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HomeMy WebLinkAbout0049 TELLEGEN TRAIL - Health 49 TELLEGEN TRAIL CENTERVILLE _r A = 230 148 Ow ord, NO. 1521/3 ORA 10% i 4 �pf IME T Town of Barnstable " ABRegulatory Services MIRNSTM Thomas•F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 DATE: Fla / NUMBER OF PAGES TO FOLLOW: I TO• FROM: PHONE: PHONE: (508)862-4644 /-goo- Gsl FAX PHONE: FAX PHONES (508)790-6304 CC: NOTES/COMMENTS: J:\Fax Form.doc III WALL SEPTIC SERVICE P.O. Box 771 • Harwich Port, Massachusetts 02646 508-432-4908 (Harwich) • 508-778-4908 (Hyannis) • Fax (508) 430-1510 1-800-281-4908 INVOICE TO: DATEOF-SERVICE: TAJ2 SEPTIC TANKS,CESSPOOLS GREASE TANKS&TRAPS PUMPED,CLEANED&REPAIRED SEW��� / r/�G�L ��� NSPE TIONS SERVICE FI JOB SITE: 3 d TITLE 51NSPECTIONS&CERTIFICATIONS LICENSED DRAIN LAYERS CALLUS FOR NEXT SERVICE DESCRIPTION CHARGES BALANCE BALANCE BROUGHT FORWARD Cesspool pumped&cleaned Septic tank pumped&cleaned Grease tank pumped&cleaned Leaching facility pumped&cleaned Tight tank pumped&cleaned : Sewerooter service :i Extra hose { Extra labor Extra locating&uncovering time Town Disposal Fee In ection of septic system ^ iscellaneous JOB DESCRIPTION: s r 1 �i SALES AMOUNT Signature ON ACCOUNT Afi charge of per month(24%annually)will be applied to BALANCE DUE un- balances.Any collection fees,legal fees or court costs to be paid by customer. �ou TERMS: PAYMENT DUE UPON COMPLETION OF SERVICE. By placing an order for service,the customer acknowledges that Wall Septic Service will hold no responsibility for conditions unknown or not reasonably identifiable at the time of service, including but not limited to damage to underground sprinklers, or utilities when locating and/or digging. Town of Barnstable y�P tio� Regulatory Services sAs Thomas F. Geiler,Director 9�A •0� Public. Health Division tEp Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 10 2007 Mr&Mrs Dennis Burgess 49 Tellegen Trail Centerville,MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 49 Tellegen Trail, Centerville, MA, was last inspected December 291h 2006 by Jeffrey M. Wall, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system"Fails"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Garbage disposal must be removed from the kitchen sink. The septic system does . not provide adequate capacity for a garbage disposal. Also, no riser proved above the septic tank inlet to bring the cover to within 6" of grade. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE TH DEPARTMENT Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health -� COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: GLF Tee/am en Td2 IL* Owner's Name: 19ulZ6e5 S Owner's Address: !Z&&I e Date of Inspection: Name of inspector: (please print) / This inspection Is based on criteria defined in Title V Company.Name: i I .0 Code 310 CMR 15.303.My findings are of how the system Mailing Address: 4. 0 - Is performing at the time of the inspection.'My inspection does not iml f}0.7 t;� any warranty or guarantee of the longevity of the septic Telephone Number: S-02- 3 O system.\nd any of its components useful life. CERTIFICATION STATEMENT I certify that 1 ha ve personally inspected the sewage disposal system at this address and that the information reported lt4low` lrrue, aci urate and complete as of the time of the inspection. The inspection was performed based on my Tining�and expt rience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved systeri inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ;'ram asses tV Conditionally Passes Needs Further Evaluation by the Local Approving AuthontN —� Fails -flsptkstor's Sjgnature: Date: The system.inspector shall s 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 0,IL6e 6&4�t eide 9 Derr—/3t° 1<7C/'nJV e ��,M j�2 �T �r .'`"`��'C, �e- Sj�S7'�wt. iS �aT ?�2S'. 6.►c� .71 T 73 41-).,J •••'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in.the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 r rage z of 1 j OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: p.A �rwrjj Owner: P-44 Date of Inspection: ` m A Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys em 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: One or more system components as described in the"Conditional Pass"section need to be replaced or ,rcpaire The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no o of determined (Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is me d over 20 years old* or the septic tank (whether metal or not)is structurally unsound,exhibits substantial in i tion or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a comp ing septic tank as approved by the Board of Health. •A metal septic tank will pass inspection ' it is structurally sound,not leaking and if a Certificate of Compliance indicatin- that the tank is less than 20 years is available. ND explain: Observation of sewage backup or break out or high tic water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribu ' n 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 pip ). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: ' Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fail' to protect public health, safety or the environment. 