Mor.tgagc Taal. . ............................... ....... Aare ... %
Monthly Payments S _...........:....... .... .... ............ Tern-;:. . ........... ............. ....Approx. Cash Req'd $...........;...,,. .......
Mortgagee AIey?,? itchenl...And:erson..wi-i dows*. al :new..ca t5,••all• new..floor ng,-•all.,newly............
Comments .rewdel.ed,...new..landscaping_. ..]Qxlt> shed.,. cable••TV..................:.......................
..
................LGtnTER.LEVF; ..has..electric..heat.,in . drooms..in..addition..to..FHA..heaT:�....Qpe;1..f1ooK..gla,,:,
lnformotion herein is believed to be accurate but is n # w:orrdnted._. country flail'.
AFFIDAVIT
I, George L.Norris, of Marston Mills,Massachusetts,after being duly sworn, do depose
and say as follows:
1. That my wife and I purchased the home at 100 Taramac Road,Centerville,
Massachusetts, on August 16, 1973. When we purchased said property, it had three
bedrooms on the fast floor and an unfinished basement.
2. From 1983 to 1985,I remodeled the home by converting one of the first floor bedrooms
to a dining room and finishing the basement, adding a family room,two bedrooms,a
laundry and mudroom and a V2 bathroom therein. All of this work was completed in
1985, at which time the home had four bedrooms.
3. In 1988,when I sold the home to Robert and Janet Johnson, it still had the four
bedrooms.
SUBSCRIBED AND SWORN TO under the pains and penalties of perjury this /day.
of April,2006.
eorge L.N 's
COMMONWEALTH OF MASSACHUSETTS
Barnstable, ss.
On this2-�day of April, 2006,before me,the undersigned notary public,personally
appeared George L.Norris,proved to me through satisfactory evidence of identification to be the
person whose name is signed on the preceding or attached document, and who swore or affirmed
to me that the contents of the document are truthful and accurate to the best of his knowledge and
belief.
Notary Public
My Commission Expires:
DAWN L.CORCORAN
x Notary Public _
Commonwealth of Massachusetts .
My Commission Expires 6=011
L
WE r
ti
Town of Barnstable darnstable Regulatory Services Department j e`ca�j
B"NSTABM I 'm
Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2847 8971
October 4, 2016
Johnson, Robert E&Janet L
100 Taramac Road
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 100 Taramac Road, Centerville,MA was inspected on
09/21/2016 by Scan M. Jones, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Need to replace compromised pipe between septic tank and leaching pit.
You are ordered to repair or replace the septic system within one (1) year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Tho& s McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letteis Septic Inspection Failures or Future Evl\100 Taramac Road Centerville.doc
Town of Barnstable
♦ a
a
+ IARNSTAHLE,
Regulatory Services Department
Public Health Division
200 Main Street, Hyannis MA'02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code
§360-9.1)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHERIII^ 1
Q(.� IuCe a,M fodVl! P� , e �J�Ivvice.h Je �z ���� 'q d
Repair deadline: a r-
Q:\SEPTIC\DEADLINES TO REPAIR FLED SYSTEMS.doc
\� Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson ;.
Owner Owners Name 'r
information is
required for every Centerville ✓ Ma 02632 9/21/2016
page. City/Town State Zip Code. Date of Inspection OD
1-`
t�
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 S f 75--
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S.M.Jones Title V Septic Inspection
Q Company Name
74 Beldan Ln.
Centerville Ma 02632
Citylrown State Zip Code
774-248-4850 smjonestitle5@gmail.com SI4522
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
9/21/2016
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:5ubudace Sewage Disposal system•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is Centerville Ma 02632 9/21/2016
required 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:
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•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owners Name
information is required for every Centerville Ma 02632 9/21/2016
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):
Orangeburg pipe from tank to leach pit is compromised and needs to be replaced
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is required for every Centerville Ma 02632 9/21/2016
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 day flow
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is Centerville Ma 02632 9/21/2016
required for every
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation_
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is required for every Centerville Ma 02632 9/21/2016
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?
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): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 gpd
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is required for every Centerville Ma 02632 9/21/2016
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15203): 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 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
owner Owner's Name
information is Centerville Ma 02632 9/21/2016
required for every
page. Cityfrown 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool.
