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HomeMy WebLinkAbout0016 THISTLE DRIVE - Health - Q 16. HISTLE DRIVE t C e- terville =A= 171 - 051 K I No. 4210 1/3 ORA 1000 `Q ® m m o r r • 1 W osl Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive —� Property Address Scott&Laura Annand Owner Owner's Name information is Centerville ,� Ma 02632 11/612020 required for every Citylfown State Zip Code Date of Inspection page. 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 Information 5/ filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Company Address Ma 02632 — Centerville State Zip Code Cityrrown 774-248-4850 smjonestitle5@gmail.com, SI 4522 sean@smjonestitle5.com License Number i 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 maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails �- 11/6/2020 — 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 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. Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page 1 of 18 t5insp.doc•rev.7/2612018 c Commonwealth of Massachusetts Title 5 Official Inspection Form Ip Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 16 Thistle Drive �" tly Property Address Scott&Laura Annand Owner Owners Name 02632 11/6/2020 information is Centerville Ma -- required for every ;5ty/Town State Zip Code Date of Inspection page. C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: I have not Y found an information which indicates that any of the failure criteria described ® in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 16 Thistle Dr Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank and two 1000 gallon precast leach pits. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the of"Conditional the Ps or section epair, eed to b approved by replaced or repaired.The system, upon completionreplacement 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): Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 t5insp.doc•rev.726/2018 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive Property Address Scott&Laura Annand Owner Owner's Name information is Centerville Ma 02632 11/6/2020 required for every Cityrfown State Zip Code Date of Inspection page. C. Inspection Summary (cost.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms 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 CHAR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: i"die 5 oftai inspection Form:Subsurface Sewage Disposal System•Page 3 of IS t5insp.doc•rev.7/262018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive Property Address Scott&Laura Annand Owner Owner's Name information is Ma 02632 11/6/2020 required for every Centerville State Zip Code Date of Inspection page- Citylrown 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) h y protects the public health, manner that ro is functioning �n a P determines that the system 9 safety and environment: The system has a septic tank and soil absorption system (SAS)and th e SAS is within ❑ � 140 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 ** . private water supply more from a p 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 I 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 official inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 l5insp.doc•rev.726/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive Property Address Scott&Laura Annand Owner Owner's Name information is Centerville Ma 02632 11/6/2020 required for every city/entery State Zip Code Date of Inspection page. 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 El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 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- El10,000 gpd. ® The system fails.I have determined that one or more of the above failure El 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. 6) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. 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 El ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection pp Area—IVUPA)or a mapped Zone II of a public water supply well Title 5 official fnspeamn Form:Subsurface Sewage Disposal System•Page 5 of 18 t5insp.doc•rev.7/28P2018 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Dispose!Sys tem ival Form Not for Voluntary Assessments 16 Thistle Drive Property Address Scott&Laura An nand Owner Owner's(dame 11/fi/2020 information is Centerville Ma 02632 — — required for every City(rown State Zip Code Date of inspection page. C. Inspection Summary (cont.) have answered es to any que stion ion in Section C.5 the system is considered a significant If you ha Y e system has failed.The a above the large Section C.4 abo 9 Y threat, or answered yes to any question in Sect o owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. " following for all inspections: indicate es or no for each of the o g 6. You must Y 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? ® El 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? ® ❑ 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)] Title 5 official inspection Forth.Subsurface Sewage Disposal System•Page 6 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive Property Address Scott&Laura Annand Owner Owner's Name information is Centrville Ma 02632 11/6/2020 required for every Cente ry State Zip Code Date of Inspection page. rrown D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms (actual): 330 gpd DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 2 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.) ❑ Yes ® No Laundry system inspected? Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: ❑ Yes ® No Sump pump? current Last date of occupancy: Date Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 t5insp.doc•rev.7@6=18 Commonwealth of Massachusetts -Not for Voluntary Asses icial Inspection Form Title 5 Off Assessments 1• Subsurface Sewage Disposal System Form 16 Thistle Drive �'x dA dress Property .Scott&Laura Annand Owner Owner's Name 02632 11/6/2020 every ry information is Centerville Ma for State Zip-Cod e Date of Inspection page. CitylTown D. SY stem Information (coat.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) .ft. etc.): rsons/s ) Basis of design flow(seats/pe q ❑ Yes ❑ No Grease trap present? ❑ 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 occupancyluse: 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: Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 t5insp.doc•rev.712612018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive Property Address Scott&Laura Annand owner Owner's Flame information is Ma 02632 11/6/2020 required for every Centerville State Zip Code Date of Inspection page. CitylTown D. System Information (cont.) 4. 