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Home My WebLink About0006 WASHINGTON BURSLEY WAY - Health 6 Washingon Bursley Way Centerville P A = 172 165 I i SENDER:COMPLETE THA SEC-r1ON COMPLETE THIS SECTION ON I ■ Complete items 1,'2,and 3.Also complete w _ A.S' re DELIVERY Item 4 if Restricted Delivery is desired. Print your name and address on the reverse X '' 9enf so that we can return the card to you. ' A ee ■ Attach this card to the back of the mail bY��?^n Name) of Delivery or on the front if space permits. [(� 1. ArtIcJB Addressed • D. Is elive to. ryaddress`d nit from its `11 ❑Yes If YES,.enteydelivery�ad below: ❑No tAy/< 3. Se � r/ ❑Certifi 130 c'ress Mall ❑Registered ❑Return Receipt for Merchandise O Insured Mall 0 C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes t 2. Article Number. i a, t (Transfer from servlce labs; t '### E E _ ! !E* d f E i#i i r !# Ott fill -it, 3 fit t .tt �it �i i dt ti PS Form 3$11,Febniary 2004' ,i ;Domestic Return Receipt 102595.024A-15401 I I r UNITED STATES POSTAL SERVICE . . , ... • Sender: Please print your name, address, and. is box ,M Town of Barnstable Health Division 200 Main Street Hyannis,MA 02601 c- . {y{{tt { 9 4 i {st { r r, 11111!ltitll'`111111lti'lf1111.11111171.111III111111111fillttl1i1f' Town of Barnstable. �FIHE: do Regulatory Services Thomas F. Geiler,Director BARNSTABLE, " : •��` Public. Health Division lFp�(a. Thomas McKean,Director 200 Main Street,.Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 28,.2006 Mr David Brajczewski 6.Washington Bursley Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,Title.5. The septic system owned by you located 6 Washington Bursley, Centerville, MA,was last inspected On June 26t'2006 by, Patrick O'Connell,.a certified septic inspector for the State of Massachusetts. The inspection of yourr septic system showed that your system has "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00).due to the following: Septic tank is structurally sound, leaching pit has been full to top of structure leaving system with no effective leaching. You have 2 years from the date of the of the system failure to bring the system in to compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEAL DEPARTMENT mas A. c ean,R.S., C.H.O. Agent of the Board of Health `I COMMO NWEALTH OF MASSACHUSETTS w ^ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION • M A� �t �O V 6�• TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 Washington Bursley Road Centerville MA 02632 Owner's Name: David Brajczewski — Owner's Address: Same 7 �. Date of Inspection: June 26,2006 Job#06-168 _' _ Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a Do�Rullt►ll approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: OFF Passes Conditionally Passes P yG HIC .m Needs Further Evaluation hv the Local Approving Authority o ;M_ X Fails 'C LL Inspector's Signature: Date: 6/26/06 �''�i,�� F��Q�Q•.�� I NSP 11EG� 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. Notes and Comments: Septic tank is structurally sound,leaching pit has been full to top of structure leaving system with no effective leaching. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 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. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No —X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _Yes_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply 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. Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks _X_ Has the system received normal flows in the previous two week period`? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X_ _ 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 stem Absorption S SAS on the site has been determined based on: P Y (SAS) Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:0 Does residence have a garbage grinder(yes or no): unknown Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):No Water meter readings, if available(last 2 years usage(gpd)): Two years total: 93,000 gal.=127 gpd. Sump pump(yes or no): No Last date of occupancy: unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1970's Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 BUILDING SEWER:XX (locate on site plan) Depth below grade: 1' Materials of construction:—X—cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: I Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Linuid level at bottom of outlet invert,tank is structurally sound with no evidence of leaks GREASE TRAP: No (locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" 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.): Liquid level currently at bottom of outlet invert PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 SOIL ABSORPTION SYSTEM(SAS):XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X leaching pits,number: One 6x6 pit _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.): Leaching pit has heavy staining indicating pit has been half full for a lone period of time Staining on too half of pit is light and solids were observed on top of inlet pipe indicatine pit has been surchareed over maximum operating capacity. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Washin ton Bursley Rd Water Service 2 36 47 8 • Page I I of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Washington Bursley Road,Centerville Owner: David Brajczewski Date of Inspection: June 26,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: A perc test will be performed prior to repair to determine groundwater elevation. Town of Barnstable �OFHE do Regulatory Services Thomas F. Geiler,Director u • .RARNSTABLE.; "''' Public Health Division �AT.Y639�A�0 FD kAA . Thomas McKean,Director 200.Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 October 4,2006. Ms..Joyce.W..Bird-Jezyk - 90 Wilton Drive Centerville,MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system owned by you located at 90 Wilton Drive, Centerville, MA was.last inspected August 28th by,Raymond Dumas, a certified septic inspector for.the.State of . Massachusetts. The inspection of your septic system showed that your system"Failed"under the .. guidelines of 1995 TITLE 5 (310 CMR 15.00) due to.the.following:. Single cesspools automatically fail in the Town of Barnstable. You have.2.years from the date of the system failure to bring the system into compliance... If there.are.any questions about this reminder,please feel free to.contact the Barnstable Health Department.. BARNSTABLE HEAL DEPARTMENT Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health gag/05 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �?a;� -�.�o Property Address: qD W.c.Pi - �6/- Owner's Name: Owner's Address: / c Date of Inspection: = { Name of Inspector.(please print) .,H va t� bU Company Name: D v,,�s}s c rdruse� �.vST• - Mailing Address: 4-g V AcA Ste€ �• Telephone Number. q-0 ES CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper fimction and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15—W of Title 5(310 CMR 15.000} The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Inspector's Signature: � o. ,. Q Date:- 17—aO—Oee 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. � . Notes and Comments .2- ****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 win perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 I t Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �fiLke�cu� �'�tc Owner: Date ' Date of Ins tin: 9--eP—r7G Inspection Summary: Check AAC,D or E/ALWAYS complete all of Section D A. System Passes: WO I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15304 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 thereplacem ent or repair,as approved b the Board of H will aPPI'o Y ealtb, Pass Answer yes,no or not determined(Y N ND)in the for the following statements.If"not determined"please explain- The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank fadure is imminent.System will pass iron 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 StrUd ally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: . Ft Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)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 obsh=W 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ci'0 W 11&'j, Owner: Date of Inspect n: V r U q-te -0 C. Further Evaluation is Required by the Board ofHeald,: N 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—VX1)(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 _phj Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9ca da Owner. Date of InspeMoR17 . D. System Failure Criteria applicable to all systems: You must indicate`W 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 cessp e/ ool �L scharge 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 40 Liquid depth in cesspool is less than 6"below invert or available volume is less than%Z.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. _NQ Any portion of a cesspool or privy is within a Zone 1 of a public well. 1Yq Any portion of a cesspool or privy is within 50 feet of a private water supply well. _40 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fafiure criteria are triggered.A copy of the analysis must be attached to this form.] V � (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 YYoou must indicate either`des"or"no"to each of the following- (The following criteria apply to large systems in addition to the criteria above) yes no c/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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: '7ro (414-&n r�t Owner. Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No t/ Pumping information was provided by the owner,occupant,or Board of Health ✓Were any of the system components pumped out in the previous two weeks? f Has the system received normal flows in the previous two week period? &/—fave large volumes of water been introduced to the system recently or as part of this inspection? i--"— 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: Yes no Existing information.For example,a plan at the Board of Health. _ ""'—Determined in the field(if any of the f dlure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 . 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: !'U �.c-f1.� - lq4tAo-� ./ Owner: Q+tr..,c z b.�L Date of Inspection: �, FLOW CONDFITONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):Z:�!3[if yes separate inspection required] Laundry system inspected(yes or no): 16S Seasonal use:(yes or no): vo Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Wo Last date of occupancy: yoa) COMMERCIALIMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design floK ftetc.): Grease trap presenIndustrial waste hnt(yes or no): Non-sanitary wasthe Title 5 system(yes or no):Water meterLast date of oc a OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_ N&?7 4d.4,!4,6 Was system pumped as part of the4nspection(yes or no): VV 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 — "-wr c.. tiP Overflow cesspool —ivy —Shared system(yes or no)(if yes,attach previous inspection records,if any) _InnovativeJAltemative technology.Attach a bopy of the current operation and maintenance contract(to be obtained from system owner) Tight tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if Imown)and source of information: /Yd T K glklaW f-{d d c r_ /3 v;t)- j 4Le i Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 5 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Ins on: 9-fa-DEo BUII DING SEWER(locate on site plan) Depth below grade: /,Z% sit Cl- Materials of construction: cast iron z_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK—(locate on site plan) Depth below grade: X0 Material of construction:_concrete metal fiberglass,_polyethylene other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: 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: /gocate on site plan) Depth below grade:— Material of construction: concrete metal fiberglass_polyethylene_other 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.}: Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Q Property Address: TO W Qa. Owner: h,A,c2 1 Z4-la Date of Inspect%n: Q— !Q—_0& 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/day. Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: NO (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.): PUMP CHAMBER A&L(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q0 1j) o�li► Owner. Date of insp SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not looted explain why: a2 ��e.�G�%Q .cam,., -Pa l An Type leaching pits,number._ leaching chambers,number: leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number. innovative/alternative system TypeJname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: C (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer.- Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:U(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic faihme,level of ponding,condition of vegetation,etc.): Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: U G[/zt ems- rills Owner• Date of Inspe 'on: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: go W-[.� Owner: QQik c A Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water o20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Heahh-explain: Checked with local excavators,installers-(attach documentation) &-A'ccessed USGS databaso-explain: You most describe how you established the high ground water elevation: Title 5 Inspection Form 6/15/2000 I 1 • -TOWN OF BARNSTABLE 50 tv,1 LOCATION SEWAGE SEWAGE# VILLAGE Cll tLu(.(1-C_. ASSESSOR'S MAP&LOT a 0 O INSTAII.ER'S NAME dt PHONE NO. .SEPTIC TANK CAPACITY LEACHING FACII.I�'Y: (type) .� Stnte� �g��oo,s (size) NO.OF BEDROOMS 3 - BUILDER OR OWNER - PERMITDATE: / 5 COMPLIANCE DATE: Separation-Distance Between the: Jt .. Maximum Adjusted Groundwater Table and 4 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) u(i0 Feet Edge of Wetland and Leaching Facility(If any wetlands exist N'�' within 300 feet o(leaching facility) . Feet Furnished by7 0%0 I s. r , P�1 - 31 i �ii bL' �� I I P .