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is required for every Centerville Ma 02632 9/21/2016
page. CityrFown State Zip code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
system installed 1973 per town records, leaching trench added 1996
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gallons
6„
Sludge depth:
l5ins 3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title. 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is Centerville Ma 02632 9/21/2016
required for every
page. Citylrown State Zip Code Date of Inspedion
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 3
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers,took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank needs to be cleaned now for maintenance and should be done every 2 years after. Tank was
structurally sound, inlet cover is on riser at grade. Outlet pipe is rotted and needs to be replaced.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is Centerville Ma 02632 9/21/2016
required for every
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3l13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 11 of 17
gj
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is Centerville Ma 02632 9/21/2016
required for every
page. Citylrown 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 N/A
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box,etc.):
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is Centerville Ma 02632 9/2112016
required for every
page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1x1000
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1-70'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
s.a.s. consists of a precast leach pit with a 70' leach trench off of it.Water level in pit was 8" below
outlet pipe to leach trench with a stain line only I"higher. Cover is on a riser.
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is Centerville Ma 02632 9/21/2016
required for every
page. cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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 Farm.Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
-- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is Centerville Ma 02632 9/21/2016
required for every
page. CityrTown 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
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t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of V
r
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is required for every Centerville Ma 02632 9/21/2016
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'+
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:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map_
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 17
. \ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�— 100 Taramac Road
Property Address
Robert Johnson
Owner Owner's Name
information is required for every Centerville Ma 02632 9/21/2016
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 or 17
ii
r
AFFIDAVIT
I, George L.Norris,of Marston Mills,Massachusetts,after being duly sworn, do depose
and say as follows:
l. That my wife and I purchased the home at 100 Taramac Road,Centerville,
Massachusetts, on August 16, 1973. When we purchased said property, it had three
bedrooms on the first floor and an unfinished basement.
2. From 1983 to 1985,I remodeled the home by converting one of the first floor bedrooms
to a dining room and finishing the basement, adding a family room,two bedrooms, a
laundry and mudroom and a V2 bathroom therein. All of this work was completed in
1985,at which time the home had four bedrooms.
3. In 1988,when I sold the home to Robert and Janet Johnson, it still had the four
bedrooms.
SUBSCRIBED AND SWORN TO under the pains and penalties of perjury this oyday.
of April,2006.
eorge L.N 's
COMMONWEALTH OF MASSACHUSETTS
Barnstable, ss.
On this day of April, 2006, before me,the undersigned notary public, personally
appeared George L. Norris,proved to me through satisfactory evidence of identification to be the
person whose name is signed on the preceding or attached document,and who swore or affirmed
to me that the contents of the document are truthful and accurate to the best of his knowledge and
belief.
Notary Public ..
My Commission Expires:
DAWN L.CORCORAN
x Newry Pnb11C - -
C®mmonwec-11h of Nassachasntts _
My Commission Expires 6=011 � " _
i
AFFIDAVIT
I,Robert E. Johnson,of Centerville,Massachusetts, after being duly sworn,do depose
and say as follows:
1. That my wife and I live at 100 Taramac Road, Centerville,Massachusetts,having
purchased said property from George L.Norris and Sharon M.Norris on November 30,
1988. When we purchased said property, it had two bedrooms on the first floor and a
finished basement,which included a family room,two bedrooms,a laundry and mudroom
and a %z bathroom.
2. That the real estate broker's listing sheet for the property at the time of our purchase
indicated that the home had four bedrooms and a true and correct copy of that listing
sheet is annexed hereto.
3. That we have occupied said property as our home continuously since 1988 to the present
and the home is still in substantially the same configuration as when we purchase it and it
still has a total of four bedrooms.
SUBSCRIBED AND SWORN TO under the pains and penalties of perjury this 2 day
of April,2006.
Robirt E. Johnson
COMMONWEALTH OF MASSACHUSETTS
Barnstable, ss.
On this.1�day of April,2006,before me,the undersigned notary public,personally
appeared Robert E. Johnson,proved to me through satisfactory evidence of identification to be
the person whose name is signed on the preceding or attached document,and who swore or
affirmed to me that the contents of the document are truthful and accurate to the best of his
knowledge and belief.
aw"r
G _
,Notary Public
My Commission Expires:
DAWN L.CORCORAN -
Notary Public -
Com nr ny.eapth of Massachusetts
- My Commission Expires 6/2/2011
Jr
*RE—ISSUE PLOT PLADi ON REVERSE
CAPE COD
BOAF 4 REALTQS ,
REALTOR"'
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Listing s � ; Furs. Q
No, XR
Unfurn.
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Village ��nte x•.
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TypeHouse.... ..h................................. Age ......7 4..
No. Rms. ......8.......Bed Rms. ....,4...... Baths..........1 z....