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/Aitemative 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: Tank and leach pit original 1972, overflow leach pit added 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2.5 Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Sewer line clear and flowing unobstructed Title 5 oral Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 t5insp.doc-rev.7J28/2Q18 c commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewagep Disposal System Form-Not for Voluntary Assessments - F� 16 Thistle Drive Property Address Scott& Laura Annand Owner owner's Name 02632 11/6/2020 required for every information is Ma Centerville �ZlP-Code Date of Inspection State page. Cty i /Town D. System Information (coat.) 6. Septic Tank(locate on site plan): 2 Depth below grade: feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) ® e: years � If tank is metal, list age: Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000 gallons _— Dimensions: 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' 2" Scum thickness 7" Distance from top of scum to top of outlet tee or baffle 1041 Distance from bottom of scum to bottom of outlet tee or baffle Opened covers and took How were dimensions determined? 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 does not need to be cleaned now but should be done soon and again every 2 yealry sounfor d Per maintenance. Water level was even with outlet, tank was not leaking and Middle access cover is to grade on riser with light duty steel cover. Title 5 official inspe&jon Form:Subsurfaoe Sewage Disposal System•Page 10 of 16 t5insp.doc.rev.7/2612p16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive Property Address Scott&Laura Annand Owner Owner's Name information is Centerville Ma _ 02632 11/6/2020 required for every City own State Zip code Date of Inspection page. D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): B. 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 Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 18 t.5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 official Inspection Form 1" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive Property Address Scott& Laura Annand Owner Owner's Name information is Centerville Ma 02632 11/6/2020 required for every Cityrrown State Zip Code Date of Inspection page. D. System Information (cont.) 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): N/A 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.): Title 5 Official Inspection Form:Subsurface Sewage Disposal SYstem•Page 12 of 18 t5insp.doc•rev.7128/2M c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive — Property Address Exam kl�wp)_ Scott&Laura Annand Owner Owner's Name information is Center Ma 02632 11/6/2020 Centerville required for every C enter n State Zip Code date of Inspection page. D. System Information (coat.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump c ,hamber condition of pumps and appurtenances, etc.): i *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: 2 x 1000�a1 ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: overflow cesspool number: El innovative/alternative system Type/name of technology: Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 t5insp.tloc-rev.7/p6@018 c Commonwealth of Massachusetts p Title 5 Official Inspection Form � F Subsurface Sewage Disposal System Form Not for Voluntary Assessments 16 Thistle Drive Property Address Scott& Laura Annand Owner Owner's Name 11/6/2020 information is Centerville Ma 02632 required for every City/Town State Zip Code Date of Inspection page. 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.): system has two 1000 gallon leach pits connected in series. First leach pit has cover on riser to grade and was found with water level V below outlet invert. Second leach pit is h-20 with steel cover on riser Pit was found dry with no stain lines. Pit has minor root infiltration through leaching holes. 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 i 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.): Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern•Page 14 of 18 t51nsp-doc•rev.7262018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments r 16 Thistle Drive Property Address Scott&Laura Annand Owner Owner's Name information is Centerville Ma 02632 11/6/2020 required for every Cloy own State Zip Code Date of inspection page. D. System Information (cunt.) 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.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 tSInsp.doc•rev.7t2812o18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive Property Address Scott& Laura Annand Owner Owners Name information is Centille r Ma 02632 11/6/2020 required for every Cente rvry State Zip Code Date of Inspection page. 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 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 arately C� Al 1 Y A2 25 j- ? 13> S-S Title 5 official Inspection Form'Subsurface Sewage Disposal System•Page 16 of 18 t5lnsp.doc•rev.7/26/2018 Commonwealth of Massachusetts Ti Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Drive Property Address Scott&Laura Annand Owner Owner's Name information is Centerville Ma 02632 11/6/2020 required for every State Zip Code Date of Inspection page cityrrown D. System Information (coot.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 12'+ 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) ❑ 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 was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 t5insp:doc-rev.7I2612018 c Commonwealth of Massachusetts Title 5 Official Inspection Form Jug; Subsurface Sewage Disposal System Form Not for Voluntary Assessments 16 Thistle Drive Property Address Scott&Laura Annand _ Owner Owners Name information is Centerville Ma 02632 11/6/2020 required for every Cityrrown State Zip Code Date of inspection page. E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed &Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure 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 t5insp.doc•rev.7I26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of Barnstable Barnstable . .