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HomeMy WebLinkAbout0070 THOREAU DRIVE - Health 70 Thoreau Drive. Centerville P A = 191 186 , f No. 4210113 ORA a H col a V2 H(am 1000 c o o c y Commonwealth of Massachusetts W Title 5 Official Inspection Forme, Subsurface Sewage Disposal System Form - Not for Voluntary Assesgments �M 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name �Tf information is required for every Centerville / MA 02632 z March 19 2016 page. City/Town State Zip Code $..Date of Inspection wi 1-6 Inspection results must be submitted on this form. Inspection forms CA 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 David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Rapid Response �y Company Name 155 George Ryder Road South Company Address ,B Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ava��zN OF.MgS. Conditionally Passes _ _❑ Fails t ❑ Needs Furthe uatW�r th al Approving Authority ' COUGHA OWR N o. 93 March 19, 2016 Inspector's Signature SgN�TAR�PN Date The system inspector shall su it 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 0 �S Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 70 Thoreau DFive -Assessor's Map 191 Parcel 186 Property Address"''+ Connie M. and Anthony Aliberti Owner Owner's Name 0" information is required for every Centerville » MA 02632 March 19, 2016 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: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 77 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ❑ 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.orbreak 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments yF ^M 70 Thoreau Drive -Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19, 2016 page. Cityrrown 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 ..3 to or less than 5 ppm,'piro'vided 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 El ® 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 I ,M 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is Centerville MA 02632 March 19 2016 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and-nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system'the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19, 2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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): 330 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is Centerville MA 02632 March 19 2016 required for every , page.. Cityfrown 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 ❑ 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)): 267 gpd Detail 2014: 90,000 gallons 2015: 105,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current 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 holdingtank resent? Yes No p ❑ ❑ 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M, and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19, 2016 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: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons i 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19, 2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate'age of all components, date installed (if known) and source of information: Age: 8+ years. Certificate of Compliance for a new system was issued 9/18/2007 (Permit#2007-380 at Health Department). Were sewage odors detected-when arriving at the site? ❑ Yes ® No Building Sewer-(locate on site-plan): - - -- Depth below grade: - 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting,;_evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 0.5 • feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 x 5 x 6-1000 gallon Sludge depth: 6 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19 2016 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 28 in - Scum thickness 0 in Distance from top of scum to top of outlet tee--or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle - 14 in How were dimensions determined? Design Plan Comments (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grader feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is Centerville MA 02632 March 19 2016 required for every 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: ❑ 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at 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.