1. Sys m will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the syste is not functioning in a manner which will protect public health,safety and the environment: I — Cessp of or privy is within 50 feet of a surface water Cesspoo or privy is witbin 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the oard of Health (and Public Water Supplier, if any) determines that the system is functioning in a mann that protects the public health,safety and environment: _ The system has a septic tank a d soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a face water supply. _ The system has a septic tank and SA d the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS an e SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more frorh a private water supply well*'. Method used to dete%in distance This system passes if the well water analysis, perfortne t a DEP cenified laboratory, for coliform bacteria and volatile organic compounds indicates that the w is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attach d to this form. 3. Other: 3 f Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) Property Address: ,Q Owner: ry-)C, - Date of Inspection: E. AA. (j D. System Failure Criteria applicable to all systems: You must indicate 'yes"or"no"to each of the following for all inspections: Yes ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No 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 l/ Liquid depth in cesspool is 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 . _ /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 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. 1 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. To considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You must indtc either"yes"or"no"to each of the following: (The following critert ly to large systems in addition to the criteria above) yes no _ the system is within 400 feet o face drinking water supply _ _ the system is within 200 feet of a tributary to rface drinking water supply _ _ the system is located in a nitrogen sensitive area(Interim 11head Protection Area— 1WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner- Date of Inspect o: C1 HOC, Check if the follo—ine have been done. You must indicate 'ycs" or"no" as to cach of the followine: Ycs No t— 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? ✓ as the system received normal flows in the previous two week period Have lame volumes of water been introduced to the system recently or as art Y Y p 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 ? �iJGGccc�ir►S ✓ Were all system components, 5yc- ding the SAS, located on site? —Z_ 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 faciliry 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. 51/7oe)4peCZM. 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)J 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: A--n r�J Erna Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310-CMR 15.203 (for example: ) 10 gpd x N of bedrooms): 33 0 Number of current residents: © - Does residence have a garbage grinder(yes or no): U 26 Is laundry on a separate sewage system (yes or no):No (if yes separate inspection required) Laundry system inspected(yes or no): t� 9 goo- Seasonal use: (yes or no): Water meter readings, if available usage ears 2 lastd .�ov sc �3 oav T�s-= zou G ( Y Sump pump(yes or no):,,,Id d Last date of occupancy: _2o o 6 Typ tablisb anent: Design-flow on 310 CMR 15.203): gpd Basis of design flow (se ons/sgfr,etc.): Grease trap present(yes or no):— Industrial waste holding tank present (yes o Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: ��S S�/SrP,�-t itJ -euCGZ z� e0c Was system pumped as pan of the i sn pe is of n (yes or no): �Jo If yes, volume pumped:--a - gallons -- How was quantity pumped determined? /F} Reason for pumping: TYI OF SYSTEM OF 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): A7roximate age of all components, date installed(if known)and source of information: L,�S�i/eon f � Were sewage odors detected when arriving at the site(yes or no): /1,0 6 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: TeA Owner: Q Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: ee'-e­ - � i Materials of construction:_cast iron _✓40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): �o,•,� f�PF�AGz �lti- er�TP�G�PnT.io!Lo o a� .0 o emu. D Prr C 2 F Le 1'9'1­('H6 2 . SEPTIC TANK: (locate on site plan) Depth below grade: /,g ToP Material of construction:;i�concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) 11 Dimensions: 2�j� Sludge depth: 7 ' �i Distance from top of sludge to bottom of outlet tee or baffle: .2 7 Scum thickness: ✓2 Distance from top of scum to top of outlet tee or baffle: S Distance from bottom of scum to bottom of outlet tee or baffle: `3 3 How were dimensions determ - SAS Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet inven,evidence of.leaka2e,etc.): alla s anj Depth belo e: _ Material of construe concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4q ( Owner Date of Inspection: t.ion)(locate on site plan) Depth below e: Material of construct concrete metal fiberglass_polye[hylcne other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locare on site plan) �c� Depth of liquid level above outlet invert: /V 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakagc into or out of box,etc.): /30>< �7: rkine or er _ Arking order(yes or no): Cote condition of pump chamber,condition afap�d app�urten'alces,etc.): 8 i Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address:4B n Owner: 41�z Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why:. Type jesching pits,number:_ leaching chambers, number: 3 t3 leaching galleries, number: S7-0,0 2 e leaching trenches,number, length: ��� ��GocJ G�a`� . leaching fields,number,dimensions: To Toh overflow cesspool, number: y 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.): !(irk c 50 �. O L � Number and c uration: Depth—top of liquid to vert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of consa-action: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, conditt vegetation,etc.): Materials of cons Dimensions: Depth of solids: Comments (note condition of soil, signs of hydrau ' ure, level of ponding, condition of vegetation,etc.r 9 Page 10 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:L 7�.. WA .t R Owner: Date of Inspection: t- -5,Ct la 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. Air i S �- Utit/ Sa t_ f}�g�PT�n SysTew► 3 �clT�h 4y:: � to Page I I of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: m� Owner: Date of Inspection- (A SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water ' � feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked,date of design plan reviewed: ,,Observed site(abutting property/observation hole within 150 feet of SAS) /J ✓Checked with local Board of Health-explain: Z—>e fC`cttGnGQ, --- �,,,ehecked with local excavators, installers- (attach documentation) Accessed USGS database-explain: rw,o -7-o- CJf>}tCl���So<c,2fes' �+.iy . You must describe how you established the high ground water elevation: i -e7C oyrl -� I1 Town of Barnstable ` P�OFINE taY Regulatory Services B ; ABLE Thomas F. Geiler, Director y MASS. g A 3639. .