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0034 WEST TERRACE - Health
34 WEST TERRACE, CENTERVILLE A=207-120 9 0 r� 1 No. 42101/3 ORA Pro C� a ESSELTE 10% 0 0 0 0 04/03/2015 06:57AM 5442 DAVE WALSH PAGE 02/06 AQ 04-Asbestos Removal Notification Form ANF-001-Tra1:>sactioxi-4731979 Page 1 of 2 Commonwealth of Massachusetts 1 002 1 8 878R1 Asbestos Notification Form ANF-001 Asbestos Project Number Project Revision Notification Project Revision Project Cancellation A. Asbestos Abatement Description 1.Facility Location: bwD WJALSH � --� 1_34 WEST TERRACE Name of Facility ��-�-�---� Street Address 17-838-4188 City,Town Slate Zip Code Telephone fSAME � �01NNER-----�-------•---- ._...,�,.....,.,. Instructions 1.All Facility Contact Person Name Facility Comte Person Title 5ecttonsofthis farm must Worksite Location: ;6 EMENT beoompletedinorderto u._... . . . .___............__... . __...._. - aulkUng Name,Wing,Floor,Room,eta mnply W M MassDEP nodficadon requirements 2.Blanket Permit Project Approval, if applicable: — i Df 316 CMR 7.15 and Approval ID# DapaAmert of Labor 3. Non-Traditional Asbestos Abatement Work Practice Approval,if applicable: Stendards(bLS) Approval ID# noUncauon require:nante iO4r08/2015 -- 04'IIBi2015 01453 CMR 6.12 - Prolect Stan Data(MMIDD7YYYY) End Dsts(MWDDNYYY) i7ANt-BPM NA _ MessDEP Las Only Work Hours-Monday Thropgh Friday Work Hours-Saturday E Sunday V Date Received B. Other Project Revisions: 2.Submit Original j n Form To: Commonwes"in of ttfassaChtlggttE P,O. 130x 4062 Boston,MA 02211 C. Certification 11 certify that I have personally examined jDFy1l __ Note:'emparary the faragoing and am famlliar%Mth the Name Authorized Signature storege of Asbestos information contained In thls document IyP t containing waste and all attachments and that,Ua3w ort , .. material Is only a!Iowed Potklion/Tille bate(MM/DD/Y DIYY fYY) my inquiry Of tttaas individuals at the place of immediately responsible for obtaining 701.702-3390 -J LAIR SAFE - business of a DLS the information,I believe that the Telephone Representing OCenSetl Asbestos information is true,accurate,and 22 WILLOW ST CHEESE. r contractor or a transfer complete.l am aware that there are Address City/Town station that Is permitted e� txa nifint penalties for submitting Talge by MassPEp arlc 02150 Information,Including possible fines and -- operated in compliance imprisonment The undersigned hereby Stale Zip Code with Solid Waste states that I have read the Regulations 310 CMR Commonwealth of Massachusetts 19.000 regukitionsgoveming asbestos abatement(453 CMR a oa promulgated by the Deoatttnern of Labor Standards Note,Contractor must and 310 CMR 7.15 promulgated by the t3epartment of Environmental https:i/edep,dep.mass.gov/WebForms/AsbestosA3WPANFOOI.aspx 4/2/2015 04/03/2015 06:57AM 5442 DAVE WALSH PAGE 03/06 AQ 04-Asbestos Removal Notification Fornn ANF-001-Transaction##129129 Page 1 of 4 Commonwealth of Massachusetts 11o021,e7t3 Asbestos Notification Form ANF-001 Asbestos Projecl Number 2 Project Revision Project CtnroaSaSon A.Asbestos Abatement Description 1,Facility Location: OAVID WALSH WEST TERRACE Nmmd of Fadity StreCtAddrese � BARNSTABLE MA 017-838-41s8 V .i1�1)iV91:n.h1.LM-.'hi1.l-.-+.,.nu.u.• --__r—surne.-_._. ii i CitylTown State Zip Code Telephone E (OWNER _— Faclilty Cwdeat Person Name Facility Contact Petwn We Ewone 1.AN Worksite Location: eASFJNENT sed Iona of this Wm must Budding Name,Win®,Floor,Room,etc. be In v�MassD&& z.is the facility occupied?oompV FR-I yes FIJI No noKcaft requeeneM of 310 CMR 7.15and 3.Is this a fee exempt notification(city,town,diabi t,municipal housing authority,state facility,or owner- oepa<armt ofL*w occupied residential property of four units or less)?