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries - -- number: 1 I ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner. Cesspools (cesspool-must be-pumped-as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owners Name information is required for every Centerville . MA 02632 March 19 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately T HOoREAM DR§VC Q 2Lu THIS SKETCH IS BEST VIEWED.IN Cc p /�� COLOR FORMAT Q o L�Oo C A TQO,NS 3 LU —OF SEPTIC COMPONENTS a D }CYZ o —DISTANCES IN DECIMAL FEET u, WE(UNG 0 2 24.5 8.5 --- --- �� 0 3 --- --- 16.5 33.5 w O A C 1 SCREEN PORCH B '3;! DISTRIBUTION BOX 1000 GALLON 2 SEPTIC TANK NOT TO _ SCALE 1995 rOJ� i 508 364-0894 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19, 2016 page. Cityfrown 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: 25+ 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: 9/5/2007 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: Town of Barnstable GIS Department records indicate that the property is over 25 feet above the groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 70 Thoreau Drive-Assessor's Map 191 Parcel 186 Property Address Connie M. and Anthony Aliberti Owner Owner's Name information is required for every Centerville MA 02632 March 19, 2016 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 GEOHYDROLOGICAL PROFILE - NOT TO SCALE + I BOTTOM OF 'n LEACHING N GALLERY LEACH/NO IS ABOVE HIGH GROUNDWATER GROUNDWATER ELEVATION PER GIS MAPS t5ins-3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 YOU WISH TO OPEN A BUSINESS? =Yourformation Business certificates (cost$30.00 for 4.yea�s). A business certificate ONLY REGISTERS YOUR NAME in town [which o by M.G.L.-it does not give you permission'tooperate J business Certificates are available at the Town Clerk's Office, 1' FL., 367 t, Hyannis, MA.02601 [Town HaIll rn,ai n,nn c¢vua au rJg ways�"' Ov. O Z 0 U . Fi11 in phase: 11 USEu APPLIGANT'S YOUR NAME:_ r L Z,1 4 frANGO YOUR HOME ADDRESS: 9-0 -7 /Z6A t/ Od'� JOS- 22 �s43 TELEPHONE # Home Telephone Number 0 NAME OF IVEVN BU 3i E�'S I-r YA /t/f11 j s %/UT. 1m TYPE:0.1= BL751Nl=SS: A)IV T IS THIS A-HOME OCCUPATION?_ YES, �'� No... Nave-yov-1 a yive�s�pF,roiraa�f o tkia-buUdi rg-djtris nrt? `1N ��� ADDRESS'OF BUSINESS 20 T/-1 cQa?C-AtJ /i`' MAP/PARCEL NUMBER Barnstable. This form is intended to,assist you in obtaining the information you may need. You MUST GO TO 20�=in When starting a new business there.are several things you must do in order-to be in compliance with the rules and regulations of the Tow, of (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses.required to legally operate your b St.usiness in this town. 1. BUILDING COMMISSION 'S OFFICE This individual has be informed•of any permit requirements that pertain to,this type of business. uthorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual has b inform d f permi requirements that pertain to this type of bu5iness. , NNST COMPLY WITH ALL Auth ed Signature** HAZARDOUS MATERKS REGULATIONS' COMMENTS: . 3: CONSUMER AFFAIRS (LICENSING AUTHORITY). This individual has.been informed of the licensing requirements that pertain to this type of business. Authorized Signature.* COMMENTS: r T Date:��/� /d TOWN OF BAR STABLE TOXIC AND AHARDOUS AT IALS ON-SITE INVENTORY NAME OF BUSINESS: /��J �'� J BUSINESS LOCATIO 1:2 P INVENTORY MAILING ADDRESS: /ee12[/ i2 TOTAL AMOUNT: TELEPHONE NUMBER:_ �.� CONTACT PERSON: C) EMERGENCY CONTACT TELEPHONE N BER: � � 2 f o,� 3 MSDS ON SITE? TYPE OF BUSINESS: �� —�' INFORMATION/R COMMENDATIONS: Fire District: Waste Transportation: �� Last shipment of hazardous waste: �4 Name of Hauler. Destination: yJy/ Waste.Product: Licensed? Yes No 1%19 NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor & furniture strippers Other products not listed which you feel Metal polishes may e toxic or hazardous (please list): Laundry soil & stain removers re �� (including bleach)- lo�e21/ Spot removers & cleaning fluids or (dry cleaners) 4neI Other cleaning solvents Bug and tar removers �\,��y�`� Windshield wash �V ' WHITE COPY-HEALTH4A/RTMENT/CANAR COPY-BUSINESS 'ny"r+w ti_ _ .. _ _ -�.tyasa^.<^1�•r-•.c.'y�4.i9....-y'yT.��,it6J3s,'7�ro''�'f.^ay.'�7��N�-•,a.,:."..