• Public Health Division. Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 10 2007 Mr&Mrs Dennis Burgess 49 Tellegen Trail Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 49 Tellegen Trail, Centerville,MA, was last inspected December 291h 2006 by Jeffrey M. Wall, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system"Fails"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Garbage disposal must be removed from the kitchen sink. The septic system does not provide adequate capacity for a garbage disposal. Also, no riser proved above the septic tank inlet to bring the cover to within 6" of grade. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE TH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health COMMONWEALTH OF MASSACHUSETTS ; EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS t DEPARTMENT OF ENVIRONMENTAL PROTECTION Y TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFI.CATION // Property Address: �L9 Tei-t e rn P.g 77? ,L d'o` Owner's Name: e�/Z6C5 S Owner's Address: !2f.,+=e Date of Inspection: / r}9 D Name of Inspector: (please print) This Inspection is based on criteria defined in Title V Company.Name: i r 'e Code310 CMR 15.303.My findings an of how the system Mailing Address: ' Is performing at the time of the inspection.'My Inspection does not iml any warranty or guarantee of the longevity of the septic Telephone Number: SO Q- 3 O system.and any of Its components useful life. CERTIFICATION STATEMENT I certify that I ha ve personally inspected the sewage disposal system at this address and that the information reported 16,;low5s true, aci urate and complete as of the time of the inspection. The inspection was performed based on my dining-and exp rience in the proper function and maintenance of on site sewage disposal systems. I am a DEP 4pprov*ed system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: �, asses c� t Conditionally Passes icy Needs Funher Evaluation by the Local Approving Authont. Fails 1-�3nspe`ctor's S 1ign2ture: �io� Date: The system inspector shall s 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 authoriry. Notes and Commeycol>e(�_ �'f}6Z/S 6� ��l��e� r��r��e �Cr►'rJU�c� Tc r S'^)k, e SySrer�. -7-0 73;z •"'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in.the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 rags L or r 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: T (I Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys em Passes: 1 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: One or more system components as described in the"Conditional Pass"section need to be replaced or repaire The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no o of determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is me d over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial in t tion or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a comp ing septic tank as approved by the Board of Health. 4A metal septic tank will pass inspection ' it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years is available. ND explain: Observation of sewage backup or break out or high tic water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribu ' n 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 pip ). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: 2 c 06C vi >> OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 'I Owner: - Date of Inspection: I a 5 Ko Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fair to protect public health, safety or the environment. I. Sys m wIII pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the syste is not functioning in a manner which will protect public health,safety and the environment: ' _ Cess p of or privy vy is within SO feet of a surface water _ Cesspoo or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the oard of Health (and Public Water Supplier, if any)determines that the system is functioning in a mann that protects the public health,safety and environment: _ The system has a septic tank a d soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a face water supply. _ The system has a septic tank and SA d the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS an a SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more from a private water supply well". Method used to determin distance "This system passes if the well water analysis, performe t a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the w is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attach d to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 1A jj 0 D. System Failure Criteria applicable to all systems: You must indicate 'yes"or"no"to each of the following for all inspections: Yes NoBackup 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 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number �oftimes 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 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.) t1 v (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. To considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indtc either"yes"or"no" to each of the following: (The following criteri ly to large systems in addition to the criteria above) yes no the system is within 400 feet o face drinking water supply the system is within 200 feet of a tributary to rface drinking water supply the system is located in a nitrogen sensitive area(interim Ilhead Protection Area- IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 