�Fi E Town of Barnstable P ARM : Public Health Division 1 '�F 200 Main Street 3o dam® CFO �a Hyannis, MA 02601 ®PITNEY BOWES r� 02 1 A $ 04.640 7005 1160 0000 0191, 1796 ` 0004606238 AUG29 zoos MAILED FROM ZIP CODE 02601 IVIr. David Brajczbwski 6 Washington Bursley " Z3 Centerville, Ga { RETURN TO SENDER -a NOT DELIVERAMLE AS ADDRESSES UNAGLE TO FORWARD DE: 926014002oo ;. � 02601 4002^ r� I J SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ❑Ageht X ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? [:]Yes 1 1. Article Addressed to: If YES,enter delivery address below: ❑ No., Mr David Brajczewski 6 Washington Bursley Road Canterville, MA 02632 3. Service Type ❑Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7005 1160 0000 0191 17 9 6 d (Transfer from service label) t} t 102595-02-M-1540 I PS Form 3811,February 2004 Domestic Return Receipt Town of Barnstable GF tHE 1p� o Regulatory Services .� BARNMB Thomas F. Geiler,Director 9E�, Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 28, 2006 Mr David Brajczewski 6 Washington Bursley Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 6 Washington Bursley, Centerville, MA,was last inspected On June 26th 2006 by, Patrick O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under the . guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Septic tank is structurally sound, leaching pit has been full to top of structure leaving system with no effective leaching. You have 2 years from the date of the of the system failure to bring the system in to compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. B3mas"A. ABLE DEPARTMENT , , C.H.O.Agent of the Board of Health L osr n t1(TG1TTJG2 01 v(�_' .l l l ._ F �. t l `Tj i ]:)'(, 1; U:; [0 (UG LOT`!ATfJa: _ :Jl TOWN OF BARNSTABLE L° CATION SEWAGE# `J0016 '379 =Y'ILLAGE ASSESSOR'S MAP&PARCEL -7 INSTALLERS NAME&PHONE NO. `7-7 SEPTIC TANK CAPACITY 100e) v LEACHING FACILITY:(type)Z-Soo mkt C"JwJ '(size) td K& `A Z! NO. OF BEDROOMS 3 OWNERv;c�l c'ca9 GZ�P.c�S PERMIT DATE: :91Zg1& COMPLIANCE DATE: RI n- 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 n Cape- Enaixe-e—t i�g �11 /(�� AZ-� . "At 43-GZ 0 � I T WN OF BARNSTABLE �- LOCATION V (.t1a5h/n ✓' S ~' p -- � �+1 �e*,I SEWAGE#��f 'VILLAGEAV; teruw`k1C ASSESSOR'S MAP&PARCEL 17,97 16 NAME&PHONE NO �*r t'�1� QCo► ,�� I?'1 SEPTIC TANK CAPACITY ICOa LEACHING FACILITY: (type) (size) 1000 NO. OF BEDROOMS 3 OWNER J (bZ0-Zad5 k' PERMIT DATE: C9?*PftAaMft DATE: 60 �t'p 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 Washin ton Bursley Rd _ ater 1 eMce 2 36 47 8 fat r TOWN OF BARNSTABLE LOCATIO i� ,LJ SEWAGE # _ �a VILLAGJ:AiXP / ASSESSO MAP &LOT 11—O z�NNIVaS NAME&PHONE NO,:� VO IM47 SEPTIC TANK CAPACITY /000 6?oI1 n di:,2 y/-t �C/"`�-r✓� LEACHING FACII.TTY: (type) r�i �/� (size) gal NO.OF BEDROOMS BUILDER dR OWNER�06�n PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ' Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le chin facil� IOL4-716 Feet Furnished by �0 (!C�/7<S 7/,�.Ccr`/aq,�le. �� • � d ,�q� O �` - ' �� ,� �� n� No. � Fee /d 0 T THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Mi!6pool *p$tem Con!6truction Permit Application for a Permit to Construct( )Repair(Vrupgrade( )Abandon( ) ❑Complete System W4vidual Components Location Address or Lot No. 1.1* s�v 4,n J3vv 5/11 1r197 Owner's Name,Address and Tel.No. Assessor's Map/Parcel (o WaJS,.s 5 r�jJ i3��J fit) 7 Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No. 13or-4,�l,- C4pY Hrs11 C�uf�t 1-c n i) �7q n'.1 v S� -W. ol fs q Type of Building: Dwelling No. of Bedrooms _ Lot Size/ o 1�0 sq.ft. Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 730 gallons per day. Calculated daily flow 3 3 6' gallons. Plan Date )9�� 7 o& Number of sheets / —t Revision Date Title t S. `elk? , o 6 aee,)4,4 �� ,JOjJ/,% 4 JC- Size of Septic Tank-, /, ©G Gr,1 Z%;t,S2�iv,c Type of off— Sam G�t' Clams 6,3 30�X cl.$J sl ' Description of Soil S" Nature of Repairs or Alterations(Answer when applicable) ��t e 1 G r L-r L G�cz C�t i Yt 5' 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 Certifi- cate of Compliance has been issued th' B d Healt Signe Date Application Approved by Date Application Disapproved for the following re Permit No. Date Issued No. Fee /00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ' ZIpprication for Migaar bp!6tem Cowaruction Permit ' Application for a Permit to Construct( )Repair Z)U grade Abandon Complete System VIrdividual Components Location Address or Lot No. )ja S n i'141 Owner's Name,Address and Tel.No. G--o 1�rr✓i 1!e L�Iv/!. ry¢y'G Z M•rv!�t Assessor's Map/Parcel 2a `� �,rr tA7/ Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No. N 1-4?1<, A)-) 971 VG,v 5 Type of Building: Dwelling No.of Bedrooms Lot Size !,O z/0 sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3 3 G gallons. Plan Date )9,,-) 16,2604 Number of sheets 1 Revision Date ' Title s Sr Plea o �p ar,3k, 75 /V, 1�ej jl, ejc-y Size of Septic Tank 4 OoG Ga C C-X 5 A"!S Type of S.A S. d' ��G� "OM 4— 30 "4 q.;J � � Description of Soil: Nature of Repairs or Alterations(Answer when applicable) z"Plq c r• G `,� L- 4 ►vI A 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 Certifi- cate of Compliance has been issueddP this Board.of Health. Signe /' � o Date Application Approved by Date Application Disapproved for the following re or, V Permit No. W Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (-Comptiance THIS IS TO CEaTIFY th t the On-site Sewage Disposal System Constructed( )Repaired (!