-'t„s"trh�.,._ ,.. _ -. TOWN OF BAR STABLE r� f TOXIC ANDMIARDUSNAT,O, IALS ON-SITE INVENTORY NAME OF BUSINESS: �J G C 0 BUSINESS LOCATION: �� U INVENTORY MAILING ADDRESS: �l��/___'et'y _ �- TOTAL AMOUNT- TELEPHONE NUMBER: ��) CONTACT PERSON: © g 0 / EMERGENCY CONTACT TELEPHONE N BER: / `�� MSDS ON SITE? TYPE OF BUSINESS: �< INFORMATION/R COMMENDATIONS: Fire District: I,. Waste Transportation: 1411147 Last shipment of hazardous waste: Name of Hauler: Destination: �? Waste Product: /1 Licensed? Yes No a NOTE: Under the provisions of Ch. 111 , Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants j Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED �IIII Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) r Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda i 'i Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) - -- NEW- USED=­ - -Any-other`prod ucts,with-'`poison"labels = - - Paint & varnish removers, deglossers (including chloroform, formaldehyde, . Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may e toxic or hazardous (please list): Laundry soil & stain removers 9 r (including bleach) ~r` �'� ore'dq k Spot removers & cleaning fluids (dry cleaners) c'" y��. F' Other cleaning solvents Bug and tar removers r ✓til/U �WJ��� Windshield wash �G WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS �� yt�tAnt S DIA.2.� 7racr — e � 1 k SEP-27-2007 09 :52 AN LYONS 5087909270 P. 01 Town of Barnstable Regulatory Services I * I Themou F.C*Hav,D inelar Pub& Health Division Thomm McKean,Director 2M Main Street,Hyannis,MA 02601 OWmB: 509-862-4644 fax! SM790-6304 Imo.RIdgM C efteaden Farm Date: _ 7 s�rx�e Permit# ( 7 3�'U AseaWs MaVTarceI_Lj Daigners ,Ll L—6 Address: r>U f C4�1- Address: 'If 1 vclo 7 4J) 62 On % 7 r '� Y fd�d y` , �!'L(? ._was issued a permit to install a ate- (inswer) septic stem at 2 r6 p system etd( I�' based on a design drawn by rr Lya�l. dte cK- /�-�ac�igner� ✓ I certO that%o septic system references above was installed substantially according to the dwip,which may includes manor approved changes such as lateral relocation of the distribution box end/or septic tank. T I ca* tiw the septic system mference:d above was installed with major changes (i.e. greater than 10 lateral Wocatiun of the SAS or any veutical.relocm ion of any component of the septic system) bat in accordance with State&Local Regulations. Plan revision or -built by designer to follow. ,+HtNtitif�t ►i tigg�g �m LIP a i '��4�I-t'1447y;o a+ - . ._ ...'1 e.. esigner s e (A&x Resign r s Mille) ELUSE REIM T AetNUAKA starer HL&M prmo 4 R CATS OF Q.He0%%MP6znt8iVW cerffiasc.„F6=31-26604,doc TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. 130,r SEPTIC TANK CAPACITY C®O® 011 LEACHING FACILITY:(type)AZ7 nqa f,I,�I ize) je L� NO.OF BEDROOMS OWNER PERMIT DATE: q-J-p'l COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY P 09 �3�9 r TOWN OF BARNSTA.BLE LOC �i� 1 � f 'cam —� /o � SEWAGE # VILLAGE 49! � '>�, -��i4 _ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 5L- LEACHING FACIL TY: (type)/���l (size) � a NO. OF BEDROOMS —5, BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leac 'ng Facility (If any wetlands exist within 300 feetpf le ' 'n a - ty) Feet Furnished c "5 Vlore,ac wa VQ 5 IWO- 1 � � i � ' jr2/% 1 " ,I . AN r o. .00004 �l Fee (/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZPPY%cation for amigo aY 6pftem (Con0truction Ver 't Application for a Permit to Construct( ) Repair( upgrade( ) Abandon( ) ❑.Complete System Individual Components Location Addressor Lot No. ,gyp-��J �- Owner's Name,Address,and Tel.No. jfiUr'a V ged `.7 y 7,nj2:4/r ID if- Assessor's Map/Parcel 4S-`7-aa�- Installer's Name,Address,and Tel.No. l uev l/ j �� Designer's Name,Address and Tel.No. L-1S* 1761_f J3f-790--iZ—A6 Al/7�cns�i) Type of Building: Dwelling No.of Bedrooms Lot Size sq Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 Q gpd Design flow provided 3 39 3 y gpd Plan Date _T Number of sheets Revision Date Title �fvR�s C, Sw ,c Size of Septic Tank 00e, /G4 L C�c,3�,ns Type of S.A.S.��) h1i--Cam l W�L,,�bJ Description of Soil s�_e p/G. Nature of Repairs or Alterations(Answer when applicable) Z, ,-- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B of ph A Signed :/ Date 1,5 Application Approved by Date __ Application Disapproved by: Date for the following reasons Permit No. cgjj 4^-3 Y, Date Issued ————— No. :;),Oo UO �: * ti '� ; D� 1 a+ Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplication for. Mig7Upgrde( ar 6pgtem �tCon0tructton Per it k Application for a Permit to Construct( Repair( ) Abandon( ). ❑.Complete System r� Individual Components � Location Address or Lot No. prp� �- Owner's Name,Address;and Tel.No. ///U. u d Yd d `�0 C%rJ ✓,/1>' vYr!'