3 I 4 Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspect o: 0co Check if the followine have been done.You must indicate•yes"or"no"as to cach of the following: Yes No Pumping information was provided by the owner.occupant. or Board of Health 1 /Were any of the system components pumped out in the previous two weeks? ✓ as the system received normal flows in the previous two week period Have large volume w H g s of ater been tnrroduced to the system recently or as pan 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, ex ing 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. ��s/9 on peoi». Determined in the field (if any of the failure criteria related to Part C is at issue approximation of dis✓lance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �0'"_ Ma, OwDer: Li/1G�J�/> Date of Inspection: I /'-Z ,(o FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): __!�3 0 Number of current residents:—O - Does residence have a garbage grinder(yes or no): �S' Is laundry on a separate sewage system (yes or no):do (if yes separate inspection required) Laundry system inspected es or no): Seasonal use: (yes or no): N D Water meter readings,if available last 2 ears usage �"�� �3 °aa y z�s = �-oo G ( Y 6 (gPd))��n�-�3od n Sump pump(yes or no):/J b Last date of occupancy: _'2-o o 6 Typ tablishment: Design-flow on 310 CMR 15.203): gpd Basis of design flow(se ons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present (yes o -c- Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: t- e� Was system pumped as pan of the inspection (yes or no): iJo If yes, volume pumped:- o - gallons -- How was quantity pumped determined? Reason for pumping:iu/,tj. TY OF SYSTEM OF tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _lnnovative/Altemative 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): A�roximate age of all components, date installed(if known)and source of information. Were sewage odors detected when arriving at the site(yes or no): A)o 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C T SYSTEM INFORMATION(continued) Property Address:�fl I 6 A m� Owner: 2Z16 Date of lnspectio BUILDING SEWER(locate on site plan) Depth below grade: � Materials of construction:_cast iron _✓40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): �J-o,n� f3Pf��7Gi,�r- ��enTPdze 2hT.;�2ao� .0 o �i�r D Pnc� �� GefrKAGe. SEPTIC TANK: (locate on site plan) ) Depth below grade: Material of construction:;i�concrete_metal_fiberglass_polyethylene —other(explain) if tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) le /' Dimensions: /D X$r.,2 X �/ G�Ou:n t t h 4. C/S—oo 6 Hy/c> Sludge depth: 7' Distance from top of sludge to bottom of outlet tee or baffle: �2 7 Scum thickness: Distance from top of scum to top of outlet tee or baffle: t5— Distance from bonom of scum to bottom of outlet tee or baffle: `3 3 How were dimensions deterTnined:/—,71,F9f&9X?e — S rte cI6 fit,, Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet inven,evidence of.leakaee,etc.): e G C4' 'i eLo rh S -L, • .s661Q" 2LoGJ 90 o U— 'A u-C I-T C eH S' Sow , e—,0(AeQ1e.J-a—t_ iS �T � ou7zeT�tive T. �a J;t7enc.a �CF�k L� �eco�•�,e�� /3 Gz,Se2 13 f- in Sr �,r� •�Plang� �}'//��7v Dep�Lhbelo e: _ Material of construc concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bonom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Pages of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A , . a arl Owner: Date of Inspection: on)(locate on site plan) Depth belo e: Material of construc concrete metal fiberglass_polyethylene other(explain): ' Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) 7 tr/4 �-e6o 1-> 6JZ+X4C 1�� Depth of liquid level above outlet invert: /y 4 Cap 2 R GO/-/'��'.-� /G 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.): Pumps in working or er Alarms in working order(yes or no): Comments(note condition of pump chamber,coned o�n ��ndappu�rienan�c es,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Qj SYSTEM INFORMATION (continued) Property Address: vl Owner: U11 1/�-o Date of Inspection: 18-75-9, 16 co SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why% Type lceching pits,number:_ leaching chambers, number: leaching galleries,number: Q /9- leaching trenches,number, length: 1�eoo/h Recow leaching fields,number,dimensions: To overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of toil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): r' o L• oc Number and c uration: Depth—top of liquid to vert: 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,condin ve etation,etc.): 1 . (locate Oil Materials of cons Dimensions: Depth of solids: Comments (note condition of soil, signs of hydrau ure, level of ponding,condition of vegetation,etc.r 9 Page 10 of 1 l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:L -T tW dl _« Owner: Date of Inspection: J• 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. AID — -- — — to Sa ,` f�Rso2PT�n SySTrw. i 3 I D�j Cb �� ''io '� f� / / 1p, g '! ,7—t°/%6,--n to r Page 11 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: N I Aa"p m ' Owner: Date of lospection- ajaq Jd L SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water �'(� s7feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record -if checked,date of design plan reviewed: _,Observed site(abutting property/observation hole within ISO feet of SAS) Checked with local Board of Health-explain: ,r c L.trr. .Necked with local excavators, installers- (attach documentation) Accessed USGS database-explain: -7—oeO W� ��.�, You must describe how you established the high ground water elevation: i aw.0 /t G P I1 .Y � '��99 • , �/� 0 6 t TOWN OF BARNSTABLE � LOCATION TP LU_:6 CI _V0 I SEWJA'GE # ,`,'ILLAGE f 1� =�� r� I�a� ASSESS034 MAP & LOT Z TO—/y F INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /SW'Z)St?