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HomeMy WebLinkAbout0051 WATERMAN FARM ROAD - Health 51 Waterman Farm Road w� Centerville P A = 206 098 TOWN OEPARNSTABLE LOCATION S �ATee,rM� 1��41M SEWAGE# VILLAGE CC,/t 1 e rv,1L4­ ASSESSOR'S MAP&PARCEL OCl,? INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY CM'J LEACHING FACILITY.(type) /^ ��� �/� DES (size) NO. OF BEDROOMS 3 OWNER PERMIT DATE: 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 TA SthlAyr1 �D/ /a-�O-I 1 ,. 3 a i O O Li a ay 3a 3 13 j(v COMMONWEALTH OF MASSACHUSETTS a 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: 51 Waterman Farm Road Owner's Name: Centerville, MA 02632 Joseph Corsiglia ` Owner's Address: Date of Inspection: AN 24. 2009 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reportedi below is true,accurate and complete as of the time of the inspection. The inspection was perforgred based mmy p Q.,. training and experience in the proper function.and maintenance of on site sewage disposal syst-e�t . I am a`$EP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) The sY m: -v ✓ Passes Conditionally Passes Nee Further Evaluation by the Local Approving Au,hority Fail 7> Inspe.ctor's Signature: Date: August 4. 20 9. The system inspector shall subt a copy of this i spection 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 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 Waterman Farm Road - Centerville MA Owner: Joseph Corsiklia Date of Inspection: July 24, 2009 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: 2 -- I Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: SI Waterman Farm Road Centerville. MA Owner: Joseph Corsiglia Date of Inspection: July 24, 2009 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 aseptic 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSM ENTS SUBSURFACE SEWAG E DISPO SAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 Waterman Farm Road Centerville, MA Owner: Joseph Corsiglia Date of Inspection: Julv 24. 2009 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No — ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— _ ✓ Any portion of the SAS,cesspool or privy is below high groundwater elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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 System: 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered `.`yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: SI Waterman Farm Road Centerville MA Owner: Joseph Corsiglia Date of Inspection: July 24, 2009 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 nonnal 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: Yes No ✓ 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(3)(b)). 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 51 Waterman Farm Road Centerville MA Owner: Joseph Corsiglia Date of Inspection: July 24, 2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): N/a 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: 1 Does residence have a garbage grinder(yes or no): n/a 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): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently 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 Source of infonnation: Unavailable 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: Date unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSES SMENTS TS SUBS URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: SI Waterman Farm Road Centerville MA Owner: Joseph Corsiglia Date of Inspection: July 24, 2009 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Continents(on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" 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: 1000 awl_ Sludge depth: 21t Distance from top of sludge to bottom of outlet tee or,baffle: 30" Scum thickness: 4 f Distance from top of scull,to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 101, How were dimensions determined: _ Measuring stick Cotninents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,'etc.). Tees were Present. The inlet cover was 8"below. Recommend yuniyin every2 years GREASE TRAP: None (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.): 7 • 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: 51 Waterman Farm Road Centerville MA Owner: Joseph Corsizlia Date of Inspection: July 24. 2009 TIGHT or HOLDING TANK: None (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: OX: None (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: None (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTA RY RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Waterman Farm Road Centerville MA Owner: Joseph Corsiglia Date of Inspection: July 24, 2009 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: _ infiltrators 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 . g failure level� Y el of ponding, damp soil, condition of vegetation etc. The infiltrators were /z full and There did not anoear to be anv si ns offailur e The bottom to g1 ade was 3 5' A camera was used to inspect infiltrators CESSPOOLS: None (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: None (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.): 9 I • Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Waterman Farm Road Centerville MA Owner: Joseph Corsiglia Date of Inspection: July 24, 2009 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Li s-ro�.. 