� -7V Tabu Assessor's Map/Parcel �91 Installer's Name,Address,and Tel.No. 36V),V1r/111 4-'CIJ '1 Designer's Name,Address and Tel.No. 170,_j &-°I? V g9�G y�.�'l, lJ, ,��'�- ray.7�0 �y-,Q 7r"n,1 ,f Type of Building: Dwelling No.of Bedrooms Lot Size Tf _4�f soft- Garbage Grinder ( � Other Type of Building No.of Persons rr "Showers( ) Cafeteria( ) Other Fixtures " .., Design Flow(min.required) 3 7 Q gpd Design flow provided 3 7 r/ ,,. gpd - Plan !Date —TCZ, ',2 $, .)C.QS— Number of sheets Revision Date Title C1 5ly C SyS 711,1 A�r-p�Pr .J /, .,,J1sS Size of Septic Tank /,OOo Gy L 6—A01,a5' Type of S.A.S.610 /A -611, 1 w CnC, �vsJ 'Description of Soil S�r PSG h Nature of Repairs or Alterations(Answer when applicable) /7 riff;lf_ Z rZ-1 C Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B of fh. = /� Signed Date p/ f/ Application Approved by _ Date =/ �- Application Disapproved by: Date for the following reasons Permit No. c44 7 C.0 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (/ Upgraded ( ) Abandoned( )by / �j►/� CCrJJ�r�7`ip�l at 7tl 7 lie a cJ �� Ira L/--,;4,4,A, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. .2�)�- — dated Installer /jeie j C'wJA^dz- froJ Designer GiT,* L�e-1 #bedrooms Approved design flow ? _, gpd The issuance of this permit shall n uarantee that 7/019t,77 the system I function as designe . Date Inspector A A�d� ��� ,'/;�6;I�� V d �� --------------------------- ----- ---------- No. o266 Fee �Q� -� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS =igpogal *pgtem Co 4tructton Permit - Permission is hereby granted to Construct ( ) Repair ( 17 U grade ( ) Abandon ( ) System located at `7� �hrl�cs�J /� •,�,!`+•-✓,�T and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. - Provided: Co struction must be completed within three years of the date of this,pe .it Date Cop Approved by I� 1 1.6 DATE : 6/19/0 PROPERTY ADDRESS: 70 Thoreau Drive ----------------------- Centerville ,mass . 02632 ------------------------ On the above date, I Inspected the septic system at the abo a ad ess. This system consists of the following; C' 1 . 1-1000 gallon septic tank . To 2 . 171000 gallon precast leaching pit . ( 6 ' X9 ' ) tia Fy�Te� BOG. Based on my Inspection, I certify the following conditions: tio��sT 3 . This is a title five septic system. ( 78 Code ) �F 4. The septic system is in proper working order at the present time . 5 . Waste water is 31" below the invert pipe of the leaching pit . �1 SIGNATURE :, _�1 ��yC1'Z�11 tiame _z_�._ Macotrber _r�------ � Company ; Joseph-P . -Macomber-& Son , Inc , � ddress Box 66 -------------------- __Cent: ervi11e , Me_- 02632-0066 Phone : --- 508- 775- 3338 --- --- ------------ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P, MACOMBER & SON, INC. Tanks•CesspooIi-LeachfIeIds Pumpod & Installod Town Sewer Connectlons P O Box 66 Centerville, MA 02632 0066 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:70 Thoreau Road entervi e , ass . Owner's Name:Char es Dow Owner's Address: 450 Orleans Chatham Road South Orlean 2602 Date of Inspection; Name of Inspector: (pplease print) Joseph P .Macomber Jr . Company Name;J . P .Macomber & Son inc . Mailing Add ress:Box 66 Centerville Mass . 2632 Telephone Number: CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: 1/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall s mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 f Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Thoreau Drive Centerville ,Mass . Owner: Charles Dow Date of Inspection: 6/19/0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: f 11") I have not found an informatio hich indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 C R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present . time . B. System Conditionally Passes: 4,�G' 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. I Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined" please explain. 