Lot ....4.71.........x........ ........... Area ..........45.. .
.Landscaped .Yes-ne`;tly".........Garage....none. .. ....... ........:..Fireplaces ... 1. .........Porch.................Breezeway..............
LR deck
Basement: Full [N Partial ❑ Cape Cod r 1':;undation ...:.Poured..aanGrete... ......... .........................
Keating System ........... F ................I................... . .. .._t�-uel Used _.gas......Hot Water By .....gas................I......
` Roof ..asphalt............... Siding zhingyes/Tll:l.......Ci,.tidition: (Ext.) ....exc.............(Int.) exc
Insulation: Cap Walls .............:..........Screens: Do. Windows ® Storm: Doors ® Windows (Z
.l_f Flcior ' formal .dining{ftl3:).,...... J. .2x1'2}:.--. J4,1►t=zng....
full bathr.Jireplaced.livin uoomj.12xl5•).,..b.adroom .�
1Kenter..island.eat�Ln" kitchen fo_
........ .......... ... g.. (,gxl2):....::......... :.. . .:..::,
.TER .LEVEL_-..Tamely...roam.,W/.wood/.coat..stove.. -lBedroom(.9xl7.),,..bedroom(llxl3.).,......
..bath, laundry ..... ..... . ....... ................................•....... ... ......... ....•.....
Cess. E] Building Dimensions . x ... Title Reference: Book.. ..3358...
Town ❑ Tank ❑ Town :W Street Page......13 .....
S,1Nver; Septic } Gas: Piped %'Water: Well i_} Elec. .. _.. Paved ...YeS.........Zoning .....................
Grade
Iiis nce from: Beaches.....3.M......... Stores Dri.ve. ... Churches .......Drive_..........Schools: High..........Bus
Assessed Value_-'—_ Taxes Assessors 169/088
Schoo; ---
Land Buildings Total General cJ Fire Water Other Total
. �
S 20,100 $ 52,Ov^0 $ 72,10� S $ $ $ 749:.12 -
f�- — -- -- 2
— R ly INSIDE I f
Orig. MortgageS: -_.. Un aid hfort 1 i I3:�1. $ . ........ ......:.............:. .....
p g..g'; ............ ..... -I'�aiC %
haonthly Payments ......................... ....... Term; . ....Approx. trash Req'd $.:................
!Mortgagee NeW ?.?tchen.,..Ancierson.mit dows., .ad._-new..carpets,,•all:.new-•f l oors.ng t-,all.•newly.... ......
Comments re d led,...new..landscaping_...,1Oxlt3:.stied., cable..TV.................................
_........ ...........LOvER.LEVF;i..has":electric."heat in.tsedrooms..in..addition..to..FHA..heat.....gpen..floor..pka
Information herein is believed. to be nccurote but is n4,t warranted.. country flair.
TOWN OF BARNSTABLE �'
LOCATION ��0 /y1'Ap SEWAGE # q
VILLAGE <ftP+ C rk I e- ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
g ���`
LEACHING FACILITY:(type)/°00�d;-P�cp�dJ (size).,-e z a.'' tawk
,,NO. OF BEDROOMS PRIVATE WELL OR�UBLIC WATE
BUILDER OR OWNER ,/���
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: / 6
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABL.E
Apphration for Diipoiall Work,i Tonitrnr#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
100 Taamac Rd Centerville
.................•---•--.............------•------••---......--------------------------••----••••. •---•-•--•--------••-•--••---------------------•-•----...........................................
Location-Address " or Lot No.
J. Johnson � _
------------- p�q -
Ow r /v r Address
a 49.E Se e P.O. Box 1.089 ntery le.........
Installer Address
UType of Building 3 Size Lot............................Sq. feet
., Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons------------------------.... 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 ( )
1..1
Percolation Test Results Performed by........ ....................................... ......................... Date........................................
,a Test Pit No.- 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.....................
444 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
9 .....---•--------------------------------------------------------------------------------•-..............----------••-•---•--•---............----•-------..--
0 Description of Soil-----sand---------------•--------------------------------------------.....------------------------------------------------------------------------------..-----
x
V .....••••---•...............••---••••-•••••----•------•---•----•---------------•----••--••-•••-•---••--•-•----------------------------...--------------------------------•-----------••-•......---••••_..
W
.....................................................----------------------------------------------------------------------------------------------
x install an additional
Nat re of Re a'rs Alteration —Answ r v� en applicable.-.--..................................___._..____:__:..::....:.....:........._..__._._..__.....