3 a � i acl, a-► 10 Page 1 I of 11 " OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Waterman Farm Road Centerville MA Owner: Joseph Corsiglia Date of Inspection: July 24, 2009 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of.design plan reviewed: ✓ Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:' You must describe how you established the high ground water elevation: Using Barnstable topoQi chic may and water contours map Ma House has a full basement and is dry. p is showing Iy 0 to err oundri ater at this site . This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 ---��� ✓/ I / 1 I �� I� I i j FORM30 C_ HOBBSR WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOAJR D O'ER E LTH CITY TO N a lqal�o �D�PAR M _�/m. /9 IA"I< ADDRES f'/� 1M S�y`0 � ,�j� _� TELEPHONE Address ff j kb� Y� � Occupant /� Floor Apartment No. No.of Occupants No.of Habitable Rooms__No.Sleeping Rooms__ No.dwelling or rooming units No too'es Name and address of owner 1�� �1 6F Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: + Drainage i Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney:- BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom —Pantry Den —Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPQRT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI P Y. INSPECTORJQ� TITLE A.M. DATE TIME A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall'in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the,legal obligation of the,person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by-105'CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. Sullivan Engineering Inc. 7 Parker Road, Box 659,Osterville MA 02655 508428-3344 e-mail: psullye(a)aol.com fax 508-428-3115 April 12, 2007 Mr. Jeffrey Rudziak Director of Assessing Town of Barnstable 367 Main Street Hyannis, MA 02601 RE: 51 Waterman Farm Road, Centerville Dear Mr. Rudziak, It has recently come to the attention of the Trustee of the property located at 51 Waterman Farm Road that the property is only assessed for two bedrooms. The Trustee and his brother constructed the house around 1966, and it is, and always has been a three bedroom dwelling. I have attached an affidavit from the Trustee stating such, as well as page 1 of a recent septic inspection, which states that the existing septic system passes. I trust this meets your present needs. If you have any questions, please feel free to call. Very trul ours, ; John O'Dea, EIT Sullivan Engineering Inc. cn Cc:Board of Health . Building Department CX� Joseph Corsiglia a+, Members of The American Society of Civil Engineers and The Boston Society of Civil Engineers i Joseph P.Corsiglia, Tr. Horseshoe Lane Realty Trust 65 Waterman Farm Road Centerville, MA 02632 AFFIDAVIT I, Joseph Corsiglia, do hereby attest that I am the trustee of the Corsiglia Family Limited Partnership, owner of the property located at 51 Waterman Farm Road in Centerville. The house that exists on the property was built in 1966 by me and my late brother, George J. Corsiglia, Jr. The house now and at all times since its construction has had three (3) bedrooms. There are two (2) bedrooms on the main floor and one (1) bedroom in the loft area. Signed: Date: r� i 5� 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 Property Address:. 51 Waterman Farm Road Centerville. MA 02632 Owner's Name: Joseph Corsiglia Owner's Address: Date of Inspection: February 2 2007 `Name of Inspector: (Please Print) James M. Ford. Company Name:. James M.Ford Mailing Address:. P.O.Box 49 Ostervill,.MA 02655-0049 , Telephone Number: (508)862-9400 CERTIFICATION STATEMENT . , I certify that I have personally.inspected the sewage disposal system at this address andthat the information reported below is true,accurate and.complete as of the time of the inspection. The inspection was performed based on my training:and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP, approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes N eds.Further Evaluation by the Local Approving'Authority Fi Inspector's Signature: Date: February 8. 2007, The system inspector-shall subs a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this .nspection. 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 CL. DINING KITCHEN BATH ST- AIR BEDROOM 1 ST- ' AIR FAMILY CL. BEDROOM 2 CL. FIRST FLOOR 1/8" = 1' BATH CL. ST- AIR BEDROOM 3 SECOND FLOOR 1/8" = 1' 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 Property Address: 51 Waterman Farm Road Centerville:MA 02632 / Owner's Name: Joseph Corsiglia lay(0 Owner's Address: Date of Inspection: February 2 2007 'Name of Inspector: (Please Print) James M. Ford Company Name:. James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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: ✓ Passes Conditionally Passes cs, N eds Further Evaluation b the Local A rovin Autlori _ Y Pp g� ty CD F is Inspector's Signature: zmmw Date: Februww 8, 2007, The system inspector shall subs t 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 I r Page 2 of 11 R OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 Waterman Farm Road Centerville MA Owner: Joseph Corsi lia Date of Inspection: February 2 2007 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: 2 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 Waterman Farm Road Centerville, MA Owner: Josh CorsiQlia Date of Inspection: February 2. 