4)b The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: t)& Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Thoreau Drive Centervil e ,Mass . Owner: Charles Dow Date of Inspection: 6/19/02 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. S,N•stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the System is functioning in a manner that protects the public health, safety and environment: /?i The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water u s pply or tributary to a surface water supply. • The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple. / The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Alb The system has a septic tank and SAS and the SAS is less than 100 feet but 5Q feet or more from a private eater supple tell••. Method used to determine distance "This system passes if the well water analysis, performed at a DEP cenified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be anached to this form. 3. Other: 3 Page 4 or I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM l PART A CERTIFICATION (continued) Property Address:70 Thoreau Drive Centerville .Mass . Owoer: Charles Dow Date of lospeciion: (n i l g I n g D. System Failure Criteria applicable to all systems: You must indicate "yes"or"no" to each of the following for all inspections: Yes No / ackup 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 Ll/Otl� Static liquid level in the Distribution box bove outlet inven due to an overloaded or clogged SAS or cesspool iluo- _ j6e Liquid depth in�cwpoo is less than 6"below inven or available volume is less than 'A day now Requited pumping more than 4 times in the last ycar NOT due to clogged or obstructed pipe(s). Number of times pumped /A.ny ponton of the SAS, cesspool or privy is below high ground water elevation. Any ponion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface rr/ water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ any portion of a cesspool or privy is within 50 feet of a private water supply well. Arty portion of a cesspool or privy is less than 100 feet but greater than 50 fect.from a private water supply well with no acceptable water quality analysis. lTbis system passes If the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis trust be attached to this forma (YesTO) The system fails. I have determined that one or more of the above failure criteria exist as described in 3 10 CMR 15 303. therefore the system fails. The system owner should contact the Boarc _ Health to determine what will be necessary to correct the failure. E Large Systems: To be considered a large system the system must serve a facility with a design now of io,000 gpd to 15,000 gpd. You must indicate either"yes" or"no" to each of the following: (7he following criteria apply to large systems in addition to the criteria above) des no _ he system is within 400 feet of a surface drinking water supply — Zhe 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 11 of a public water supply well !f you have answered "yes" to any question in Section E the system is considered a significant threat, or answered es" to Section D above the large system has failed. The owner or operator of any large system considered a s:en:f:cant threat under Section E or failed tinder Section D shall upgrade the system in accordance with 310 CMR 304 The system pwner should contact the appropriate regional office of the Department. 4 r Page 5 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Charles Dow 70 troreau Drive Owner: _Centerville ,Mass . Date of Inspection: 6/19/0 2 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No/ 1/ 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 pan of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up ? _ Was the site inspected for signs of break out ? ✓ _ Were all system components,eluding the SAS, located on site ? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no 'T!/ Existing information. For example, a plan at the Board of Health. — Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) (3I0 CMR I5.302(3)(b)) 5 Page 6 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:70 Thoreau Drive Centerville .Mass . Owner: Charles Dow Date of Inspection: 6/1 9/0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): ���� DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): �> =� Number of current residents: O t3W_4VT Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system ( es or no):4,�Q (if yes separate inspection required) Laundry system inspected(yes or no): WA Seasonal use: (yes or no): A16 Water meter readings, if available (last 2 years usage (gpd)): 2000-36 , 000 gallons=98 . 63 GPD Sump pump(yes or no): .tflP 2001-38 , 000 gallons=104 . 