~ Regulatory Services Department j WcaC j BARNSCABM MA SS. 9. ,,� Public Health Division fDNp 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 9903 October 27, 2020 ANNAND, SCOTT W & LAURA 16 THISTLE DRIVE CENTERVILLE, MA 02632 Inspections of the septic tank at 16 Thistle Drive, Centerville, MA show that the system now"Passes" under the guidelines of 1995 Title V (310 CMR 15.00). The issue has been resolved and the septic tank no longer leaks per two private Department of Environmental Protection(DEP) certified inspectors, Sean Jones, on October 30, 2019, and Douglas Brown, on October 6, 2020. If you have any questions or concerns, please contact the Health Division at 508-862- 4644. Thomas McKean, S., C Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mai ling\Conditionally Passes Letters\16 Thistle Drive Centerville Revised 10-26- 2020.doc S rl-f� 73dN October 11, 2019 To the Barnstable Board of Health: This letter will confirm my conversation this morning with Ms. Sharon Crocker indicating my desire to be included on the agenda for October 22, 2019. Prior to our purchase of 16 Thistle Drive, Centerville, MA, a Title 5 inspection was ,completed (on 1/19/2018) and the system conditionally passed. It was determined that the seal in the septic tank was leaking. Last week I arranged for Scott Frank to come out and inspect the�tank. When I told him about the conditional pass, he asked me if the property had been vacant for any period of time prior to the Title 5 inspection. I explained to him that it was vacant for approximately 3 years. He said that when the tank is empty and dry for such a long period of time the seal can dry out and leak. Once the property is occupied and the septic system is being used normally, the seal will no longer leak. His inspection confirmed that the tank is not leaking now. His suggestion was to have the tank pumped out, and let the tank fill back up to the level where the water leaves the outlet. An inspection would then show that it is not leaking. Thank you for your consideration regarding this matter. Sincerely, Scott W. Annand 603-660-6821 (cell) 774-602-8195 (home) ��A;(' S/a.nnanj l L Town of Barnstable Barnstable Regulatory Services Department AlAm°dc'C j * BARNSPASM - 9q� 69. ,� 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 7008 January 30, 2018—Revised Year Date NATIONSTAR MORTGAGE LLC DB/A 8950 CYPRESS WATERS BLVD COPPELL, TX 75019 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 16 Thistle Drive, Centerville, MA was inspected on 1/19/2018 by Paul Martin, 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: • Septic tank is leaking. You are ordered to repair or replace the septic system within two (2)years 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 RD OF HEALTH �L Thom s c ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mai ling\Conditionally Passes Letters\16 Thistle Drive Centerville Revised YEAR date.doc Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is d for every very Centerville MA 02632 1/19/2018 . page. CitylTown State. Zip Code Date of Inspection Inspection results must be submitted on this form.' Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab. 1. Inspector: key to move your cursor-.do not Paul Martin use the return key. Name of Inspector Cape Cod Septic Services r� Company Name .350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 Telephone Number License Number B. Certification 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 s ----� 1/26/2018 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17 �e -cc�V Commonwealth of Massachusetts G Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is required for every ery Centerville _ MA 02632 1/19/2018 page. Citylrown 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 Condit ionally tionally 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. 0 Y ❑ N ❑ ND (Explain below): Septic tank is leaking and needs to be sealed.. t51ns•3I13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner. Owner's Name required for Is every Centerville required for eve MA 02632 1/19/2018 page. City/Town State. Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass.inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed_ .:: ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in.accordance with 310 CMR M303(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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is-required for every Centerville MA 02632 1/19/2018 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 r - Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w ,.•'" 16 Thistle Dr. Property Address ' Nationstar Mortgage LLC. Owner Owner's Name Information is required for every Centerville MA 02632 1/19/2018 page. Cityrrown 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 p pp y p q y 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 10,000gp.d. ❑ ® 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 El Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system.has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional.office of the Department. t5ins-3/13 Title 8 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i • Commonwealth of Massachusetts = r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate 'yes" or"no"as to each of the following: Yes No ® . — ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑. ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? �. El available 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? l ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at.the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential.Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3= 330gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 16 Thistle Dr. Property Address Nationstar.Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 . page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El 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: UnknownDate Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): rations 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 w Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 . page. Cityrrown 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: No records Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool. ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous'inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins'•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 .' . Commonwealth of Massachusetts w W Title 5 Official Inspection Form a 's Subsurface Sewage Disposal System Form Not for Voluntary Assessments . .. M 5••�'rt 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1988 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 30"feet Comments (on condition ofjoints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root . intrusion. Septic Tank(locate on site plan): Depth below grade: 20"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: 1000Gal Sludge depth: 4-611 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts y b Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments r r ,•�'' 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name Information is required for every Centerville MA 02632 1/19/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 011 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 How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid.levels as related to outlet invert, evidence of leakage, etc.): 1000Ga1 tank. Tank level at seam. Tank needs to be sealed. 