2007 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 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: 3 Page 4 of 11 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 Waterman Farm Road Centerville, MA Owner: Joseph CorsiQlia Date of Inspection: February 2 2007 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence.of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppmi provided that.no other failure criteria are triggered. A copy of the analysis must be attached to this forma No (Yes/No)The system fails. I have detennined 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 System: 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. 4 r Page 5 of 11 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 51 Waterman Farm Road Centerville, MA Owner: Joseph Corsiglia Date of Inspection: February 2, 2007 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: Yes No ✓ 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(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: 51 Waterman Farm Road Centerville, MA Owner: Joseph CorsiQlia Date of Inspection: February 2 2007 FLOW CONDITIONS �I RESIDENTIAL Number of bedrooms(design): N/a 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): n/a 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): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL 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 Source of information: Unavailable 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: Date unknown Were sewage odors detected when arriving at the site(yes or no): No 6 v Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Waterman Farm Road Centerville, MA Owner: Joseph Corsiglia Date of Inspection: February 2. 2007 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" 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: 1000 ag 1_ Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Cormnents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). Tees were present The inlet cover was 8"below. Recommend pumping every 2 years GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scorn 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.): 7 I i Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 Waterman Farm Road Centerville, MA Owner: Joseph Corsiglia Date of Inspection: February 2, 2007 TIGHT or HOLDING TANK: None (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 alann and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribuiion to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (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.): 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Waterman Farm Road Centerville, MA Owner: Joseph Corsiglia Date of Inspection: February 2. 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: infiltrators 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.): The infiltrators were dry and There did notappear to be any signs offailure. The bottom to grade was 3.5'. A camera was used to inspect infiltrators CESSPOOLS: None (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): Connnents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None. (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.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 51 Waterman Farm Road Centerville, MA Owner: Joseph Corsiglia Date of Inspection: February 2, 2607 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. 1 to 1 1 J �- 3 a i 0 0 r aq a� �- aN 3a 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: 51 Waterman Farm Road Centerville, MA Owner: Joseph Corsiglia Date of Inspection: February 2 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: ✓ Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:-- Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic map and water contours map Map is showing approximately 10'to groundwater at this site House has a full basement and is dry. j This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 T DATE : 6112103 _-__ PROPERTY ADDRESS: 51-. Natezman Faam Road 02632 ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1. 1-900, gaigon /2aecazt ieach.ing ?-it. 4'X 12' FHEALTH �si�i 9ti: 2. 1- 1000 gaiion ee/2t.ic tank. 3. 1-Diet2.igut.ion lox. N 2 U 2003 Based on my inspection, I certify the following conditions: OF BAI�NSTABLE 4. 7hi-6 .i.s a t.it.2e �.ive ze/2t.ic ayztem. (78 Code) DEPT, 5. The zel2t.ic zyztem 1a .in /22o/,ea woak.ing o2dea at the /2aezent time. 6. The 2each.ing 12 it .iz gaezentl y d zy. 7. Stain 2.ine zhowz that the waste watea has Been with-in 30' o/ the .iveat /?i/2e. It hae nevea 1?een h.ighea than th.iz. SIGNATUR Name : - J_- P . _Macomber_Jr . __-_ Corripany : )qateh per_ M_Oggm�pr d Son, Inc . address :__�Qx ------------ -_cejuecLLLLP,,- Ja--Q-2.632-0066 Prone : --508- 775_ 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY I EPH P. MACOMBER & SON, Tanks•Cesspools•Leachflelds Pumped & Installed Town Sewer Connections Box 66 Centerville. MA 02632 INC'0066 775.3338 775.6412 COMMONWEALTH OF MMSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 3 i TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 54 tda.teaman Taltm Road en Z e2D.c e, Owner's Name:;0e/? o/E.37g .ca Owner'sAddress:65 Oate2man Taitm Road Cn_n.t_v2vi1.2v.. Na.s,3. 02632 Date of Inspection: h 1 i.?