�/r L LEACHING FACILITY: (type) JO�L�S: �r�W _ (size) NO.OF BEDROOMS 3 BUILDER OR�R -S� Oda PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by o LV -544A r Vi .41 • 4 , l•0 CAT ION SEWAGE PERMIT NO. L o f 4� 4-1 7 15 Z t cc)erg �7P�+,Z -::OS - 1 IS tVILLAGE n-d E2� L L I N S T A LLER'S NAME i ADDRESS S U I'L D E R OR OWNER IJoR L DATE PERMIT ISSUED � Z 1 g DATE COMPLIANCE ISSUED 14a o i j o p. TOWN OF BARNSTABLE LOCATION e/mil ��11�6evt Tf�/�iL. SEWAGE # VILLAGE re/ZIZZ//-P ASSESSOR'S MAP & LOT,"30//4/R .NAME&PHONE NO. 7-eFF�4 &.,/ SZV- �Z,39-v98 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ZOE.&I-1AAr-oX 2'�' Sy*size) 3 NO. OF BEDROOMS 3 BUILDER OR OWNER G-e SS FE4U�HTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility °SRO 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 > �2 l � z 3 L L0CAT10 �� SEWAGE PERMIT NO. e"6'' 7 VILLAGE I N UAA LqLER'S N ME A ADDRESS . ell x 9 S ID 12 OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED od ,yo ; o _ � y� , �� -- 1 s—s�.� � �,�„ �� '�, . 4 � � �. y e • �,.� r�, J COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 510` TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 49 Tellegen !Trail) Centerville oZ5 U Owner's Name: Ann Burgess Owner's Address: Date of Inspection: Name of Inspector:(please print) W' 1 I i am _ • Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function an 'maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Sec ' 0 15.340 of Title 5(310 CMR 15.000). The system: r ' asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: /" -6 J The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanhvr 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 k DEP.The original should be sent to the system owner and copies':scnt 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. Title 5 Inspection Form 6/15/2000 page 1 ti Page 2 of 11 0 ` f 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_ 49 Tellegen Trail Centerville Owner. Ann Burgess S� Date or inspection. 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 in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Commen B. System onditionally Passes: One o more system components as described in the"Conditional Pass"section need to be replaced or repaired.The stem,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 Sept c tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exftltration 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 septi 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: Obs ation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed e(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval o B ard of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The syst in required pumping more than 4 times a year due to broken or obstnxted pipe(s).The system will pass inspection i r(with approval of the Board of Health): broken i s P P� )are replaced . obstruction is removed . W . ND explain: Pat,c3ofII C1 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 49 Tellegen Trail en ervi e Owner: Ann Burgess Date of Inspection: . C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the system is fail g 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 ystem 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 Sys in 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 frond 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 and volatile organic compounds indicates that the well is free from pollution from that facility and he presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp ,provided that no other ailure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 f Page 4 or 1 I - , t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• 49 Tellegen Trail Centerville Owner: Ann -Bur ess Date of Inspection: D. Sys m Failure Criteria applicable to all systems: You mus 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 ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ tatic liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or esspool squid depth in cesspool is less than 6"below invert or available volume is less than'h day flow _ I equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number brtimes pumped y portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within I00,feet of a surface water supply or tributary to a surface ater supply. y portion 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. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private w•atrr 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.) (YesMo)The system fails.1 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. Lar a Systems: To be co idered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd- You must dicate either"yes"or"no"to each of the following: (11e follo ing criteria apply to large systems in addition to the criteria above) yes no tlt system is within 400 feet of a surface drinking water supply _ — th system is within 200 feet of a tributary to a surface drinking water supply — _ th system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zo a 11 of a public water supply well if you have an wered"yes"to any question in Section E the system is c msidcred a significant threat,or answered "yes"in Secti n D above the large system has failed.The oA•ncr cr operator of airy large system considered a significant thr t under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The sy t n owner should contact the appropriate regional office of the Department. 4 Page S of I 1 y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 49 Tellegen Trail Centerville Owner: Ann Bur ess pd Date of Inspection: a J 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? v 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 NIA) _ Was the facility or dwelling inspected for signs of sewage back up? v _ 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 baffl s or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ 7Was the facility owner and occupants if different from owner provided ( p ) with i h 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 Z/ Existing information.For example,a plan at the Board of Health. 