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HomeMy WebLinkAbout0025 WEDGEWOOD DRIVE - Health 25 Wedgewood Dr. ( Centerville) I • k i No. 42101/3 ORA f ESSELTE 10% O O O O 4� TOWN OF BARNnSTABLE N LOCATION o�� ���'C �C�b�G SEAGE# �✓1iSi c��, VILLAGEC'-c=,)Cr ASSESSOR'S MAnP&PARCEL INSTALLER'S NAME&PHONE NO. � pc �l /@�•oca�+�-r" fi,k�d►1� +�J�L. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �y �' (size) 30` k S NO.OF BEDROOMS OWNER ; � PERMIT DATE: / CO LIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > ✓C Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) o Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / d Feet FURNISHED BY__V'i�� C_; VOtiS.��r�d 4 r 30 c� ,� k3 Commonwealth of Massachusetts 99--N41 Title 5 Official Inspection Form �' Subsurface Sewage Disposal System Form-Not for Voluntary Assessmen is _ opl, 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22, 2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information Sl* I4(ooa-- filling out forms on the computer,use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 VQ Company Address Forestdale MA 02644 City/Town State Zip Code 508-509-0802 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. Passes 2. Conditionally Passes 3. 8 Needs Further Evaluation by the Local Approving Authority 4. 8 Fails June 24, 2020 InspectTrs Signature Date The PY system inspector shall submit a co of this inspection report to the Approving Authority(Board Y P of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Y Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4:. 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22, 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) System Conditionally Passes: © One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determi d" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 year old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration r exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replac with a complying septic tank as approved by the Board of Health. A metal septic tank will pass insp tion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan is less than 20 years old is available. Y 8 N 8 D (Explain below): t5insp.doc•rev.7126/201 B Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 2 of 18 e y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner owner's Name information is Centerville MA 02632 June 22, 2020 required for every page. Cityrrown state Zip Code Date of Inspedion C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 0 Observation of sewage backup or b eak out or high static water level in the distribution box due to broken or obstructed pipe(s)or ue to a broken, settled or uneven distribution box. System will pass inspection if(with approval Board of Health): broken pipe(s)are rep ced Y N ND(Explain below): obstruction is remo ed Y N ND(Explain below): 8 distribution bo, Is leveled or replaced 8 Y ON 8 ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced Y 8 N ND (Explain below): 8 obstruction is removed Y rl N ND (Explain below): 3) Further Evaluation is Required b the Board of Health: 8 Conditions exist which requi further evaluation by the Board of Health in order to determine if the system is failing to pro ct public health, safety or the environment. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22, 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 0 Cesspool or privy is within 50 feet of a surface water 0 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (Ind Public Water Supplier, if any) determines that the system is functioning in anner that protects the public health, safety and environment: 8 The system has a septic tank and soil a orption system (SAS)and the SAS is within 100 feet of a surface water supply or tribut to a surface water supply. The system has a septic tank and SA and the SAS is within a Zone 1 of a public water supply. [] The system has a septic tank and S S and the SAS is within 50 feet of a private water supply well. C] The system has a septic tank and AS and the SAS is less than 100 feet but 50 feet or more from a private water supply we **. Method used to determine distan **This system passes if the well w er analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t at no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7t2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r; 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/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 water supply well. 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. 8 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No © 8 the system is wi in 400 feet of a surface drinking water supply �] the system is ithin 200 feet of a tributary to a surface drinking water supply the system ' located in a nitrogen sensitive area (Interim Wellhead Protection Area—IW A) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive J Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22, 2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No rl 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? 8 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 tho facility cwncr(and occupants if diftront fr3m @wncr) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22, 2020 page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow b@§@d on 310 CMR 15.203 (for @xampW 110 gpd x#of Wdro n. 466 GPD Description: Number of current residents: 0 Does residence have a garbage grinder? Yes No Does residence have a water treatment unit? 8 Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes No information in this report.) Laundry system inspected? 8 Yes No Seasonal use? 8 Yes No Water meter readings, if available last 2 ears usage d 2018= 192 GPD 9 ( Y 9 (gP )) 2019= 202 Detail: I Sump pump? Yes M No Last date of occupancy: May 1, 2020 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive - Property Address Williams Family Rev. Trust Owner Owners Name information is required for every Centerville MA 02632 June 22 2020 page. Cityrrown State Zip Code Date of Inspedion D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203). Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.)- Grease trap present? EJ Yes No Water treatment unit present? 0 Yes No If yes, discharges to: Industrial waste holding tank presen . 8 Yes No Non-sanitary waste discharged to a Title 5 system? 0 Yes No Water meter readings, if availa e: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owners records: Pumped Spring 2018 Was system pumped as part of the inspection? Yes No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance t5insp.doc Title 5 Official Ins rev.7/26/2018 Pecti on Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. 0 Other(describe): Approximate age of all components, date installed (if known)and source of information: System installed November 1996. Engineered plans on file at Health Dept. Were sewage odors detected when arriving at the site? 8 Yes No 5. Building Sewer(locate on site plan): Depth below grade: 2.2 P 9 feet Material of construction: 0 cast iron R 40 PVC 8 other(explain): Distance from private water supply well or suction line. n/a feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: eet Material of construction: concrete 8 metal fiberglass © polyethylene other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes 8 No Dimensions: 10.5'x 5.5'x 5' 1500 gallons 8" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 14" - 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 1" How were dimensions determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Tank pumped and cleaned after inspection. Recommend maintenance pumping every two years. t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is Centerville MA 02632 June 22, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: 8 concrete 8 metal fiberglass polyethylene 8 other(explain): Dimensions: Scum thickness Distance from top of scum to/bottom tee or baffle Distance from bottom of scumf outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: 0 concrete 8 metal © fiberglass 0 polyethylene 8 other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is Centerville MA 02632 June 22, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: 0 Yes No Alarm level: Alarm in working order: 0 Yes 0 No Date of last pumping: Date Comments (condition of alarm and float sw'ches, etc.): "Attach copy of current pumping contract(required). Is copy attached? Yes 0 No 9. Distribution Box(if present must be opened) (locate on site plan): 11 Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, 2 outlets. Speed levelers in place. H-20 D13-3 has riser and cover within 6" of grade. No solids carryover or high water staining over outlet inverts. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Yes No* Alarms in working order: Yes No* Comments (note condition of pump cha/er, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 8 leaching pits number: 0 leaching chambers number: 10 infiltrators w/ stone leaching galleries number: leaching trenches number, length: leaching fields number, dimensions: overflow cesspool number: innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2612018 Title 5 Official hspec6on Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive " Property Address Williams Family Rev.Trust Owner Owner's Name information is Centerville MA 02632 June 22 2020 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field located and inspected with camera. 2 rows of 5 infiltrator units with T of stone on sides and between. No standing liquid in units at time of inspection. No sign of past hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow Yes 8 No Comments (note condition of oil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26W18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Dnve Property Address Williams Family Rev. Trust Owner Owner's Name information is Centerville MA 02632 June 22 2020 required for every , page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, sign/ohydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7f26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 15 of 18 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is Centerville MA 02632 June 22, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage_disposal system, including ties to at least two permanent reference landmarks or benchmarks_ Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately �� ��� -`'a�ems✓` J , 10 t t5insp.doc•rev.7r4VM18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope 8 Surface water Check cellar Shallow wells Estimated depth to high ground water: >5 feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 06/18/1986Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: 8 Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: maps.massg is.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole to 11.4' (elv= 18.6)found no ground water in 1986. Base of units at elv= 25 per engineered plans. Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Wedgewood Drive Property Address Williams Family Rev. Trust Owner Owner's Name information is required for every Centerville MA 02632 June 22, 2020 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Forms Subsurface Sewage Disposal System•Page 18 of 18 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40,00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: APPLICANT'S YOUR NAME/S: D€ l col BUSINESS YOUR HOME ADDRESS: D TELEPHONE # Home Telephone Number NAME OF CORPORATION: S NAME OF NEW BUSINESS TYPE OF BUSINESS oLI IS THIS A HOME OCCUPATION? YE NO , r ADDRESS OF BUSINESS S EW Q 0� C MAP/PARCEL NUMBER i I`t [Assessing) When starting anew business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 2.00 Main St. — (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in th's toTU MUST COMPLY WI1H HN1E OCCUPATION 1. BUILDING CO ISM ER'S OFF RULES AND REGULATIONS. FAILURE TO This individu I ee in o f%npekr t e ui ement that pertain to this type of business. COMPLY MAY RESULT IN FINES. Au prize Sin I t MENTS: ** 1 -F k OM ` � O r �O u LU I' - 2. BOARD OF EALTH This individual has been informe er it r quirements that pertain to this type of business. RDOUS MATERIALS REGULATIONS ALIthorizedSiig ature** COMMENTS: / v &= 92 ey 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Commonwealth of Massachusetts , Title '5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `wM 25 Wedgewood Dr. Centerville; MA 02632 ,;: Property Address r7 Ann Williams Owner Owner's Name '�•� information is � wired for every OsteXil le Nkf o l(,,i MA 02655 8/18/2015 ,2. Ci frown State Zip Code Date of Inspection t-y • r�,a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services Company Name 350 Main St Company Address W.Yarmouth MA 02673 Cityrr wn State Zip Code 508-775-2825 S15016 Telephone'Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper-function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/20/2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of.Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. j 0jid Vs t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in working condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E). Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a-nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have.answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x4= 440gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ` w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2013=156gpd 2014=247gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1996 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10,feet Comments(on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 11211 Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500Gal H-10 Sludge depth: 8-101, t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 4-6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal H-10 tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers 17' below grade. Tank to be serviced 8/28/2015. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 2 lines out in good condition. Box is clean and solid with some solids carryover. No sign of overloading or hydraulic failure. Cover is 20" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 10 ❑ 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.): 2 rows of 5 Hi Cap Infiltrators with 3' of stone in between and around units. Units were found to have minimal effluent at time of inspection. No sign of overloading or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +13' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger to 13'with no water encountered. Max bottom of leaching is 7'. Minimum of 6'separation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 25 Wedgewood Dr. Centerville, MA 02632 Property Address Ann Williams Owner Owner's Name information is required for every Osterville MA 02655 8/18/2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I A ' 1.2 J3 f: �u l" Fir COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION r 4 F l� Y V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM PART A CERTIFICATION Property Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 LIO Owner's Name: ROBERT HOLLENBACH Owner's Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 Date of Inspection: 4/16/01 A F Name of Inspector: (please print) JOHN GRACI cFi�F Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 T • Telephone Number: 508-564-6813 FAX 508-564-7270 otiF�Feq g ZD�J Tele P Ty FATTge�F CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information r rted below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Furthi Evaluation by the Local Approving Authority Fails Inspector's Signature: ii Date: 4/16/01 The system inspector shall subm a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe tion. 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 THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that thne.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 IncnFntinn Fnrm A/1 50000 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 LIO Owner: ROBERT HOLLENBACH Date of Inspection: 4/16/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 L10 Owner: ROBERT HOLLENBACH Date of Inspection: 4116/01 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 L10 Owner: ROBERT HOLLENBACH Date of Inspection: 4/16/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow _ X Required pumping more than 4 times in the last year N -T due to clogged or obstructed pipe(s).Number of times pumped n1a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. d Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 L10 Owner: ROBERT HOLLENBACH Date of Inspection: 4/16/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 L10 Owner: ROBERT HOLLENBACH Date of Inspection: 4/16/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):440 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no):NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1996 Were sewage odors detected when arriving at the site(yes or no): NO F Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 LIO Owner: ROBERT HOLLENBACH Date of Inspection: 4/16/01 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1500G L 10' 6" H 5' 6" W 5' 8"" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle:30" Scum thickness: 2" 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: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL L1F GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 L10 Owner: ROBERT HOLLENBACH Date of Inspection: 4/16/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): n/a PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a e I 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: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 L10 Owner: ROBERT HOLLENBACH Date of Inspection: 4/16/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a INFULTRATORS leaching chambers, number: 6 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: nla n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 L10 Owner: ROBERT HOLLENBACH Date of Inspection: 4/16/01 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. A 1 Deck. tT e B A ZnrF g rr,ra AnAF FA 5yL 15 in 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: 25 WEDGEWOOD DR CENTERVILLE,MA 02632 M189 P146 L10 Owner: ROBERT HOLLENBACH Date of Inspection: 4/16/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 10+FEET No. //� l�(C/� Fee (CS O THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for ;Digpozat *potem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Z: WE oet E Owner's Name,Address and Tel.No. `77,9-Z:3 pjc Assessor'sMap/Parcel `*Y.