/o 7 Name of Inspector: (please print)_aozel?h P. Nacomgea a/t. Company Name: ,?. P. Nacomget & Son Inc. Mailing Address:(30 x 66 C'vnivn v, f1r)Ai. 02632 Telephone Number: 5 0 8- 7 7 5-3 3 3 8 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shal ubmit 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 Page 2 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5�f Oate2man Tanm /toad Cen eltvitte, Mazz. Owner: 10,3e12h on.s.cg .ea Date of Inspection: Inspection Summary: Check A,B,C,DorE/ALWAY complete all of Section D S stem t I have not found any information which indicates that any of the failure.criterJia described in 310 CMR 15.303 or in 310 CMIt 15.304 exist.Any failure criteria not'evaluated are indictsted�below. J Comments: The zept.ic -6y.etem .iz .in paopea woak.ing otzdez,_at Q,zo6onf fimo_ t 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 exliltration 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: Vd 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 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: V. Oateltman Taam Road en eay.c e, a.s.e. Owner: ao.6e12h o/tztg .ca Date of Inspection: C. Further Evaluation is Required by the Board of Health: Ak Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,_safery or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(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: /tVThe 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 b t 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: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5t Val-eaman Taam Road Cen.te/tv-ii.2e, (1a,3.3. Owner: lozeRh COaz l.C/tia Date of Inspection: 6112103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No / ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _✓ Static liquid level in the distribution box abovf outlet invert due to an overloaded or clogged SAS or cesspool �s.I" ^ ed A4, L 4 —7 _ squid depth in 4sespvt7 is less than 6"below invert or available volume is less than h day flow �equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 0. 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. _ fAnAny portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 trust be attached to this form.) (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 a system is within 200 feet of a tributary to a surface drinking water supply v the system is located to a nitrogen sensitive area(I.nterim Wellhead Protection Area—iWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE CTION FORM PART B CHECKLIST Property Address: 5 j Uate2man ra zm /toad Lenye2ycQQ , l7a.s� Owner: ;ohe/2h 02 .cy .ca Date of Inspection: 677-27-03 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 ? ...j,/_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Jz_ 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,&luding 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 / de th of liqu id, depth of sludge and depth h of scum ? v _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage Y disposal systems? P 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 failure criteria related to Pan C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)) 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 51'. 0a.te/zman Falzm /toad en e2v.� ems. Owner: I .6e/2h olizig .ea Date of Inspection: 6172103 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): 00 Number of current residents: 0 Does residence have a garbage grinder(yes or no):A41 Is laundry on a separate sewage system (yes or no):.I& [if yes separate inspection required) Laundry system inspected es or no): S Seasonal use: (yes or no):AP Water meter readings, if available(last 2 years usage(gpd)):2001=83, 000 ga—pi on,s=227. 40 gPD Sump pump(yes or no):� _ , ga 2.2 o n�= 16 7. 13 qP D Last date of occupancy: 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:_4 OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):If& If yes, volume pumped: CS gallons-- ow was quantity pumped determined? Reason for pumping: TYpi£ OF SYSTEM _✓Septic tank,distribution box,soil absorption system Al,' 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 aTight ined from system. owner) tank 'ZA Attach a copy of the DEP approval 4LYOther(describe): �d �A ximate age of all com onent$, 4.ate installed(if known)and source of information: r Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51, Oateitman ;a zm Road C_en.te2v.iiia, mazz. Owner: to.6eRh CO2.6•igPia Date of Inspection: 6112103 BUILDING SEWER(locate on site plan) d Depth below grade:_ J � Materials of construction: cast iron 40 PVCA/O other(explain): V,4 Distance from private water supply well or suction line: /D f Comments(on condition of joints, venting, evidence of leakage,etc.): �o.inY-6 aR/?e.a/L t.iaht. No evidence o e Peakage. The 6y-6tem i,3 vented .thaouyh .the hou-6e ventz. - SEPTIC TANK: Zlocate on site plan) 1"14*1W6 R Depth below grade: �y � Material of construction: i/concreteAle metals fiberglass polyethylene ilia other(explain) If tank is metal list age://j is age confirmed by a Certificate of Compliance(yes or no).00�(attach a copy of certificate) v� " f a Dimensions: Pl/44'f Sludge depth: f Distance from top of,51udge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 1/dgAee- Distance from bottom of scum to bottorp of outlet t e or baffle: d� How were dimensions determined: _/'VM2/P&J Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of.leakage, etc.): A-�nf it, (rink o»onii�_ 3 warzl .t T -eof & oul—ee•t •teeb ate in r�ee� the 4r," b6 �t�r«ctcuta2P�,r 6nuarl nnrl Ahowi no p,y.idpnc o)e .Peakage. L.iqu.id 2eve2 at .the outlet inveltt .ih 51" GREASE TRA141"locate on site plan) Depth below grade: 101 Material of construction: concrete/1/,4metafiberglaspolyethylenwU19 other (explain): " Dimensions: 14M Scum thickness: /01 Distance from top of scum to top of outlet tee or baffle: A*f 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.): ,2 i,3 not R2e.6ent. 