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 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner . Owner's Name information is Centerville MA 02632 1/19/2018 required for every page. Cityfrown 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >••''r 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 page. Cityrrown 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.): No box present 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-3N3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Dr, Property Address Nationstar Mortgage.LLC, Owner Owner's Name information is .required for every Centerville MA 02632 1/19/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-6x6 ❑ leaching chambers number: ❑ leaching galleries number: ❑. leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of bonding, damp soil, condition of vegetation, etc.): 2-6x6 Block pits in series. Both pits found dry at inspection. with no evident staining. No sign of overloading or hydraulic failure. Cestpools (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 l5ins 3N3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632. 1/19/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cone.) 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•3113 Title 5 Official Inspection Form: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 � 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name. information is Centerville required for every MA 02632 1/19/2018 page. City/Town State Zip Code Date of Inspection D..System Information (Pont.) 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: 0 hand-sketch in the area below ® drawing attached separately t5ins•3H 3 Tige 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ° Commonwealth of Massachusetts Title '5 Official Inspection Form Subsurface Sewage Disposat System Form Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is.required for every Centerville MA 02632 1/19/2018 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: +13 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: El Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: No water 4' below pits Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 J a � . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M ••�''� 16 Thistle Dr. Property Address Nationstar Mortgage LLC. . Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 page. Cityrrown 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 I t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 m J"IbbU bbiiiv,4S-J3uIIL l.aras Page 1 of 2 TOWN OF BARNSTABLIS LOCATION__-A�_ Ind," }�(� A y' SEWAG11# VILLAGE._ c tul'ell o(k ASSESSOR'S. MAP& LOT 17, -e_SI . INSTALLERS NAME&PHONE NO. - -77r 3.5 V SEPTIC TANK CAPACITY LEACHING FACILITY:(tppe) p )r (size) If 1--vo NO.OF BEDROOMS. ^PRIVATE WELL Olt'PUBLIC WATER BUILDER'OR OWNER_ 9DATE PERMIT ISSUED: DATE COEIPLIANC.E ISSUED; VARIANCE GRANTEn: Yes__ No < i SS httu.://www.townofbarnstable.us/Assessing/14Mdisnlsv.acn?n,annar=l 71 051,Z-cP„-1 t October 7, 2020 C?' C1;z_C7 To the Barnstable Board of Health:° This letter will confirm my conversation this morning with trlls. Sharon Crocker,indicating my desire to be included on the agenda for October 27, 202.0. Prior to our purchase of 16 Thistle.Drive, Centerville, MA, a Title b inspection was completed (on 1119/2018) and the system conditionally passed. It appeared that the I seal in the septic tank was leaking, When i arranged for Scott Prank to come out and inspect the tank due to the conditional pass, the ylst'thing he asked me Was if the,property had been vacant for any period of tit'rie prior to the Title 5 inspection. I explained to him that it was vacant fair approximately 3 years He said that when the tank-is empty and dry for such a Tong ,k x P "o"dr di f t the ealy can dry+ out and leak. C?nee the properly is oceupied and tl e septic s e � sed normally, the seal.wilt no longer leak. His irspectiirt nth t # IMA a:kot Iealcing now. ,e � 33 x. r. Itthen3l� d� .. taklb �ected by (2) licensed inspectors (Douglas.A. 8rc�vn & S.M. WN At li, b 4 Apr vtded written certification that the tank is not leal. king, t have r O Y F CI���Ci �el StartTYlenyl;5? / _ Y w ocen'sideration regarding thtN is utter; . r> E y yy .s /Y4 �' . ✓5R6 !►� r� r y � i h g _ Y t, 74 Seld4n t, . C jt. "Ille Ma.Q2b3 C,- 77+4-248 4850 may , ` To . It©tn it11ay cancer, Oh October 30" 2019 the 1000 gallon septic tank at 1 6 i Th stle� Centerville 1 a, was inspected'by me. At this time the,.water level Was observed to be`evert with the outlet e l djCatjn� that the tank i strcictural � sa nd r d, r rat #eaking, A�a Pgyq � g �} 5 sE c � y R gym: "a a t §� ✓>a 3- �i } a Douglas A. Brown,, ln'c. Centervilme, MA 02632 50S=42U-4534. 508 400.715 dabrown$@comcast.net Septic System Contract Name: Scott Annard pate: 1p-6-2ll2tl Address: 16 Thistle dr Centerville phone Number: No.of Bedrooms: Description of Septic System: topendd both Septic tank covers d found iipu ici ai opdratlno ieveis with no sins of leakage in tank. an Qougtas A Brown A "A ; st d TV Date - § x � y � � tf nditictns nrl b vim'; iiAdaereltest is perfonriea. stated e,ren3tfv�q�wso�ls,and ieplacernent sa�iii if needed am at an sdditiQnal-cost, , Kz �c �r t x s ns�b a t3r damdipf age tt +d a w$ys,irrigation systems,foundations or any other,underground device,due to.heavy s l Pam" I �� �'� �� � u mIS any ex� g utilities xf 'ded(s at an additional cost ppl`ed wy once,guarantee of growth and maisttenance are owner's revollsibility. R n,' a .. Up v encowitered are_due in full upon completion charged for any balance not paid in foil upOrcoml lotion. �" a components{ll:pump t,floats,alarms,etc) o t: q< Crocker, Sharon From: Crocker, Sharon Sent: Friday, October 23, 2020 2:32 PM To: 'Scott Annand' Cc: McKean, Thomas Subject: 16 Thistle Drive Centerville - Do Not Need to come to BOH-Oct Hello Scott, cell 603-660-6821, home 774-602-8195 I` Tom McKean, Director of Health Division, and his staff reviewed your item submitted for the Oct 27, 2020 meeting and they made the determination that you will not need to come to the Board of Health meeting next Tuesday. The documentation submitted from the two separate septic contractors, inspecting the tank for possible leaks sufficed. Original Inspection performed by Paul Martin 01/19/2018 Conditional Pass—teak leak. House Unoccupied 3 