7/- - Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 ', Page 6 of l I r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 49 Tellecien Trail Centerville Owner: Ann Bur. ess Date of Inspection:_ `' FLOW CONDITIONS RESIDENTIAL / Number of bedrooms(design):. 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 1 .203(for example: 110 gpd x N of bedrooms): Number of current residents: ' Does residence have a garbage g6nder(yes or no): /_a Is laundry on a separate sewage system(yes or no):,�P [if.yes separate inspection required) Laundry system inspected(yes or no):- 1 Seasonal use:(yes or no):— Water meter readings,if available(last 2 years usage(gpd)): 2004 — 98, 000 Sump pump(yes or no): 2003 — 88, UOO Last date of occupancy: COMMERC' NDUSTRIAL Type of establshment: Design flow aced on 310 CMR 15.203): gpd Basis of des' flow(seats/persons/sqft,etc.): Grease tra present(yes or no):_ Industrial aste holding tank present(yes or no):_ Non-san' waste discharged to the Title 5 system(yes or no):_ Water eter readings,if available: Last d to of occupancy/use: OT ER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part df the inspection(yes or no): ,C� If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPF�OIF SYSTEM peptic 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 ob_tained from system owner) - _Tigbt tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: 64- �L/tom Were sewage odors detected when arriving at the site(yes or no):kG 6 ICI 1'agc 7 of I I ✓I . OFFICIAL INSPECTION FOIA'I—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIITATION(continued) Property Address: 49 Tellegen Trail Cen ervi e Owner: Ann Burgess Date of Inspection: -- UUILDiN SEWER(locate on silt plan) Depot belo grade: Materials f construction:_cast iron 40 PVC_other(explain): Distance ont private wvatcr supply well or suction Ilrte: Commcn s(oil condition ofjui►tts,venting,evidence of leakage, etc.): SEPTIC TANK: � locate on site Ian Depth below grade:_� Material of construction: uncrete metal fiberglass_pol)-etlrylene _otlur(explain) If tank is meal list age: Is age confinned•by a Certificate of Compliance(yes or no): certificate) —(attach a copy of s , -1 + Dimensions: d"`O Sludge depth: j Distance from top of sludge to bottom of outlet tee or baffle: ,T/ Scutt thickness:_6 r , Distance from top of stunt to top of outlet tee or baffle: Distance from bosom of scum to bottom utlet Ice or banit. t I low•were dimensions determined: C rex- (f,n ui s2 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related tm!+'et in---rt,evidence of leakage,etc.): l U 6I CREASE TRAP:_(locate on site plan) Dcpdt below Oadc:_ Material of construction:_concrete_metal fiberglass Itolyethylene-_outer (explain): — Dimcnsioni. Sturm thickness: Distance/front top of scum to top of outlet tee or baffle: Distance front bottom of scum to bottom of oullct tee or baffle: Date of last pumping: as dents(on pumping teconunendations,inlet and outlet ice or battle conditio:t, structural integrity,liquid levels as rcl�led to oullct invcri,cvidcncc of Icakagc,cic.): 7 'age&of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIIIAT►ON(continued) Property Address: 49 Tellegen Trail Centervtlle Owner: Ann Burgess Date or inspection: �� TIGHT or ll WING TANK: (tarilc must be pumped at time of inspection)(Ivcate on site plan) Depth below grade: Material of onstruction:_concrete_metal fiberglass____pulyelhylerte other(explain). Dimension Capacity: gallons Design FI w: gallons/Jay Alan»priscm(yes or no): Alarm lei cl: Alarm in working order(yes or no): Date oast pumping: Comm Vast (condition of alarm and float switches,ctc.): DISTIUBUTION BO X:_(tf present must be opertcd)(locate on site plan) Depth of liquid level above outlet invert: 0 Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,ctc.): L< PUMP CHAMBER._( cate on site plan) Pumps in working order 'Cs or no).— Alamis in working ord (yes or no): — Comments(note cots 'lion of pulnp clrantber,condition of pumps and appurtenances, etc.): �. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Tellegen Trail Centerville Owner: Ann Bur ess Date of Inspection: J SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: ing pits,number: 3;i�ing chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): S74G CESSPOOLS: (ce spool must be pumped as part of inspection)(locate on site plan) Number and configur ion: Depth—top of liqui to inlet invert: Depth of solids lay r: Depth of scum la r: Dimensions of c sspool: Materials of co struction: Indication of oundwater inflow(yes or no): Comments(n to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (I cate on site plan) Materials of co struction: Dimensions: Depth of soli s: Comments ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 ` w 3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Tellegen Trail Centerville Owner•Ann Burgess Date of Inspection: 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. 3 i� Iry 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Tellegen Trail Centerville Owner. Ann Burgess Date.of Inspection: — — SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: 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 mkt describe ho yo established the high ground water elevation: O O 11 No. i ! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application for Digogal 6pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(t/)Abandon( ) -['Complete System ❑Individual Components Location Address or Lot No. %-1 Owner's Name,Address and Tel.No. Assessor's Map/Parcel ���g f��i'� 61-ez`f�ws Inst s �e,Add�re^ss, d Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 130 gallons per day. Calculated daily flow —Z—gs— gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank P C Aaiv Type of S.A.S. S Description of Soil Nature of Repairs or Alterations(Answer when applicable) .. J V ,CG f o's I 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 place the system in operation until a Certifi- cate of Compliance has be�jss ar Health. Signed Date �� (� Application Approved by Date Z �d Application Disapproved for the following reasons Permit No. 7 M I'Z Date Issued n No. C �� / V ; �1 3 - ';t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACH'USETTS Rpplication,for Migpogar *pgtem Congtruction Permit V Application for a Permit to Construct( )Repair( )Upgrade(t/rAbandon( ) 1Xomplete System El Individual Components e Location Address or Lot No. l ~ ,,ii Owner's Name,Address and Tel.No. Assessor's Map/Parcel C�I� r�1 60--1 T9 Inst ergs g e��di s`,aid Tel.No. Designer's Name,Address and Tel.No: ., o h .ST f r-eT— t Type of Building: ,,; Dwelling No.of Bedrooms_?� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ` a C_'"T^&,% Type of S.A.S.�JrL4'C11W S 36: 7& Description of Soil Me e'—Aulib 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 t place the system in operation until a Certifi- cate of Compliance has bee,�,�,n issued-by this.,oar Signed �` Date 6 Application Approved by �' Date 7!;�-0 Application Disapproved for the foflowing reasons F. _t 1 Permit No. UrQ I Z tl Date Issued Z q— xfU t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that On-site Sewap-Di sal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by a" at Q\ i Tc c has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Z ay/— tt�bdated Installer Designer The issuance of thi pe t shall not be construed as a guarantee that the syste 11 fun�rtiltdesj,, d. Date `��Z6 ?,�01 Inspector04— / No. ��� Z � � —————— ..Z 3��/C J�----------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mg;pogal *p5tem ongtructton Permit Permission is hereby granted to Construct( )Repair( ✓)'Upgrade( )Abandon( ) System located at Sk :351e�C, r-,J r-T 12, a(� -- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thia Z /Date: iA Approved by ��- S} 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. p Y Y CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, - , hereby certify that the application for disposal works construction permit signed by me dated z U , concerning the l property located at meets all of the following criteria: Ud • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 5�(/ IYB) G.W.Elevation Z5 +the MAX.High G.W.Adjustment. _ DIFFERENCE BETWEEN A and B / SIGNED : DATE: Q [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert / CA rq I 4�A C_G lu(E ftci\, 2 Fles...$15.00..... "x.. THE COMMONWEALTH OF MASSACHUSETTSir`"r';: BOARD OF HEALTH Torah.....................OF.......Barnstable ...... • ------------------------------•-----•-............. Appliration for Diipusal Works Tonotrur#iun amit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: . Te l legen Trail r_enjjeX_Vjjjp. ......... 9 Location-Address or t No. David Burlinoame 49 Tellegen T3a Centerville, Ma. --------•••------• ........•• •-----•.......... ...............................•---•-----•- ---............. Owner Address gOQI...SQxV r-e.................................... . ......128...Bk5hivs..Te xlac'm.......Hyannis.,--.Ma..... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) G" 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...._..__....._......__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------•---•---•----------•-----•--•---•----------...........---•--------....---•----•--............................................................... 0 Description of Soil........................................................................................................................................................................ W UNature of Repairs or Alterations—Answer when applicable___-_1QQ®___gallon_•sL-P i.C---tank With D-Boy. --------•--------------------------••-----••----•----------•------------......-•----.......-----•••---•--•--•---.---•-•--•---------.......----------_....••------- ......•--...---......----...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System,in accordance with the provisions of iITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Siged ................................. Dje Application Approved By.................. ...-- . ----- . �-•-•..................--•---••------- •---..1 Z-!. DApplication Disapproved for the foll 'ng reasons:..•-----•-•-•-----••...................•••--•-•--------•------•----------------------------- .............. .........................•--••----•---------------...----•---•-------------•---------------•----•-------------•---------•------------------------••---------------------•---------•-----•---------•..... Date PermitNo.......................................................- Issued_.............................................-•-------- Date No................_....... Fzs...1- .00..._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town.....................OF......BarnstaIDle .._....... Applirtt#iun for Disposal Works Tonstrudian Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ................lleaen_Tzaail---•Centerville...................... ... ..#49 ........................•--•---•---.......................----•---........----........ Location-Address David Burlingame 49 Tellegen TrIA No, Centerville, Ma. - • ............ ... ...................••••........----....--•--- --••-••--•--•-----•-----.........-..........._..............--------............._..... Owner Address a .___.. .. B Cesspool._Service ................... ......128 Bishops_ Terrace. . Hyannis, Ma. Installer -." ----�q:.---� Address Type of Building 3 Size Lot............................S feet Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( ) `4 e � Other—Type of Building •-•-•----------------------- No. of persons....--------......------.... Showers ( ) — Cafeteria ( ) d Other fixtures .. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Dept h................ x Disposal Trench—No..................r.. Width.................... Total Length-----------------_ Total leaching arm...................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ►.. Percolation Test Results Performed bY.......................................................................... Date........................................ 0.