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 f' Wa.te2man Faltm Road en 7 e2v.e T 7 e, Mazz. Owner: ozeph o/Lz ig .ea Date of Inspection: 6 11210 3 TIGHT or HOLDING TANK (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: //9 Material of construction: concrete 4111 metal fiberglass 4Zj polyethylene M other(explain): AM Dimensions: Capacity: AM. gallons Design Flow: WIt rallons/day Alarm present(yes or no): Alarm level:�_ Alz� in working order(yes or no):v,f Date of last pumping: Comments(condition of alarm and float switches,etc.): __-7a qhi nn hniding iank.s aze no.t R2e,6en.t DISTRIBUTION BOX:1--,/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invervAb 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.): —iiaig Lion lox lz z one ia.te2ai. No evidence o zoiidz cai aw_ nVe _ No vDIdence of 2eakaae . n.to oa out o/ e 7ox. PUMP CHAMBER (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.): atQZ a man f 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: 51 Glateaman Faam Road en e2U.i e, a.s,s. Owner: Jozel2h Coaz-iy.2.ia Date of Inspection: 6112103 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 1-LP-600 gateon R2ecaz;t .teach-ing 12.i..t. (4 'X12' � If SAS not located explain why: fe)rnfor]- .C,o o �n Typ leaching pits, number: leaching chambers,number: leaching galleries,number: �- leaching trenches,number, length: a leaching fields,number,dimensions:_ /✓ overflow cesspool, number: 0 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 e.i n,3 o . h daau2.ic la.iivae oa _ond.ing. So.i.�a ate day. Vegetation i.6 noama /?2e,6ent.Py day. CESSPOOLSY�cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 0 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.): ('oz,tnna,PA rind nn,t 121ze—Sonf _ PRIVY4,jbil(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.): -,�-.z••,t-t;�g�—i-,s ��a����-���r��, 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:5'f Oate.¢man ;a z Road Cente/tvii2e. maA . Owoer: lozeph CoAzi -Pia Date of lospecdoo; 6112103 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 publie.tiwater supply enters the building. A.. 10 1 ' r i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town of Barnstable .................................................................... 2 0 0 0 NO.... . .-.7Q FEE....$.................. Disposal Works Tonstrurtiun rrrntit Permission is hereby granted.....d•V-F•.•MaCGbe-r.......................................................................................... . to Construct ( ) or Repair tX{ an Individual Sewage Disposal System ( C o r s i g 1 i a ) at No.....51...W tparman...Earm...�4dd...Centervill.e............................................................................................ Street as shown on the application for Disposal Works Construction Permit No.g '3\7ee... Dated.......................................... .. • .................................. .......... DATE................. Hor.d.J.f...Hat.h........................................... FORM 1255 HOODS & WARREN. INC.. PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............t.a.Wn.................OF....... Barnstable ............................................................................ (Inrtif kate of �IItlt tliMntP THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or RepairedX)� by..:.J:.P:rlacQlnber....................................................................................... InstalIv .................................................................. at...... .1...Wa-toermaa...Earm...Ro.ad....Ceatexmijl.e............. ( Corsiglia ) has been installed in accordance with the provisions of TITLE ............................................... 5 of The State Sanitary Code as desc ' ed in the application for Disposal Works Construction Permit h'o......$$'.-. 7d dated........ '.l...." ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RF I_nA1cYmten AC Page 11 of I 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:5,1 Uate2man Ta2m /toad en Z e2v.c I I e, 77 a.6.e. Owoer: ao.ae/2h o2Tc y .ca Date of lospectioo. SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water A'? feet Please indicate(check)all methods used to determine the high ground water elevation: y£S Obtained from system design plans on record-if checked,date of design plan reviewed:6/1210 3 yam—Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Heal.h-explain: NO 1/ Checked with local excavators, installers-(aupb docurn tation�ta�2e, ma, u�,. S_Accessed USGS database-explain:hz t12:// own. aan You must describe how you establishes the high ground water elevation: Merl: Gah,?PY L R 11i -evn ftdeP 12116194 Ground wate2 e.Pevatl.onz agove .aea ieveP. L,6ed. LISGc naA,, , uni ;nn )jo00 rIn}n, �nnv 1992 #2 Annu�,0 ge4 o-/ a2ound wate2 a &4 ,1anua2u 1992 Leaching Pit ;cct Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 rrnr+ -n•rrr-.