yrs. Second Inspection of tank—by Sean M Jones 10/30/2019 Tank is not leaking. jOf� � Third Inspection of tank - by Douglas Brown 10/06/2020 Tank is not leaking. Report dated 01/19/2018 will be considered—PASSED. Thank you. Vr r 'fA Sharon r� Sharon Crocker Office Manager Town of Barnstable—Health 508-862-4739 The information contained in this electronic transmission("e-mail"),including any attachment(the"Information"),may be confidential or otherwise exempt from disclosure.It is for the addressee only.This Information may be privileged and confidential work-product or a privileged and confidential communication.The Information may also be deliberative and pre-decisional in nature.As such,it is for internal use only.The Information may not be disclosed without the prior written consent of the Director of Public Health and/or the Town Attorney,.'s Office of the Town of Barnstable. If you have received this e-mail by mistake,please notify the sender and delete it from your system.Please do not copy or forward it.Thank you for your cooperation. 1 October 7, 2020 To the Barnstable Board of Health, This letter will confirm my conversation this corning with Ms Sharon Cracker indicating my desire to be included on the agenda for October 27, 2020. Prior to our purchase of 16 Thistle drive, Centerville, MA, a'Title 5 inspection was completed (on 1/19/2018) and the system conditionally passed. It appeared that the seal in the septic tank was leaking. When ! arranged for Scott Prank to come out and inspect the.tank due to the conditional pass, the 1st thing he asked me was if the property had been vacant for any period of time prior to the Title 5 inspection { explained to him that it was vacant for approximately 3 years. He said that when the tank is empty and dry for such a long �x Y , fpenodc►f�#tree a seal.can dry out and leak. trace the property is occupied and the � tsfer a is tr UMN11 used normally, the seal will no longer leak. His inspection tq titne is not leaking now. X i�h ri to 00-the t�r s ected by(2) licensed inspectors (Douglas A, Brown & S.M. �� k F mX rh rY 'f. yx '� . k a � � threybot# prarrrded written certification that the tank is not leaking. I have r f� l�a��l�ther�s ter��ents, r . het k � HI ours £ rderation regarding this utter. � 3 � w a ° � i / ' 3 71 ��� � r 101 2,s{/� Rb gall � h ° 761 e ' 43 k 3: £ F r RG 6,M 40NES TME V SEP-TIC INSPECTION 74 Seldan LA, Centerville Mc.02632 774-248-4850 $R ! « s4j T hom 1t May Concern, On October 3C? ' 2019 the 1€ 00 galltan septic tank at �� '�h�stle �3r Gentenr lie trll`a. was inspected by me, At this time the water level was observed to be even with the outlet inve t indicating that the tarok is structurally sound and not leaking. ts- ��, �rr�?•"t^ f� r1�.. '�i/£�" ( Yam+�t R�'�`t�.� by� k*��A,y�, �� y 6` s.'��✓k �k•�' �w W^i 3 �P�i �� � � � � M ox AN y S Jfiy � Ot as IARIIR - 6' 3yE 3 4 sX.F #N �U k € r _ D ugloiS 1 , r >aWns . C P.O Box 145 Centerville, MA 02632 5084204514+► 508-400.7:159 dabirownS orncas.tnct -Septic System Contract Name: Scott Annard _-___ _ puto; 10-04026 Address; 16 thistle Or Centerville Phone Number: No.of Bedrooms:. . Description of Septic System: Loperied both septic tank covers and found liquid at operating tevels with no signs of leakage In tank. E3ou91'a A Brown IN � kl- IN z mW E c9 �.Sy L �6d Cond"itcorts SM, tis perFortned. � � « tlnless¢stated abfle it7flv1't; " 1e ils,ante:replacement sand if needed are at an additiorial cost. $ hhd 4�FyG WW •Ati► no } � 01e for Cl to oire� rays,irrigation systems,foundations or any other underground d ce due to heavy tY?GIC�1 * '�g '-, �� - - err �+, , any exist hg s,I' esil'I d at an additional cost. aid tf n l ll lie; pp ied only on'co,,guarantee of'growth anal maintenance are owwner's ra onsibilit . b ' p ceand a r#encountered are:dtie in Full upon completion. - a ,.ti e char ed,far any bahince not paid in full upon completion. comppnents(IE pumps;floats,alarms,etc.)M ' October 11, 2019 cg;2.0 To the Barnstable Board of Health: This letter will confirm my conversation this morning with Ms. Sharon Crocker indicating my desire to be included on the agenda for October 22, 2019. Prior to our purchase of 16 Thistle Drive, Centerville, MA, a Title 5 inspection was completed (on 1/19/2018) and the system conditionally passed. It was determined that the seal in the septic tank was leaking. Last week I arranged for Scott Frank to come out and inspect the tank. When I told him about the conditional pass, he asked me if the property had been vacant for any period of time prior to the Title 5 inspection. I explained to him that it was vacant for approximately 3 years. He said that when the tank is empty and dry for such a long period of time the seal can dry out and leak. Once the property is occupied and the septic system is being used normally, the seal will no longer leak. His inspection confirmed that the tank is not leaking now. His suggestion was to have the tank pumped out, and let the tank fill back up to the level where the water leaves the outlet. An inspection would then show that it is not leaking. Thank you for your consideration regarding this matter. Sincerely, Scott W. Annand 603-660-6821 (cell) 774-602-8195 (home) L ya�o�,Cyr'1 oF�"E'as Town of Barnstable Barnstable AgAmaleaCRY Regulatory Services Department * BARNSTABLE. '""SS Public Health Division µAY"� 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 7008 January 30, 2018—Revised Year Date NATIONSTAR MORTGAGE LLC DB/A 8950 CYPRESS WATERS BLVD COPPELL, TX 75019 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 16 Thistle Drive, Centerville, MA was inspected on 1/19/2018 by Paul Martin, certified Title V Septic Inspector for the State of Massachusetts. �I { 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: • Septic tank is leaking. You are ordered to repair or replace the septic system within two (2)years 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 OF HEALTH �L Thom s c ean, R.S., CHO Agent of the Board of Health i I Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\16 Thistle Drive Centerville Revised YEAR date.doc j I Crocker, Sharon From: Crocker, Sharon Sent: F�day�N� beTlt 2'019�'02 PM To: slannandl @yahoo.com' Subject: FW: Board of Health Agenda - Tue Nov 26 Attachments: Agenda.doc Ode C;-7 TO: Scott Annand RE: 16 Thistle Drive,Centerville Attached is the Board of Health Agenda for this coming Tuesday's meeting—November 26, 2019 We'll see you there. Regards, Sharon �d hvi� w cc/,)Oa��Ow- C, � sd7 �� � (�'i In i5-�l:�e= r 0 r- r- OFFICIAL � Certified Mail Fee r'is � 9 $ i Extra Services&Fees(check box,add fee as appropriate); ®, ❑ReturnReceipt(hardcopy) $ d-^ 0 ❑Return Receipt(electronic) $ c%gark C3 ❑Certified Mail Restricted Delivery $ I �+iNlfl , �'H�►I .