/<Upgraded( ) Abandoned( )by l r; d 1 J # Cow S7wuc to y at 6, 1 n /e,v 1. '"S Y Geri �.n ��/� P ha Aconstructed in accordance with the provisions of Ti 5 and e,for Disposal System Construction Permit N©, ' ated Installer � - ' `' Designer E'The issuance of this pe�rmi)shalino�e+ construed as a guarantee that the yste wi�.u ction as a ig d. Date '� CJ Inspector ` No.--�� — -------- ———————Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migoat *pgtem S�Con!5truction Permit � Permission is hereby granted to onstruct( )Repair(r/)Upgrade( )Abando ). System located at G�JGS �� `�� 1�orS�*y GCJG , I and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Consttr�uc 'on n t^be c mpleted within three years of the date of this Dpeit // Date:_ 1 (� Approved by PP � r TOWN OF BARNSTABLE u LOCATION /5 VILLAGE ASSESSOR'S MAP&PARCEL I :Z '0 INSTALLER'S NAME&PHONE NO. ��'y �s SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 1a 1 geQA`IK `J,J (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: 1 I v 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 � � � 3qce m�,�/a o ,,- RECEIVED OCT 2 2 2003 COMMONWEALTH OF MASSACHUSETTS BLE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS T�L�HEALTN OF H DEPTH Z W DEPARTMENT OF ENVIRONMENTAL PROTECTION w d MAP n �o1M SJe�o PARCEL TITLE 5 LOT OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner's Name: DAVID KICILINSKI Owner's Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Date of Inspection: 10/6/03 Name of Inspector: (please print) JOHN GRACI,INC. COPY Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function 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: X Passes _ Conditionally ses _ Needs Furth aluation by the Local Approving Authority Fails Inspector's Signature: Date: 10/6/03 The system inspector shall submit lopy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectif 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 SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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 S Incnectinn Form F/1 50000 � Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a 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: n/a n/a 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: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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 n/a "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped SYSTEM HAS NOT BF PUMPED IN THE LAST YEAR PER OWNER- - X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection '? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site`? X _ 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 ? X _ 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 X _ Existing information.For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] I S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): YES Water meter readings, if available(last 2 years usage(gpd)):aLa, UZ—Q ,J -0 Sump pump(yes or no): NO i"" Last date of occupancy: 10/1/99 �0 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system (yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: SYSTEM HAS NOT BE PUMPED IN THE LAST YEAR PER OWNER. Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1977 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO C Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 BUILDING SEWER(locate on site plan) Depth below grade: 20" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 14" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10"" Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 1 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD I' OF LIQUID IN IT AT TIME OF INSPECTION.BOTTOM IS AT 10 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ln.r �J�nLAU I ja C r, e Rp qb � aa� BC 3 i t� 3� �n Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 WASHINGTON BEARSELY WAY CENTERVILLE,MA 02632 Owner: DAVID KICILINSKI Date of Inspection: 10/6/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to.ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. it BORTOLOTTI CONSTRUCTION, INC. • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop c�/7/ 5Z5� 1. - - ------ ------------ -- ----- ----------- -- - - ---------------- ---- --.. - --- —----- - - Date of Inspec) Ma arcel Owner CHECK IF THE FOLLOWING HAVE BEEN DONE: PART A — CHECKLIST PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE 9 SI EfN U 113FEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCE I THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED, NOTE IF THEY ARE NOT AVAILABLE WiTf H, THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. 