••n- rnrmr•newr�-nrtrsnrr+�rn�r+:�•�e►t+nrnr•ren•tsrrnZ�+�'�rr�sta�s �'n"nrr-tr—r-..-.,r-..,` TOWN OF Baanztagie BOARD OF HEALTH l z•,�r SUfiSUftFACF SEWAGE I)i DISPOSAL SYSTEM INS SI'g FCTION FORM - PART D .- CERTIFICATION I -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 5f 0atezman Fazm Road CentezViiie, 0a,3,3. ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME ;ozeph Cont•igl•ia PART D - CERTIFICATION r NAME OF INSPECTOR obe/�h �� zP��ig6ra�e2 a2. COMPANY NAME 1. P. Oacom>'e2 & Son Inc':w COMPANY ADDRESS Box 66 CenteAviiiz Oazz. 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 775 - 3338 FAX ( 508 J 790 - 1578 n 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 of -inspection . 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 , Chec one : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public IlealLh or the environment as defined in 310 CMR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection wilict, I have con ilcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CfITERIA of this inspection fo m . Inspector Signature i Daterw ..-_�•• ne copy of t}�is ce ification must be provided to the OWNER, the BUYER ( where applicable and the BOARD OF HEAL1'II. * If the inspection FAILED, the owner or"operator shall u he within one year of the date of the inspection, unless alloweddortreguiredaystem otherwise as provided in 3.10 CMJR 16 . 306 , purtd .doc ASSESSORS MAP NO: 6 V PARCEL NO: THE COMMONWEALTH OF MASSACHUSETTS Q 1Vb iQ 5 PA4V BOAR® OF !-ZEAL TOWN OF BARNSTABL ' Appliratiuu for Disposal Works T Us Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at r `.5.1 .... ...... ...... ...... ..... ......... r!. . ....•.......................... cation-Addr sg or Lot No. ........ ...rl.•.............. l r s ............................... ................................_.._...... / ` / 'W1 ......... �._. ..L-C1/ � 0` i!C.-J&7 W.......................... ...//( ......1.✓_l e t --........................es a�,1_ ...•--.....���P.�� Installer r � ��v �• - Address U Type of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms....................j---____--__..___--__Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid-capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ 0 a •--•----•••-----------------•••------•--------•-----•----•---•-----••-----.........-••••••----...•-•-•••----.............------•---•-•-- ...... Description of Soil.................................................................................................................................................... W V .....•--•-•---------•--•--•---•••------•-•-----•---•••------------------••----------------•••••----••••---------•••-----....--••--------••------••------•---••------------......----•---•••-------...... W x ..........................-............................................................................................................................................................................. V 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl' s issued by thyboard of health. Si ne SCK Date Application Approved BY ` .t........ ......j.............................--- ---------------------....................... �5`-r!3s Date Application Disapproved for the following reasons- -- ------------- ------------------------------ -------------- ------------- -- -- ---------------------- ------------ ................................................ ------------------------------......................... -- ....--.-----.....-- --..........-- -- ------ -------........................ Date PermitNo. ��- .. .f...9 ------------------------------ Issued --------------- .............-- ----- ....--- Date No..:1.. ...._ �1�. V `�THE COMMONWEALTH OF MASSACHUSETTS 7i BOARD OF HEALTH TOWN OF BARNSTABLE,- Appliration for DisposalWorks' Toustrnrt��rntit Application is hereby made for a -Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: i ... ......... ,1, 1� r, ....._ r41:r_.....I A2..---• ..... ----------le.�................................ ocation-Addr ss or Lot No. ........ .._(�.�_............. 4.1.5 ............................... W ............Owndl Address '05 .......... _ -11_.W..4...G).t1�. _h.<J� 1.DAJ..-•....................... ..'WA......... p,L..._..?11__........... 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 ( ) Q' Other fixtures ..................... w Design Flow............................................gallons per person per day. Total daily flow_.........................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by...................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------------------------------------•-------•------------------.........••-••-•-•----•---•••-•-•......................--••--------------•-------.....••-- 0 x Description of Soil.......................................................................................................................................................•.......-•-•••..., U .....•-•••----••-•••-•-....-•--•••--••--•--••-•--.....•---•-•--••••-•--•-•-••-•-••-••••-•--•-•••-----••-•••-......••••..............................................7----------------------------------- --------------------------------------------------------------w U Nature of Repairs or Alterations—Answer when applicable.___---.