� 0 []Adult Signature Required $ s• ❑Adult Signature Restricted Delivery$ f� Por. m PS N $ 4 Tot Ln $ NATIONSTAR MORTGAGE LLC D/B/A se 8950 CYPRESS WATERS BLVD ram- COPPELL, TX 75019 cfi :,. r r r rrr••.- - Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail •A unique identifier for your mailplece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this , delivery. 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Signature ■ Print your name and address on the reverse X ❑Agent❑Addressee so that we can return the card to you. D � 7 ■ Attach this card to the back of the mailpiece, B. Receive1D&(f61NdP11mebher C. Date of Delivery or on the front if space permits. a "a...'^AAA--A ---- --- ___n—ts_derlivery address different from item 1? ❑Yes S,enter delivery address below: ❑No NATiONSTAR MORTGAGE LLC D/B/A 8950 CYPRESS WATERS BLVD COPPELL, TX 75019 0 Adult Type ❑Priority Mail Express® Adult Signature ❑Registered MaiITM ❑ duk Signature Restricted Delivery ❑Registered Mail Restricted edified Maii® Delivery 9590 9402 1933 6123 1781 18 Certified Mail Restricted Delivery �Return Receipt for ❑Collect on Delivery Merchandise 2._Article_Nlimber(Transfer fmm ���� — on Delivery Restricted Delivery ❑Signature Confirmation ry �'015, .17 3 Q 0 1t'4 9 8 7 7 011181 �IMail ❑Signature Confirmation a Mail Restricted Delivery Restricted Delivery IIr over '00) PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt USPS� # First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9402 1933 6123 1781 18 I United States •Sender:Please print your name,address,and ZIP+4®in this box* Postal Service �— -- �— I � E I '4? Town of.Barnstable I 1-lealth Division � 200 Main Street llyannis, MA 02601 I r October 11, 2019 To the Barnstable Board of Health: This letter will confirm my conversation this morning with Ms. Sharon Crocker indicating my desire to be included on the agenda for October 22, 2019. Prior to our purchase of 16 Thistle Drive, Centerville, MA, a Title 5 inspection was completed (on 1/19/2018) and the system conditionally passed. It was determined that the seal in the septic tank was leaking. Last week I arranged for Scott Frank to come out and inspect the tank. When I told him about the conditional pass, he asked me if the property had been vacant for any period of time prior to the Title 5 inspection. I explained to him that it was vacant for approximately 3 years. He said that when the tank is empty and dry for such a long period of time the seal can dry out and leak. Once the property is occupied and the septic system is being used normally, the seal will no longer leak. His inspection confirmed that the tank is not leaking now. His suggestion was to have the tank pumped out, and let the tank fill back up to the level where the water leaves the outlet. An inspection would then show that it is not leaking. Thank you for your consideration regarding this matter. Sincerely, Scott W. Annand 603-660-6821 (cell) 774-602-8195 (home) // FIE T°� Town of Barnstable Barnstable Regulatory Services Department 1 e`c j BARNSTABLE. ' , 039. ,.� Public Health Division m jf°1AA�� 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 7008 January 30, 2018 —Revised Year Date NATIONSTAR MORTGAGE LLC D/B/A 8950 CYPRESS WATERS BLVD COPPELL, TX 75019 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 16 Thistle Drive, Centerville, MA was inspected on 1/19/2018 by Paul Martin, certified Title V Septic Inspector for the State of Massachusetts. t� The inspection of the septic system showed that the system "Conditionally Passes" V under the guidelines of 1995 TITLE V 310 CMR 15.00 due to the following: �� g ( ) S1 ''J • Septic tank is leaking. You are ordered to repair or replace the septic system within two (2) years 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 RD OF HEALTH �L Thom s c 7ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\16 Thistle Drive Centerville Revised YEAR date.doc L • Commonwealth of Massachusetts ' -051 Title .5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Thistle Dr. r, . Property Address Nationstar Mortgage LLC. ; Owner Owner's Name J Ij information is required for every Centerville MA 02632 _ 1/19/2018 � page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form: Inspection forms may not be altered in any - way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not P8U1 Martin use the return key. p Name of Inspector Cape Cod Septic Services r� Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 Telephone Number License Number B. Certification nzp Gl L 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 1/26/2018 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owners Name information is. required for every Centerville . MA 02632 1/19/2018 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): Septic tank is leaking and needs to be sealed.. t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 'Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner, Owner's Name information is Centerville required for every MA 02632 1/19/2018 page. Cltyrrown State. Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed. ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(§) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑. obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required b the Board of q Y 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. I. System will pass unless Board of Health determines in.accordance with 310 CMR 15..303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W W Title 5 Official Inspection Form o. Subsurface Sewage Disposal System Form - Not for Voluntary Assessment s F 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 16 Thistle Dr. Property Address . Nationstar Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 page. CitylTown 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.) have determined that one or more of the above failure® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance.with 310 CMR 15.304. The system owner should contact the appropriate regional.office of the Department. t5ins•3/13 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name required on is every Centerville required MA 02632 1/19/2018 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® . ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential.Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x3= 330gpd t5ins•3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar.Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ❑ No .Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owners Name information is required for every Centerville MA 02632 1/19/2018 page. Cityrrown 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: No records Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool. ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 �.' . Commonwealth of Massachusetts W Title 5 Official Inspection Form . aX Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632 1/19/2018 page. CttylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1988 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30� feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 3011feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root . intrusion. Septic Tank(locate on site plan): Depth below grade: 20" 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: 1000Gal Sludge depth: 4-611 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts u. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t y 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name Information is required for every Centerville MA 02632 1/19/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 011 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000Gal tank. Tank level at seam. Tank needs to be sealed. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts v. Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner . Owner's Name information is required for every Centerville MA 02632 1/19/2018 page. Cityrrown 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: El concrete Elmetal Elfiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts n W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is Centerville required for every MA 02632 1/19/2018 page. Cityrrown 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.): No box present 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:. l5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 12 of 17 r , Commonwealth of Massachusetts w u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage.LLC. Owner Owner's Name information is . required for every Centerville MA 02632 1/19/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-6x6 ❑ leaching chambers number: ❑ leaching galleries number: ❑. leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 276x6 Block pits in series. Both pits found dry at inspection. with no evident staining. No sign of overloading or hydraulic failure, Cestpools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 117 ' Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name information is required for every Centerville MA 02632. 1/19/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cone.) 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name. information is Centerville required for every MA 02632 1/19/2018 page. Cltyrrown 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: El hand-sketch in the area below ® drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owner's Name is required for every. Centerville MA 02632 1/19/2018 page. Cityrrown 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: +13' 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: No water 4' below pits Before filing this Inspection Report, please see Report Completeness Checklist on next page. j t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1S of 17 e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Thistle Dr. Property Address Nationstar Mortgage LLC. Owner Owners Name tion isrequired for every Centerville MA 02632 1/19/2018 page. Cityfrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 rT,abwbuig tiS-DUHL uaras Page 1 of 2 TOWN OF BARNSTABIJI. LOCATION A(s I,�, }�Q tr SEWAGE N - SOS VILLAGE NY o(k ASSESSOR'S. MAP LOT t71 -oSi . INSTALLER'S NAME&PHONE NO._ .YHA(,0x: t sb 'a-3.3 7 SEPTIC TANK CAPACITY LEACHING FACILI.TY:(type)) (size) fir ' NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER'OR OWNER ,�` ,DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED; J^ a VARIANCE GRANTED: Yes,__ Na 1-1 http.://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=171051&.seq=1 1/17/2018 ' r ti Town of Barnstable Barnstable Regulatory Services Department M�ftedcae j `v IAMSPABLE ' 69. ,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# 7015 1730 0001 4987 6834 January 30, 2017 NATIONSTAR MORTGAGE LLC D/B/A 8950 CYPRESS WATERS BLVD COPPELL, TX 75019 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 16 Thistle Drive, Centerville, MA was inspected on 1/19/2018 by Paul Martin, 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: • Septic tank is leaking. You are ordered to repair or replace the septic system within two (2)years 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 c ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditional ly Passes Letters\16 Thistle Drive Centerville.doc Town of Barnstable - + AaL7l7GT1A7F A Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA'02601 Office: 508-862-4644 Richard ScA Dircaor FAX: 508-790-6304 Thomas A McKcan,CEO Feb 6, 2007 Rev. 5111116 DEADLINES TO*REPAIR FAILED.SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An`x"marked in the o is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA o Discharge or ponding of effluent to the surface of the ground w . o Pumping more than 4 times during the last year not due to clogged or obstructed pipe. .. o 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 ter 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 wafer analysis indicates the well is free from pollution). q Single Cesspool y"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o 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) OTHER Repair deadline: a SEPTICQEADLINES TO REPAIR FAILED SYSTEMS.doc AsBuilt Page 1 of 2 TOWN OF BARNSTABLh LOCATION[_ 64If l,� SEWAGE# 505 VILLAGE___�yy��Z�1J !�. ASSESSOR'S MAP & LOT 17, -Q,�L INSTALLER'S NAME& PHONE NO._ (,o*W t5-o n -7a-`.�.3V SEPTIC TANK CAPACITY LEACHING FACILITY:(tppe) i T (size) 1� 0 NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER-OR OWNER_ DATE PERMIT ISSUED:_ 1;0 DATE COMPLIANCE ISSUED; VARIAN(7E GRANTED: Yes No j Ile CTv �Ssi j � f http://issgl2/intranet/propdata/prebuilt.aspx?mappar=171051&seq=1 9/11/2017 TOWN OF BARNSTABLI LOCATION 16 1 ,4•fle 1� SEWAGE #� 50S� _ VILLAGE C2YfWVl i k- _ ASSESSOR'S MAP & LOT 17/_GS _ INSTALLER'S NAME & PHONE NO. Y►jd_�o�,� +Sa m -775'-3.3 �. SEPTIC TANK CAPACITY LEACHING.FACILI.'FY:(type) p _r (size) NO. OF BEDROOMS_^PRIVATE WELL OR PUBLIC .HATER BUILDER OR OWNER_ ,L6 .4 DATE PERMIT ISSUED:_ DATE COMPLIANCE ISSUED: �� VARIANCE GRANTED: Yes No l _-7� r 7"� OS/ FRB......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........Town...Of.---......O F...............Bar.n.s.t.ab.le........................................... ApplirFation for Disposal Murks Tonutrurtion Prruat Application is hereby made for a Permit to Construct ( ) or Repair �X� an Individual Sewage Disposal System at: ........