2 (-THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. __,,(,-ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. --I,-THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC`.TTANi y_W S'IN, Ebb FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,<DEH OF"SL• GE, DEPTH OF SCUM. HE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. -/-'THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL — -- No of Bedrooms -- ?_ _No of Current Residents Q Garbage Grinder LDS Laundry Connected to System Seasonal Use NON RESIDENTIAL: - Calculated flow WATER METER READINGS,IF AVAILABLE: Pumping Records an GALLONS]d Source of Information: J / SYSTEM PUMPED AS PART OF INSPECTION? �IF �VOLU�MEPUM�PED = GALS Reason for Pumping: TYPE OF S TEM: I Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes,attach previous inspection records, if any) Other(explain) Appr ximate age of all components. Date installed,if known. Source of information. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI ON FORM s PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below grade: /I Dimensions: Material of construction: Concrete Metal FRPO Other} Sludge Depth Distance from top of sludge to bottom of outlet tee or baffle Scum Thickness Distance from Top of Scum to ,p of outlet tee or baffle Distance from bottom f Scum to bottom of outlet tee or baffle �y Com ents: DISTRIBUTION BOX: ( DEPTH OF Comments: LIQUID LEVEL ABOVE OUTLET INVERT PUMP CHAMBER: Pumps in working order? Comments: SOIL ABSORPTION SYSTEM (SAS : IF NOT PRESENT,EXPLAIN: TYPE: — / �� _ v ; Cc m ants: �J t i '< co 7 CESSPOOLS: Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Materials df construction Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' 0 31 I� DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: �'oX%n��t �a �► S 1, - '� i�la�^ Flo /mil SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI ON FORM PART C — FAILURE CRITERIA / (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.) ��/ Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? A Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Aj Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? I� Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? N Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for col'iform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS j COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT I CERTIFY THAT 1 HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION 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 O : I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED AREAS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: —7 1 ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY r LOiCATION f SEWAGE PERMIT 0.- o hi I�SI VILLAGE r e INSTALLER' NAME & ADDRE;SS v" B UI'LDE R OR OWNER Al�►. _ � DATE PERMIT 'ISSUED g MPLI A ISSUED DATE CO NCE � l 2. r ' r I c � a yv�� /a J t � � 17a;7 No" U--- F>mc... J�..................... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD F HEALT )31. Appliration -fur 15itiputitt1 Works Tonfi#rurtion Vrruift Application is hereby'made for a Permit to Construct ( ) or Repair ( } an Individual SewageZisposal System at: ,Location dress T,nT r Ns. Owne;,� Address Installer Address // Type of Building Size Lot.,lS/,47R�____-Sq. feet Dwelling—No. of Bedrooms----------0...........................Expansion Attic (AVZ Garbage Grinder (IW40 aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------------- W Design Flow............................................gallons per pet-son per day. Total daily flow........ ....................................gallons. WSeptic Tank—Liquid capacit�"gallons Length---------------- Width_.............. Diameter----..-------_ Depth.-.-----_-.-.-.- x Disposal Trench— o.................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.... , _�'Diameter-------l --------- Depth below inlet____________________ Total leaching area-------_. .......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------- ---------------•-----••-------•---.........._.....------•-------- Date--.---••-------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-.._.-_---__--____-. Depth to ground water....---..-_---.--.--.. (_, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_..-.-..__-----..-.--.- ------------------- ----------•------- O Description of Soil-----.........L_6lIfS ........Slf-�-----------TU----------��_-'77 x --------------------------------- ------- ----------------- -- V ----------------------- ----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- Z ------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------- U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------.