�1 s ._.._I—itw.....�...................... --------------------------------------•-------•----••-•------•---••---•----•------•----.......-•--••--•-------------------------•-•------••-----...----•-•-----.._........----•----•••••••-••-•••-•---•- Agreement: i The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliane� as issued by th board of health. Signefl . ..� PC�2.� ------------------------- ------ Dare Application Approved B �...-�f-r,- .�------------------------ -------------------------------------- De /r-- ar Application Disapproved for the following reasons- -- ------ - --------------------------------------------------------------------------------................................... .....................................".......------... -- ------ -- ---...."...-----..........------------. . .------- ..................----------- ------................................. ------.---------.......---........... Permit No. ------?a.^..... 7.�.- ---- ------- --- -- Issued Dare Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE A VCPrtifi ate of TontylianrjC THLUS TO CsERTl Y, Th t the In ividual Sewage Disposal System constructed ( ) or Repaired (X ) by .... 1`. .... .. l..a. .s.. r:.0 c�. -'v----------------------------------------------------------------------------------- -... . /' / 1 scaller C 1 at -----------Jam' .--.........w.A �"�.rm�^.. ........f.L4.r !� �. -......� - 1 �°"!t! U e r " '............. ...._.-. ............ has been installed in accordance with the provisions of TITLE 5 The State Environmental Code as described in the application for Disposal Works Construction Permit No. ----- 1...f-,Q.............. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------- -----"........----..--------........---...................... Inspector -------- ---------- -}..-----...............................------=-----.....------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C� TOWN OF BARNSTABLE No...�! :._� Disposal �nrki Tnatgtr ion ami# Permission is hereby granted........... ` 7. __�D.tJS--r u c----- `.--'v•................•-----.....-•------.....---................ to Construct ( ) or Repair an Individual Sewage Disposal System at No.......... ..........qZV ✓ a �x�. �- /....•---. re'`�.1�� q ----------------------------------------------------- as shown on the application for Disposal Works Construction Permit Street ✓� ��c�__ Dated........... .......................... . . DATE_ Board of Health FORM 38308 HOBBS 6 WARREN.INC..PUBLISHERS i No.... FEE..... 2.Q.-M). THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town......................OF.........Barns t abl e Appliration for Disposal Works Tonstrnrtion Vvrrmit Application is hereby made for a Permit to Construct ( ) or Repair iXXat an Individual Sewage Disposal System at: 51 Waterman Farm Road Centerville ----------------------•-----.................----........------.....................----------..-- ------------•-•--•-•----....-------------------•--------...._...--------....-•-------...---•-----' Location-Address or Lot No. ........rnr.s i-g1ia-------------•----...........----'-----------------•-------------. -•---••--•-----•••---•--------------------------------------------------•------------------------- Owner Address W ......................................................... -•'•--------------------------------------•----. •------•-------•--•'----•------------------ Installer Address UType of Building Size Lot............................Sq. feet �-, Dwelling X-XNo. of Bedrooms.............3.............................Expansion Attic ( ) Garbage Grinder ( ) a4 Other—T e of Building No. of persons............................ Showers YP g ---------------------------• P ( ) — Cafeteria ( ) Otherfixtures ------------------------•-----------------------------'-•--•••---•-----------'----------------- --------•••-•••---•'---'---••-'•-----•--'--------•-•• W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter................---- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date.....................----------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...........--..-..----_ (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' '---"'-------------------------•.....-••---•---••-•---'---•-•--••••'---•--•.............._.................................................................. 0 Description of Soil........................................................................................................................................................................ U ----•--•--•----••--•--•--•'•----........................................... and._._... W U Nature of Repairs or Alterations—Answer when applicable.----------------------------------------------- ---------------------------------------------- --------"'-•---'---------'-'--L--Leajch...pLi.t.................................................1-1000 gallon tank Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITI LE 5 of the State Sanitary Code— The undersigned further agr s not to place the system in operation until a Certificate of Compliance has bee issued y tj boa d of heal . Signed-- /,'(/ • '•-- --- ........ .....7.,/-6/.aB..-------- Date Application Approved By...................•. -• . •--�_ ------.... Date Application Disapproved for the following reasons---------------••---------------------------•--•---------------•-------------•---------•-•------'--.....