11 GPD Last date of occupancy: m7i'tr �( COMMERCIAL/INDUSTRIAL Type of establishment: AA Design flow(based on 310 CMR 15.203): 417 gpd Basis of design now(seats/persons/sgft,etc.): Grease trap present(yes or no): A�,Q Industrial waste holding tank present (yes or no):�/� Non-sanitary waste discharged to the Title 5 system(yes or no):'d/� Water meter readings, if available: ylQ Last date of occupancy/use: OTHER (describe): /14 GENERAL INFORMATION Pumping Records Source of information: ,fJditot? ,4;x0r A--,4 (J Was system pumped as pan of the inspection (yes or no): VO If yes, volume pumped: t_gallons -- How was quantity pumped determined? 161* Reason for pumping: 1W lYP OF SYSTEM Septic tank,dtst�i�i�ea�iax, soil absorption system io�sstingle cesspool 4.k?Overflow cesspool Privy 4?4 Shared system (yes or no) (if yes, attach previous inspection records, if any) .VZ)Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) /VTight tank 41,9 Attach a copy of the DEP approval .Ud Other(describe): ,(J Approximate a2e,of all components, date installed (if known)and source of information: &d se 2�"Wr� 1'%( - Were sewage odors detected when arriving at the site(yes or no): i 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 70 Thoreau Drive Centerville .Mass Owner: Charles Dow Date of Inspection:6/19/0 2 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: .Wcast iron _Z40 PVC /pother(explain): .tW Distance from private water supply well or suction line:,0f- Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight . No evidence of leakage . The system is vented through the house vents . SEPTIC TANK: (locate on site plan) 1cta0 A4)aV5 Depth below grade: '/,Zy Material of construction: I/concrete Vd metal,!/Qfiberglass4&j polyethylene 4v4other(explain) lb If tank is metal list age:4L/f is age confirmed by a Certificate of Compliance (yes or no):'�(attach a copy of certificate) Dimensions: Sludge depth rt Distance from top of s,clge to bottom of outlet tee or baffle: 3� Scum thickness: y` 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: As gdre2 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of.leakage, etc.): . Pump the septic tank every 2-3 years . Inlet & outlet tees are in place-The tank is structurally sound .Liquid level at the outlet invert is 51" GREASE TRAP44&(locate on site plan) Depth below grader Material of constructionvA concreteWA meta l,,A flberglass.d�olyethylene4O other (explain): .()i4 Dimensions: 1144 Scum thickness:_�1 Distance from top of scum to top of outlet tee or baffle: 4� Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Grease trap is not present . 7 r Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Thoreau Drive Centerville ,Mass . Owner: Charles Dow Date of Inspection: _6/19/02 TIGHT or HOLDING TANY4b"' (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: IdA Material of construction: A)A concrete X14 metal AM fiberglassAIri Polyethylene Aother(explain): A?R Dimensions. AM Capaciry: AN gallons Design Flow: W14 gallons/day Alarm present (yes or no): _414 Alarm level: Xji Alarm in working order(yes or no): Date of last pumping: A?,4 Comments(condition of alarm and float switches, etc.): Tight or o ing tanks are not present . DISTRIBUTION BOXA4&e_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:._ Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Di_s_tribut; on box is not present PUMP CHAMBER*C � (locate on site plan) Pumps in working order(yes or no): 4)4 Alarms in working order(yes or no): AO Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Pump chamber -is not present . 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Thoreu Drive Centerville -Mass . Owner: Charles now Date of Inspection' 7Z 1 A n 9 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) 1-1000 gallon precast leaching pit packed in lam ' stone If SAS not located explain why: Located ; See page 10 Type leaching pits, number: leaching chambers, number: ��► leaching galleries,number: G leaching trenches,number, length: leaching fields,number, dimensions: C7 overflow cesspool, number: innovative/alternative system Type/name of technology:/�,/2e Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to boney sand to fine sand No signs of hydraulic failure or ponding Soils are dry Vegetation is normal CESSPOOLS(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Q Depth---top of liquid to inlet invert: Depth of solids layer: A)A Depth'of scum laver: Dimensions.qf cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspools are not present .:., PRIvt'it,Idv )(locate on site plan) Materials of construction: Dimensions: _ 4 Depth of solids: Ally Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present . I 9 r Page 10 of I I OFFICLa.L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continucd) PcOPcrry Adoro,,:70 Thoreau Drive en t ervi e , Owoer s Dow Date of Intpcctioo: 67T772 SKETCH OF SEWACE DISPOSAL SYSTEM PTQ'ide t Ikctch Of the Icw1Ie ditPoltl tyllcm Inelvding llcs to at Ieast two permanent reference jLn mUkS of ocn<rvnvkt Lom< ill wcllt within 100 (cot. Locatc whcfc public water tupPly cnlcrs the bvilding. wsw l�Y,u 1W®r 10 Page 1 1 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Thoreau Drive Centerville ,Mass . Owner: Charles Dow Date of Inspection: 6/19/0 2 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: ,t2L Obtained from system design plans on record- If checked,date of design plan reviewed: /�A bserved site(abutting prope bservation hole wit in 150 feet of SAS) 412) ecke wit oca oar o ealth-explain: AN Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: h t t p : 11 t own , b a r n s t a b l e . ma . u s . You must describe how you established the high ground water elevation: Jsed ; Gahrety & Miller Model . 12/16/94 Ground water elevations above sea level . Jsed ; USGS ; Observation Well Data . June 1992 Jsed ; IIISGS ; Technical Bulletin. 92-000-1 Plate #2 . Annual Ranges of ground water lev, tions . r un Leaching /� Pit y 1" 'eet 1J T ' Groundwater: Feet Below Bottom of Pit I�igh,Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom Of the leaching it and the adjusted o P � groundwater table is?,�? feet. 11 `-•rrn r+•-n•rrr-•r•r•rn:mr•r�rs�•r.sen.rs-r:•.�•+•:+e+r:+rrrenrm r+s*�ta*a'RTs.r+•r .�•.rta--r-�r—.-..-.,r-.., TOWN OF Barnstable BOARD OF HEALTH J SUBSURFACE SEWAGE DISPOSAL ,SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••T'• •T••.-•..•—-. r.--T'rl,T.rn1•R:rT1 TT 1fTTt a1•:r••r+r-t'1."1n+r�1•mrr-T•�Rv1.r RTNn•s'fw1R1 n•n If .. -TYPE OR PRINT CI•EARLY'- PROPERTY INSPECTED STREET ADDRESS 70 Thoreau Drive Centerville Mass . ASSESSORS MAP , BLOCK AND PARCEL # 191-186 OWNER' s NAME Charles Dow PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber & Son Incr:e COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City Stet• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 790 - 1578 !'t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time ofeinspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : _Z/System: PASSED i The inspection t+hich I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have cona'acted has found that the system fails to Protect the Iltlblic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature r Date •- �•--gin=— - 0�nd copy of this t,ification must be provided to the OWNER, the BUYER ( where applicable and the 130ARD OF HEALT'il. * If the inspection FAILED , the owner or"'oporator shall upgrade ' the eyatem wit;liin one ,year of the date of the inspection , unless allowed or required otherwise as provided in 310 CHR 15 . 305 . partd .doc Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map11 Abutters Map Size . 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M i 1 _ t�,,11,4 .lt" BARNS ABLE ' 2008 SEP 26 PM 2: 23 DIVISION r � LOCA L SEWiiCkE PERMIT UO. VILAGE IWS . LER• ME �-ADDRESS__ - --$UILDER 5 Q &V A _ _ADDR.E SS Db\TE-P.ER"IT 1.55UED--� __ _D AT_E COMP_LI.A,tI10E _ISSUED ._. _ . �V No Fx�..., .. .... v THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OX H EA ........OF........... ..)k, Appliration for Miip .gal Morks Cnonstrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System. V 0e)-wroo f `r Loca -0es* ` or Lot,No f � Owner ddress - a ------------------------ .-------------------------------------------------------- ---------- = .................................................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............. .........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria PA Other fixtures ...--••-----•------•----•-----------•••-•--•-----• • . W Design Flow.................... _ .................gallons per person per day. Total daily flow.... =:__._:_.__..__......._...gallons. W Septic Tank—Liquid capacity ..gallons Length................ Width................ Diame ter......._........ Depth................ x Disposal Trench—No..... _...-..___ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.... � 5 ,% Diameter.................... Depth below inlet....._...... ...... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) d� _ /C - /f// Oyu Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ PT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil........ l'.._ _._..._. .._ . _hE _"/ , . .0 a4 — - ..__. � U Nature of Repairs or Alterations—Answer when app'licable.....................................................•._.___.___.__.__._.__.._....._........._._ ------------------------•--------•----•--•-------•-----.......•---.....• -- ..........�'- --- a ' Agreement: /� ` �'� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code— The undersihined further agrees not to place the system in operation until a Certificate of Compliance has been 'ssued by pth boar of health. Signed.... __ ,�-7 I �i Date ApplicationApproved By.................................................................................................. •-----------------------------------•-•- Date Application Disapproved for the following reasons--------------------------------------------------------------•--•-------------------.......--••---•-•---•....... - ---------•-••. .....-- Permrt No......................................................... Issued.. ..:............. ..............•--••-------• Date ........:........... ... LTH THEBOARD A OF ® ��AL L,sETTs Li ..Jlf... - .....OF....... .. ...... .................... Apphration. for Uiipviiat Works Tomitrurtion runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .... .. .........- ... ............ Lo d res + or Lot 0. ��?+v Owner fit#-u °ddress ,f Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............:. .Expansion Attic ( ) Garbage Grinder ( ) U aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 114 Other fixtures - -----------------------------•---•---••------------------------------ W Design Flow....................�7.6.................gallons per person per day. Total daily flow........ ._._ ..__............._..gallons. 04 W Disposal Trench tic Tank—LiquidNo capacity /_ gallons LengthTotal Lengthidth--_- Total leaching area__Depth................ Z /. Diameter--------------------- Depth below inlet.................... Total leaching area... ............sq. ft. Seepage Pit No...61" Z Other Distribution box ( ) Dosing tank '-' Percolation Test Results Performed by.::.:.................... W1 Test Pit No. 1..................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2..................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r4 --•---. { � - ----- O Description of Soil...............i� "' " ----sq -- +-� �j /. - YA , ? � UNature of Repairs or Alterations=Answer when ap'p ica. le..........._____________________________........................................................... ------------------•-•---•-•--..........----------------- ............ .... ...... Agreement: ,t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersillied further agrees not to place"the system in operation until a Certificate of Compliance has been •ss ed by AK boarA of health. Signed. :. - =- --" i - Date Application Approved B PP PP y............................--------------------•- Date Application Disapproved for the-.following reasons:... ..............= = --------------------•--••-•-•----•---•----..............------------------•--•-------------------------•---------•----•------------•............------------••••--.._...------------•--------••----•-•- Date PermitNo......................................................... Issued._:..................................................... Date .,� , . , • a :ti � ' c r � � � � � Ii { I �� � �� � � �. � � � .� � � �, � � � � �� � � �� /� _� � � �._�.� i � i r -.�� � .,a.�..�..�..,,,,.�.�.,_......�. ,.r_....�.....�,.y...� � � � ;t�, �' �� .� �-�- � 6 a t I 1 i S � 17 i 1 �a TALLON TANK DISTRIBUTION BOX HIGH CAPACITY INFILTRATORS C NOT TO SCALE NOT TO SCALE 102.5 COVER TO BEWITIIIN6"oFGRADE \ T INSPECTION PORT TO B=-WITHIN 6" OF GRADEI YA MIN. 12"COVER 4"s .40P. .0 4"SCE.40 r.v.0 y 3" 1/811-1/2" WASF.ED STONE 0.01 rdw. ' 311 - �4 98.25 " F. 97.65 j .0' .92' 4.0' 97.5 97.2 A 95.2 3/4"= lf2".J)QUBL> WA3HliD. TOI .•.. 1.08' 0.'op:STQNR . DERI,A C 1.51 25.0' 1 5' 9.0' 28.0' BOTTOMOBS 89.2' MAX. >3' ?4 HOURS ,OORDINATE M191 P186 .35 ACRES THOREAU DRIVE, WATER AS - --- - - ;: _ .. WOODED-AREA GARAGE TH 1 \ a, � i , . PROPOSED 7H`2> ; i i 4 INFILTRATOR 2' X10.83' X28' CREENE �"'`�i TRENCH PORCH t i VENT TO BE INSTALLED y� 1 y E LEACH PIT 1 0 TO BE n � �m h y: REMOVED • I f, BM — TAP STEP r � � T 4 5+a 4 i+ �, -, r. °r, R"•�r 'fir� SCALE 1 . 30 } �g y y