-_--..-__-_---_--.--.--. --..-----------.--------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ued by the boar �ealth.Signe -- -. --- ---------- ---- ------- e-� ................................ O .7-7 Date Application Approved By______________ _ '`L to -.�.0. 7 7 . -• -------•----•-•••--•••--•----------••••--•------------------------------• ---..._........-----..... Date Application Disapproved for therollowing reasons-------------------------------------------------------------------------------------------- a.t.e.............. ------------------------------------------------------------- -••-•-------------------......•--------•--. .................. Date PermitNo.---,?.r-zp�-----------------•--------------- Issued........................................................ Date 4 16 No.-•••--•......--•••••.-- FEs.... la.................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ' . f . .1 / Application -for 43iiposttl Morkii Tomitrurtion Vauld Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: t Location-.Address or Lot No. Owner - Address .................•••••••. --- •-•••-•...........---'•-••--••..................' ...............,-f_.. o d--! Installer Address d Type of Building Size Lot_Z_._: ......`.-).....Sq. feet Dwelling—No. of Bedrooms---------- -- ------------__.---.-.-_.Expansion Attic O v)(. Garbage Grinder (/►.)Q pa, Other—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow............................................gallons per pet-son per day. Total daily flow.....__-:s, G.._._._------------._-.--gallons. WSeptic Tank—Liquid capacity's'__'_`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 ( ) Percolation Test Results Performed by------- ---- ----_------_-............................................ Date-------------------------------.-..----- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water...._---.-_-..--.-..... f� Test Pit No. 2................minutes per inch Depth of Test Pit_------------------ Depth to ground water........................ n; ---•---------------- --------••--------------............................................................................................... ............... 0 Description of Soil---------------- - a/,, 4 '- -j✓ / �r V --------------------------------------------------------------------------------------------------= Gil x ••--•-------------------------------------------------------- -_---•-------------•-•--•-------•---•------•------•--•--------•------•--------------------------•------------------------•---------------- U Nature of 'Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------- --------------------------------------------------------------•-------------------------------------•--------•------------•--•--•------------•----------------•-...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board.of.health. Signed........ . c - L«11 1 -�--• / _ 1 7 •-- -----•--•---------•--•----------------------------------- ----------------------- r Date ApplicationApproved By----------- ----------------------•--------------------------------•-••------._...••-- .............. •--•- '' `- bate Application Disapproved for the following reasons--------------------------------------------------------------------------------------------------- ------------ ....................................................... --•---••-•-------------'---"----•.................................---------------------------------------------------------------------------- Date PermitNo.- �L �--------------------------------•..... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF........../.,... .n......l....:................................................. Trdifiratr of 0,11utpliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) r Installer /, .� t r //,r / at. _......•'--'------•-•--••--•----•-•••••'--.------------- •--"---------------------•----------•--------.--•------------•-----------•----•-------------•-------_------------ has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... _!!r________________________ dated........ __,_. ----------�._?._.._____........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS / lit 4 BOARD OF HEALTH "e, t.j Il e . ,. > O. --'=---=------------- FEE_ ........................ �i��o�ttl ork� �o�t�fr�tr�i�at �rrTatit Permission is hereby granted ..----------- .=' `:=r----------- ;-=. ' to Construct (x ) or Repair ( ) an Individual Sewage Disposal System atNo-------------------•'--••••...... �•---- ' Street' . r, £ as shown on the application for Disposal Works Construction Permit No---- ----- ----- Dated__-.__f_..'___-..?......___-•--..