---_----- -•---------------------------•---•-----................._..---'-----------------•-----••-------------•--------...---------- p�,. Date Permit No........sa?Q ...�4------------------------- Issued Date No 22,::E�70 Fnic. ..,, l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..M'71?._................... ?rorti}rle - O F....................:...................................................................-- lei A;I;Airttttun for DtupuFal Works Tuntratrttun 'rrrantt Application is hereby made for a Permit to Construct ( ) or Repair CCX)f an Individual Sewage Disposal `f`..,-System at: ., 15? Waterman_ Farm, Read Centerville :... - ...................... ....................................... ••-•-•............_.......--------••---------••-••.---........................................... ��vv Location-Address or Lot No. .._..__4�? .fi1 ...........................................•-_................... -------•-•-••-••---------------------•-•._.....-----.._..._.------•-----._.._.._......_.._.....--- Owner Address ......................................................... •---•----.......--•---....................-----......-•---•-----...-----------....----......•..._. Installer Address Type of Building Size Lot............................Sq. feet Dwelling y-XNo. of Bedrooms.............. ..._......_..._._...........Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers a g ---•--•------------•---•---- P ( ) — Cafeteria ( ) QOther fixtures ..---•--------•-•..............•-•-•-----•-•---.....---------•••-•----------•-......•-- ............................................................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water----------.............. fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -•••-••••-•---•-••--•---•••-----------------------•---•-•...------........------•---•-------•.....••....................................... --•---------.----- 0 Description of Soil----.....--•----•--•-••-•---•--•----...-----SaTId••..............................•••-------------••--•-------•••------•-•............---•••--....•--•--••-••----- V ....•-••-•••-•--•••--•......-----•---••-•-----------------•-•------.....-•--•-----------..._•••----••-•-••--•---------.......------•-•••••--•-•-•••-••------•••----•------------._...----••......------. W ............................... ---•-••••-----•-----------•----•----•-••-••-•-•••-•-----------......--------•---•--------------••----•••-•-----••-•-•-------•-•---••••----------••......-----••••--_.... U Nature of Repairs or Alterations—Answer when applicable........... .. •-•---•--•----•••-••--•-••••-• 1 z `? :?.It...................................................--.................................................................... .................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with t'Ix - the provisions of/•1Ti-1 t� 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of healtff. Signed..... ! + f y Date Application Approved By................... -�`'''� ..E,E,: ,:,�.. Date Application Disapproved for the following reasons:................................................................................................................ ...................................••---.........._----------...•••------------••-•-••-.........-••---.....----------------------••-----•-----------•-•------•-------------------•-•---•---••-----•-••--- p Date PermitNo.- -©.$ .... ).20-.......................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �'ovn 'L rnsta ale ..................OF..................................................................................... Trrttftrate of Tompli ana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ' by......._....Macom.ber ..............................................................•-•-•----•--•-----------•---------....-----------....-•----......----...-•----......---•••------•-----------. taller at_..._51 _1-.,I .tert�an Farm, Road CF nt-ervi Te ----•-----------•....................................................•--•------•-----•-----•---------...........-------•----•--.....-----------...--.................................. has been installed in accordance with the provisions of TIT E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...__...M.,2>24-----__-_- dated_------------------------------------_-_-___-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................... ..-••••---•--•......•.�- - . .� Inspector... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No..... -j7 OF........................................................._........................... $ ?C. `.�Q V p._.. FEE....................... Disposal Works Tonutrttrtton frrutit Permission is hereby granted....J-.t?...MIcouibe C --------------•--.........__....-----.......----......_........-----................••....... to Constut ,(, or Repair, Y Indiviciu a Sever a tposal System at No.._..�.....via ermaxi r. ...•: t tUat t✓e b :r gi 1 . Street as shown on the application for Disposal Works Construction Permit No.9 .�2 70.. Dated.......................................... .................................. .....0.................................................... DATE................... ....................... .......... Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS i t t