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ L�. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------- -.... ---------------------- ----------- -... ------------ ---------------------- . -•.--•-••-----•-- ----••-•----••••-•........... .-•-•... ... 0 Description of Soil...................•-•----------.......-•----------...............-•-•--------•-----.......................---•----••---•-•----...........•--••---•-•-......_....•--•... W .......................••-•••-••-••--•••--------••-••-•-..........._...•-----•.._...----....---•••--•----•----••-•-•---••-..............•-•-•.. ........---........---........_.... x ................-......................................................................................................................................... V Nature of Repairs or Alterations—Answer when applicable...._. 000_-gallon Septic t2iTik itiii tIi Box ---------------------•---------•---------...-••••-••••--.......... .. .....•-••--•...-•-•--•...............•.....-••••••--••-•••----••••--•-•-••-••-•-•-•--•••-•-•....••-•-------•.....•••-•-••••--....-----.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ........................ Date ApplicationApproved By................................................................................................- Date Application Disapproved for the following reasons:........................................................................................ ..._....___ ......................................••------------------•---............----•-••------•...-----------.....------...---------......•........................----•-----.......__.......I.----•----....._ Date PermitNo..................................................._._. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town OF Bar nstable ................ ....................................................................... Trr#ifiratr of Tomplittnrr THIS IS TO CERTIFY, That the Ind 'du��S w� a Dis osal Syst constr cted ( ) or Repaired ( X} b A & B Cesspool Service N9 ES i0 S Terrace,. IyaWfs y...-•--.........•----• ......................•--....---•-......---- ••------...----•------...........- .................. ._...._ .... . ..... at......49 Tellegen Trail Centerville, Wa."- David Burlingame ..•...---•-----•--•--•---•-....••--••••......--•-••••..................•--••....--•....--•-..........---...... has been installed in accordance with the provisions of TITIE,_ 6.1�e State Sanitary Cok f,� � in the application for Disposal Works Construction Permit I�'o.................... .....__.-....... dated....._......:.,_...... ..._:_..-.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UED AS A GUARA TEE THAT THE SYSTEM WI�L FUNCTION SATISFACTORY. DATE................. L ...... �-------------••............_............---•- Inspector........--...... ...----•-••......--•-•.....-----............_................... V THE COMMONWEALTH OF MASSACHUSETTS d David Burlingame BOARD OF HEALTH Town Barnstallble $1 S.00 No.g� ...........................................OF..................................................................................... FEE........................ �is�rusttl 0�1 �o�s,�� ln �.eruti# Permission is hereby gra d -•-••----•••••--••••••..............................:........................................................_.. to Construe( or Rvj) irL(, £)&. kdiviftjlCwage&VMLE&stem atNo.. ---.....................•--•••---•----•---............-••--•••••-•----- Street _ 17- 2 as shown on the application for Disposal Works Construction Permit No. . --- Date .. !� ... ........................... .........................._ !.3 Board of Health DATE........... •...... ............... ........ FORM 1255 A. M. SULKIN. INC.. BOSTON 02-10-2000 04:06PM CENT OST FIREDEPT 5087902385 P.02 anaxe a ocaoon to tocai rrre ue arime"s- pp p f Pira Department retains original application and issues duprate as Permit. a . i Y - �y�i,L7.T•vyf2H�1�dY C-?�'Ulrf'CJP/1=?1Gf.'Gv— .`,�UGCIArQ�O��iX�' :J"?rfi!:'dlZCl�Gv72 ffi� APPLICA`TI®NI and PERMIT Fee:_�?s_nn for storage tank rerncual and transportation to approved tank disposal yard ilt accordance wiftthe provisions of M.G.L. Chapter 14.8-Section 38A, 527 CMR 9-00, application is hereby mcc@ by: ;.�— Tank Owner Name{� �print) Dan Gallagher _ X �✓ k • 3 niwvrs"Pt iD rg 4 Dw/M41 I Address_ 49 Tellegen Trail, Centerville, MA 02632 - i-wr City - sure Z'D Advanced Environmental Advanced Environmental Company Name_ I Co.or Individvai vnnr Prv+r Address P.O. Box 472, S. Dennis Address _ Signature(, pptyinoc frr=erm Signature T apptyir �::el i PC!Corti- Other IFCI Certified - '_ ?T Other Tank Location 900 Shootf lying Hill Road, Centerville r Tank Capacity(gaitcm 1,000 Substance Last Storer_ #2 Fuel Oil Tank Dimensions(diar, -r x length). Remarks:` a :. . r• • r Firm transporting waste Advanced Environmental State L;.-# M'JS083856100 — Hazardous waste 5.P.A. R s Approved tanK disposal•herd J.C. Grant Tank yard# 008 _ Type ofinertgas Tank yard address Wolcott Street:, Readvi.11e, MA Centerville 01920 City or Town_ FDID� _Permit# February 10; 2000 February 24, 2000 I;l Oate of issue Date of expiration. i Dig sate approval numke r 20000700851 /., Dig Safe Toil*nee Tel.Number-860.322.43a4 Signature/Title ct Oft—.panting permit After remova!(s)send Fx-:F?-290R signed by Local Fire Dept.to i)ST Regulatory Cumpliarc Unit.One Ashburton Place, Roor:n 1310,Sostcn.MA-M-08.1618. KC.�a7!mviwrl AAn1 TCTRL F.i32 4f.k 1Y v f .� tY !T 4+.Fa;_`' 3 '�''• P. '' 1 5 TOWN OF BARNSTABLE LOCATION F L ��14 r SEVuAGE # VILLAGE C r tV�V �� T� ASSESSO. MAP & LOT Z ?Q—/Z/ INSTALLERS NAME&PHONE NO. ✓ SEPTIC TANK CAPACITY > `/��— I (size)LEACHING FACILITY: (type) l NO. OF BEDROOMS 3 BUILDER OR�R PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well.and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by.. LV � ' ® i � �7•n it �/�" ;J ► - A)- t.. i io of Lh ��