-- . .. ..�!- -------- DATE. 1!f— 7 >Board oflI641;f------------------------------------- ----------------------------------------------------------- / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i i J /c7 (OZ PeoP P.r .f0 fsr' O Peo o �C? LIN i,t — ' t 15f , R { CE 0-TI P ID LdcA*ricvtJ C_1=NT�2�/lGt,,C GMVTtf=Y Ti4AT' T!-1G 1-avhlD�j'tb►.� SUawt.1 pt-4t~! 1Zr=pEzc�Jca NEQ�L�►,1 CChAAPLYS WIT" TWE �IDELIt-lEr � G� A$QtD SETPaACVG VGQU(CeM E:"TS DF= Tt4e TowL� O� 'q�A e�.1yTA'�L.0 '�j DATlr �D�za '7 1 tP' L Dk. 30(� p(� �•-.�a aA7CTEtZ WYE= cZCGIStt1Z�D LAWO SUeVE-(OtZ.S T%4IS VLAW t5 WOT G,AgEt7 ca AW 0STE2V%t_LG o toA.SS JSt'Cc��.1; SvcZv Y TtlC c�r~C'; �'S St4owts> APPL.tCA,► -r .bT EC USGU TO DC1:TEZMitlE L.0"r' Ltt.le5 l AA4" SYSTEM PROFILE NOTES Wequuquet TOP FNDN. AT EL. 62.3' Luke ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT M SCMI) ACCESS COVER TO WITHIN 6' OF FIN. GRADE APPROXIMATE NGVD ACCESS COVER A 1. DATUM IS o o WITHIN 6' of FIN. GRADE UNICIPAL WATER IS EXISTING /- a _4 /r6-1.4 MINIMUM .75 OF COVER OVER PRECAST / 2X SLOPE REQUIRED OVER SYSTEM 61.0' 2. M o ood _ I } * 60.3' RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. Loker+ EXISTING FOR FIRST 2 OR GEOTE MLE FABRIC «EXISTING 1000 3' MAX. 4_DESIGN LOADING FOR ALL PRECAST UNITS TO' BE AASHO *EXISTING GALLON SEPTIC TANK P5�8.9 S. SUMP H 10 �, E 59.18' 1774f- FLE58.62' "�� 58.45' S. PIPE JOINTS TO BE MADE WATERTIGHT. �; �aoc DODO 0 0 0 0 0 Cb 58-38 Q p 0 .0 0 0 0 0 p o 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH � \-- DEPTH OF FLOW 4' 6' CRUSHED STONE OR MECHANICAL p p l] p p p p p p COMPACTION. (15.221 [2)) 2' p p p p p p p p p o 56.38' MASS. ENVIRONMENTAL CODE TITLE V. LOCUS SIZES: .. . _ INLET DEPTH = -1-0" _3/4" TO 1 1 2" DOUBLE WASHED STONE 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO . / BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. OUTLET..DEPTH 14" ( _Ix SLOPE) (1 x SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. R006 28 FOUNDATION EXISTING SEPTIC TAN 28' -p'--BOX_ _. 9• LEACHING FACILITY 6.38' 9. COMPONENTS NOT TO BE BACKRI I ED OR CONCEALED SCALE: 1 " - = 2,000"± _------ •'=`- ---___, - ______ __ ' ' WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD, OF HEALTH. ! *THE INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM MIN. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING ASSESSORS MAP 172 PARCEL 165 LOCATIONS"'OF ALL UTILITIES AND A EPTIC TANK SIZE AT 1000 GALLONS AND DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION LOCUS IS WITHIN AP OVERLAY DISTRICT � B SUITABILITY FOR RE-USE BOTTOM TH-2 EL 50.0' OF ALL UNDERGROUND & OVERHEAD. UTILITIES PRIOR. TO I PRIOR TQ INSTALLING- ANY PORTION.. OF.- S I S COMMENCEMENT OF WORKS SEPTIC .SYSTEM �->> 11. EXISTING LEACH PIT SHALL BE PUMPED AND FILLED WITH CLEAN SAND OR PUMPED AND REMOVED. . i 12. ANY UNSUITABLE MATERIAL-ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED i LEACHING FACILITY. .LEGEND SYSTEM DESIGN: 100.0 PROPOSED SPOT ELEVATION GARBAGE DISPOSER IS NOT ALLOWED i / DESIGN FLOW: 1 BEDROOMS 0 110 GPD = 330 GPD +i00:00 � EXISTING 'SPOT* ELEVATION / USE A 330 GPD DESIGN FLOW 1 00_o PROPOSED CONTOUR > / TH-1 - - 100 - - EXISTING CONTOUR SEPTIC TANK: 330 GPD (2) = 660 6� 30.0 *RE-USE EXISTING 1000 GAL SEPTIC -LANK TH-2 .of , LEACHING: SIDES: 2 (30 + 9.83) 2 (.74) = 118 GPD BENCHMARK �5 oo+ BOTTOM 30 -x 9.83 (.74) 218 GPD j TEST HOLE LOGS CORNER CONC. ] , 60 � BULKHEAD �h. L � TOTAL: 454 -S.F. 336 GPD ELEDAVID FLAHERTY, R.S. - ENGINEER: p rn USE (2) 500 GAL LEACHING CHAMBERS (ACME OR EQUAL) DAVE STANTON, R.S. WITNESS: - WITH 4' STONE AT ENDS, 2.5' AT SIDES AND 5' BETWEEN -UNITS - DATE: AUGUST 15, 2006 \ PERC. RATE _ < 2 MIN/INCH �'�/ EXISTING SEPTIC TANK l ON, LOT- 102 UTILITY `, `' 'cF 15,040 SFt ; CLASS I SOILS # CLUSTER. lg MA �. o \ APPROVED DATE BOARD OF HEALTH 4 _ " � ELEV. . � ELEV. V' 61.3' on 61.0' ( TITLE 5 SITE '. PLAN A A OF . LS LS \ 10YR 3/2 10YR 3/2 so.2' ``�`° �s2--' EWIING _ oN�,DN 6 WASHINGTON BURSLEY WAY 10 60.5 10" \ 3 BR DWELLING e \\ TOP OF FNDN=623'\ (CENTERVILLE) BARNSTABLE, MA ly ��LS LS / �\�F' I PREPARED. FOR '9S \\\ � 10YR 5/6 • " 10YR 5/6 y s 32„ 58:6 / \ 26 58.8 \ BORTOLOTTI CONSTRUCTION/ i �o \\ DAVID BRAJCZEWSKI PAVED I _ C 2 �� o. RIVE i PERC , DATE: AUGUST 16, 2006 i E MCS MS l�< ��\ •��0• off 508-362-4541 2.5Y 5/4 2.5Y 5/4 !y �`` .a . fax 508 362-9880 5% COBBLES 5% COBBLES j�°F +s ��H ofs o� ARNE H. ti� i 14, AH EN� � down cape engineering,' inc. o o OJALA OJALA y CIVIL C/1//L ENGINEERS No.26 8, No. 0792 LAND SURVEYORS 132" 50.3' 132" 50.0' �oF o�'P �'o NO. GROUNDWATER ENCOUNTERED - Scale:1. 20' 8f�6 �q \ s/ONAL E�'G\? 939 Moin Street - YARMOUTHPORT, MASS. 0 10 20 30 40 5o FEET DATE ARNE H. OJAL.A; P.E., P.L.S. E DCE #06-180 06-180 130RT0L0TTI_BRAJCZEWSKI.DWG (DDF) C