- /4t& Te e� 4Y Installer's Name,Address,and Tel.No. T -!_-4' - Designer's Name,Address and Tel.No. 'Am O—f& Type of Building: Dwelling No.of Bedrooms Garbage Grinder(43) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 46&, Z_ gallons. Plan Date �/- /- `�'C.= Number of sheets / Revision Date Title Description of Soil 7-9 -S 9is"t> 5 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of nd entdl Code and not to place the system in operation until a Certifi- cate of Compliance has been issu this o Signed Date Application Approved by Date Jz- 46 --( - Application Disapproved for t e following reasons Permit No. � Date Issued ( No. Fee ©s - i THE COMMONWEALTH OF MASSACHUSETTS / 1 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS f Zippfication for Oiopaal braem Construction permit Application is herebytmade for a Permit to Construct( )or-Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. _ to/,-: -,ct c t it �, C,-,v Owner's Name,Address and Tel.No. 77,t-Z,'1>4-* r is 7. , . Assessor's Map/Parcel /G y !4& Installer's Name,Address,and Tel.No. 7`� Designer's Name,Address and Tel.No. -7`7 Type of Building: Dwelling No.of Bedrooms 4 Garbage Grinder(00) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ` gallons per day. Calculated daily flow 410 le, t-. gallons. Plan Date I/- - '1C,. Number of sheets / Revision Date Title Description of Soil 7".9�S Nature of Repairs or Alterations(Answer when applicable) Date last inspected: i t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system Fin accordance with the provisions of Title 5 of tl� nv' ental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu �y this �` d'of . Signed :A Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ;Y, ——————— — — ——————————————————— r_T,HE,,COMMONWEALTH OF MASSACHUSETTS r J f 1, 1, :.`_BAONSTABLE)`MASSACHUSETTS �'` i >. . r "dCertififate of Compliance THIS IS TO CER ,that the On-site Sewage Disposal,Astern installed( )or repaired/replaced( )on E by �%� ' t �..?. t LInstaller" at l' has been constructed in accordance with the provisions of Title 5 and the for Disposal System•Codstruction Permit No. 6_0 dated r Date "' Inspector _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. r —————————————————— r————————————————————— No.���- Sloo Fee D c , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS liq.oga[ *pgtem Construction Permit Permission is hereby granted to Na LC to construct(repair( )an On-site Sewage Systoln located at No.# vL .S— Lv .+� Stwe and as described in the above Application for Disposal System Construction Permit. quo 13&0 S i No. uate 1 The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. _ Date: '-::; g Approved by Board of Health 8/9/20211 ShowAsbuilt(1700x2800) -�725 TOWN OF BARNSTABLE LOCATIONL-1er/O SEWAGE d t%E-JdL' VILLAGE /',62WAXbE E ASSESSOR'S MAP&LOT I 6 INSTALLER'S NAME&PHONE fNO. __L3.ACJOTlt'- 4Q6 SEPTIC TANK CAPACITY fjfUrJ LEACHING FACILITY(1yp,)Cj 4fTd5 3�S'To/� (size)f i� NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATERpUKic BUILDER OR OWNER lAftf.N Ct VSr DATE PERMIT ISSUED: I I - y -U DATE COMPLIANCE ISSUED; _11 -97 VARIANCE GRANTED: Yes No / i I I 15061 �Ri'rnNK https://itsgldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=251124T00&sq=1 1/1 2� TOWN OF BARNSTABLE LOCATIONLoric LV&aCt a y w< SEWAGE # 6.5�0 VILLAGE 11"&AMeA ASSESSOR'S MAP & LOT��n INSTALLER'S NAME & PHONE NO. r SEPTIC TANK CAPACITYe1� LEACHING FACILITY:(type) � * (size) t NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER C BUILDER OR OWNER ri1&G,y Ce1 DATE PERMIT ISSUED: ► I 1 G q DATE COMPLIANCE ISSUED: -o• VARIANCE GRANTED: Yes No ° Levi MapM`189 pc1 146 - Test pit #P-5815 Made 6-18-86 Septic design Wit. T. McKeen No bedrooms . 4 '_:No water encountered Disposal no Perc. less 2 min per 1 ' ~ \, Req. septic tank1500 , gal . N1 �, Re . leaching 440gpd T P 1 T P 2 g , q 30,t. 3Z:9 15x30=450x.74= 333 .0. T & S T . & S Wedgewood \ \ 90x2=180x.74 = 133 . 2 Drive_,, . . Total .leaching--466,2.'._gpd. . z8. . 3vs 40 ' wide �- medium medium �n , lr. 6 •� 4ta sand sand _ I 4?'. Lot' I� 9 ; r 2 catch basins._ .. . ---"-- _ 4-rs-R, ®q LOt 10 33�� 3A9 17508 sf o0'3 zs' ISoo H u ._, 3 i8r Fuller Road Profiles no scale Use 10 Infiltrators 5 each row with 3 ' stone on sides and middle 3 as shown. T r 4' 4 P� __._ -._ - - --- - ' g Pu c Q � C r .. � V i _... �V N �Q. /4y I� �r,— .r �. ��DUr✓'(/✓d rw ..+iu ' xiun,,;:ts• 5 - .. J .� -.._L�// 1`fie.is�",cJ`�� G'dEiwk:i,'• ' .'..._' !...--'-!._`._i,r i—. !, ... /._�12 - J u.:;�u✓ti ...3/� 'f,Z ✓p.,c�..C.0 vic.^.va .. ..__. _.__ ..._ Oki is, j _ T?t se . t f ►I.I�-�A,7— �N�H 20�.rMl T,_ _ 111 111 111 ..�. Y1 u•t�—.ic:Gu+'- :::v d:..,:,.s,.6,. 3/4,'- 1 YZ' STo�4? c31 au''(>°v -cu '.m .W4Jc"++ �4 Site Plan of Land in Centerville, MA ___.:�._. . . -,For Ti,nory Cons-t.,Ti i Being lot 10 as shown on plan in book 243 page 69 . Elevations are on NGVD i - -- --- - -- Barnstable board of--Health Scale 1"=30 ' Date 11-1-96 All Cape Engineering ate 49 Harbor Road Hyannis, MA 02601 • . H. , No.32490 e r A U�� ''►Zr.ir =