--.1. Th i s t 1 e Drive Cent e r g 11 e,Mass............................................................................................... Location-Address or Lot No. John_ _.Du99.Q Owner Address aJ.P.Macomber 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 ( ) Otherfixtures -------------------------------------------------------•••--•------•-•••--•••-•-•••••------••-•---------•••••---•-••--••.....---•----•............... 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..---................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....---------.--._..---- 9 •-••••-•--•------------------•••••---•••••••••••••••--------------•••---------------.....-•---------......................................................... 0 Description of Soil----------------------------••• Sand...& c[r ave l x w x -•••--••-•••-------•--•-----••---••••------------------•••••--••--••••-••-•-----•--•-•-••-••-•---- --•---••-•••---------------•-----••-----••-------•--••••••••--•-----•-••......••----••-------•--•--- U Nature of Repairs or Alterations—Answer when applicable----------------------_ .-.....------..........----....--...---....----.--................. ..............-..................------------------------------------------------------•--.......-------------------------1--1_0 . .. •gallon................... l e a ch......_...l... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of mTT . 1- 5 of the State Sanitary Code—Xb �t undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issue oard of alth.Signe 11((// --- --------•- ........ $. -----•-- Application Approved B --•.-. ...__ .......... - Date Date Application Disapproved for the following reasons---------------------------------------------------------------------------- Date PermitNo.........ff•.S ' .......................... Issued-------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct or Repair ix� an Individual Sewage Disposal System at: Location'Add"ss or Lot No. � v""= Address .............. -------------------------------- ___'--'--__-__-'__'-'--------------'---'-'__--- Instmler Address Type ofBuilding Size Lot............................Sq. feet Dwelling—No. of Bedrooms............3L.............................Expansion Attic ( ) Garbage Grinder ( ) Other—Typeof Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( ) ^4 Other fixtures --..-----_--.----------------__._._.________.__._______________________ D�u��o Flow.-------..-----------_�allooaper person per day. TotalduJyflow------_----.-------.��looa. � —Liquid* ............gallons Length................ Width................ Diameter................ Depth................ Trench--No..................... Width.................... Total .................... Total area....................sq. tc Seepage Pit No..................... Diameter.................... Depth below inlet---------' Total leaching area.--------ml. ft. Z Other Distribution box ( ) Dosing tank ( ) '- Percolation Test Results Per-formed bv.......................................................................... Dutc-------------.-----. Test Pit No. l................oiootcayeriocb Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per iudz Depth of Test Pit.................... Depth zoground water------ ...............................'........................'..'.......................'..............'.............'.............................'............. 0 Description cf Soil.........-.__--_-_-' l ________________________________________ --`--'-----`---'---`--------'----`-----------------`----`-----'--'------`—`--`--`-`---'------ M. ----_-----------------'-------.—._--_-'__-_-_—'_.----'-----'—'-'-'---__'_----_--_ L) Nature of Repairs or Alterations--Answer when applicable-------------------------- .......................................... | '---------'--'-----------'--------'----'--'-----------''---'---'--'----'--------'--'---- � Agreement: The undersigned agrees to install the afozrdc»cribcd Individual Sewage Disposal System in accordance with the provisions of'T'IE 5 of the State Sanitary Code The od igned further agrees not to place the system in operation until a Certificate of Compliance has b n issue4.,by ihe board of health. / 9/l/88 - ~ ----------' ----.--..-----'--- \ ^�- y �� um= Aool�at��o Approved By-'---' --\���`'�~__~.� � ......................- ^^ ^^ �� � Date Application Disapproved for the f reasons:................................................................................................................ ........................................................................................................................................................................................................ Date Permit No............ ___ ____ THE COMMONWEALTH or MAssAoHuSsrrs BOARD OF HEALTH ---'Tg!��------��F_____Bazustable____________. TwWrtifir«44e of THIS {ST0 CERTIFY, That the Individual Sewage Disposal System constructed ' ) or Repaired bc----^I..'P^zuazcuuloa-c........................................................................................................................................................ ��� o�_____l6._Tl�i.�tl��__Dr_i,�!�__C��t����,�i_l_la___________________________._____..._._________________ has been instilled in accordance with the provisions of TLITI8 5cr The State Sanitary Code as described in the application for Disposal Works Construction Permit No...........9\&­-.ci4l-5~-' da1cd------.--.--.--.----. THE ISSUANCE OF THUS CERTIFICATE SHALL NOT BE CONSTRUED ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATUS Rl� «� �7�� [��T]�--------_-_-_______�_��_;I__�_��_��______ Io»p��oc_______ �__\ j________________________ THE COMMONWEALTH oFmAsaAo*ussrrs � BOARD OF HEALTH Town Barnstable .��--------------� --------------'--------- $ 20.00 I�u-_��� FoE'----�--'--^- Permission is hereby granted...........................j "m... to Construct ( ) or Repair ( X){ao Individual Sewage Disposal System ' at No.--lh...I.his-tle-IlI.....L----_----_.—.—.--------------'.------------------ -- / Street � ua shown oothe application for Disposal Works Construction Permit � ...............................7-.....`~--'...................................................... ��� \ / u"=u � H°�� � C��IE----------��� ... ................................. v � ST 1871 - —114a - 59z --- --62s -- - 171" --- ---33-z" - 24" -------72"----- ;' 24"--. -33a"_ 35 --43a,-_ 36a, _21�, 41$ 18"- 69 s' 14 e"_ 23e"- 24;, -52a,. - 66;,, --52„ - - 42" - / !2(-, _- A � „Im 7/ , ' ! y r t \.,'4 * �° (—. 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