U MenepYcaKed precas leac Ipi I..., -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia e has b issued b the board of health.
Signed ............ .............__.._...y
--------------------------------------
Due
Application.Approved By .............. J �' - _.... ... - ...... ....
Application Disapproved for the following reasons- -- -------------------------------------------------------------------------------------------------------------------------
............... ................................._.._.......-----------------------....._-------.............---------------------------...-----..__............................................ ----------------------------------.:..
Permit No. ........(J� $. Issued �r"��t ......................
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of CIImyliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x)
bw-..E.R._.Rc� insc� + .S.er�ti-r..--ce v-i-ee----------------------------------------.._..._._-------------------..-----...-......--. .--.-------------_
Y InstaI lei
100 Tatamac....Rd-.. .Centervil.le----------------------............................................................._.........-....-----..------------------------.
at ..........................
has been installed in accordance with the provisions of TITI.E 5 cif The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..---y -. 5��� --------- dated ...-.. .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE 1 '� 1 '- - Inspector ---------------------------- ------�;---
------ -
-- -- ------------�--m--._—_._r--_--._,.------------_.—_,4�_._---- - __ _---__---J
J. Johnson THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 30.00
.....................� FEE........................
Ripisal Workii Tomitrution f rrmit
W.E. Robinson Septic Service
Permissionis hereby granted------------------------ --•--•---------•---------••--•-•----------------------••----------------------.......------------................
to Construct (( ) or Repair (( x) an Individual Sewage Disposal System
i Ot7 2atamac � d Centervillw
atNo........ ••-••-•----•-•-•-----••-•---•-----...••-••................ ......•--•.....-•--•--•-•----•-----------------•------------•------••----------------.....---•---•------••-..............
Street
as shown on the application for Disposal Works Construction Permit No. --.---------- Dated...... ........
............................... Board of Health
DATE..................... `..
FORM 36508 HOBBS A WARREN.INC..PUBLISHERS
.�_, _
- Fps 30.00
.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
, pphratiun for Ditjipuittl 3Vurk.i Tunutrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
100 Tagamac Rd Centerville
............................................•-----------•--••-------••••-•---•--------------.._... .------------•-•----•-•-••-----•---••........-----•-••-•------------..._...._.....--------....--•-
J J. Johnson Location-Address or Lot No.
y'�y/ y�y
a Own r /.',l!�e ��3L1�� � Address .....
g^h�^cam Sept�i.,c._Se�we P.O. Box 1089 Centerville
W • _ _._ .
Installer Address
Type of Building 3 Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria
dOther 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 ( )
aPercolation Test Results Performed by------- ------------------------------------------------------------------ Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-_----._-_-_---_-_--.
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ----------------------••--------•---••-----------------•-•-•--------•---------------....------...........---------•-•-•--......--------....----..............
0 Description of Soil.......sand......................................................................................---------------------------------------------------------------
V ---------------------------------------•--••----------------------------------......-------••----------•------•----••-----•••--------•--------------•-•-------•.....--••--------•-•---------•-----......
W `
------------------------------------------------------------------------------------------------- --------------o----------- -------- ------------
x install an a1 V. Nature of Rack or Alterations—Answer when appli�ble________________________________________._.......��?�8 ...........___................
s�c..xzep�tcxect precast ------------ '
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the/board of health.
Signed .. . ...........:....C -''.,t^� YV�ca :{L2-� �v
\..... ..........................................
lV .................Dace....-.............
� Dace
Application.Approved By ...............`�. ,•..,. .4 - :.--------------- .-- --=5''.:.�7�......
CJ... J -..... ......
Application Disapproved for the following reasons: ..... . . . ........................................ .. ...........................................
................................. ............. ............................... - ------------------------- -----------------D....are......------------
C�
Permit No. ..... .�....--.7 9 �- ............... Issued ..........�- 4
Dace
10 A
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)
hereby certify that the application for disposal works
construction permit signed by me dated , concerning the
property located at 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 stem
P P P p Y
• The observed 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.
SIGNED : DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
j:cert
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TOWN OF BARNSTABLE
LOCATION �y R/� �' SEWAGE #
VILLAGE �G✓ �' ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY / t, 00
LEACHING FACILITY•(type) /"00 Gjc.�ct (size).Z gocl,iv,� -aNcl+
NO. OF BEDROOMS PRIVATE WELL OR(UBLIC WATERI
BUILDER OR OWNER Pahlei—� �0 4- S cf%
DATE PERMIT ISSUED: 3�L'g/l
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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