�Yss '5 Na swndards(DLS) noncabon rewirsnrarb 4_Blanket Permit Project Approval, if applicable' -------ram of4W CMRe.12 AWE ID 4 b.Non-Traditional Asbestos Abatement Worts Practice Approval,if applicable: , MeseDEP use only Appmvd Asa Asbestos Contractor Date Received I Addd�reWA z Submit original Form To: Cityfrown State Zp Coda Tela hoot TAW r 0 V rba eommonvriaefltu of AC000464 Corrtratt ©1Nrttten mnuchuseds AILS License 0 Aabeah%Program -----�— __ 5080847 t3ostorr, P o M 11200117 MA0211a- Name of Conh=brs on-Ste SupervaodForeman DLS Certraetlon A o21 0087 8. w� M060787 Neme of Project MOM& DLS Ceram 5 9. 1 WO-001-20 f Name of Asbestos Analytksl Lab DLS Ceditatbn 0 10.1D4703f2015 i I03/2015 � Prolect Start Date(MMIDDNYYY) End Date(MMIDD/YYYY) AM-6PM NA ^, Work Haas-Monday Through Frtday WoAt Hours-Saturday 8 Sunday V hqs:i/edep.dep.ioass.gov/WebForms/Asbestos/BWPANFOO 1 aspx 3/19i2015 04/03/2015 06:57AM 5442 DAVE WALSH PAGE 04/06 AO 04 -Asbestos Removal Notification Form ANF-001-Transaction#729129 Page 2 of 4 t1. Coemoliuon ❑ Renovation Repair Ohe -Please specify:I I 12.Abatement procedures(check all that apply): tt Glove Bag �Enap sure cauIation �Fincia rl Disposal Only I�1Cleanup uFullWortment C;Other-Please Specify. 13.Job is being conducted: Indoera 'D outdoors 14.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,er encapsulated: Linear Feet(Lin,Ft) $girare Feet(Sq.FL) Boller,Bresching,Duct,Tank r Transits Pipe Surface Coatings Lin.Ft Sq.Ft. R ln,Ft, Sq.Ft Pipe lnsuration [:=( -j Trenslte Shingles � Lin.Ft. Sq.Ft. Un.Ft. Sq.Ft Spray-On Fireprooflng r= i� Transits Panels i Lin.Ft. $q.Ft. Lin.Ft. $q.Ft Cloths,Woven Fabric$ 3 Other-Plesse^speclfy: Lin.Ft, 5q.FL Insulating Cement Lin.Ft $q.Ft, Lin.FL $q.Ft. 15. Describe the decontamination systems)to be used: I2 CHAMBER DECON --- --------------------- _..-. ^l �I i 16. Describe the containerizationldisposgl methods to comply with 310 CUR 7.15 and 453 CUR 6,14(2) (g)= _ . 16 MIL POLY BA3$ ~I V� 17.For Emergency Asbestos Operations,the MassDEP and DL$officials who evaluated the emergency: Name of MassOEP Official Tittle of MassOPP Official Date of Authorization(MM/ODNYYY) Waiver# Name of DI,$Official Title of DL$Otdclal I Data of Authorization(MM/DD/YYYY) Waiver# 18,Do prevailing wage rates as per M.G.L.c. 149,§26.27 or 27A—F apply to this ;�,1Yes �iNo project? I� B. Facility Description https://edep.dep.mass.gov/WebForms/Asbestos/BWPANFOOI.aspx 3/19/2015 04/03/2015 06:57AM 5442 DAVE WALSH PAGE 05/06 AQ 04 -Asbestos removal Notification Form ANF-001-Transaction.#729129 Page 3 of 4 ofAsbastoe.contEdning C. Asbestos Transportation & Disposal waste rnate6si is only saowad a the place of 1.Transporter of asbestos-containing waste material from site of generation: business of a DLS licensed Asbestos ❑1 plrecgy(o Landrlf or j To Tampofry S�Ordge Lgca£tOMTfdrxsf�S�tiOn conlrador or a transfer I sman that Is pe YW9!d by MessMr and AIR SAFE operated In oompiiance Name of Transporter Addtess with Sottd Warts CHIISEA i 021�i 781-762-3390 Regulations 310 CMR Citylrown State zip Code Telephone 19.0m 2.if a temporary storage Iocationttransfer station is used, list name of transporter of asbestos containing waste material from temporary storage location/transfer station to final disposal site: SB2VICE TRANS 8 PYLES LANE � � Name of Transporter Address NEW CA5MEE- - - -------1 [D 01972 '- Cltylrown state Zip Code TelaoxxIm 3.Name and address of temporary storage location/transfer station for the asbestos containing Waste rnsteriel: IR SAS - a 22 WILLOW ST ....- Temporary Storage Location Name Address Cltyrrown• State Zip Coda Telephone 4.Name and location of final disposal site(asbestos landtllo: f W1NERVA Final Disposal Site Name Final Disposal Site Owner New QWd MINERVARD (Vote;Cornreatar must Addt'ess sign this MM for DLS 1111 NESBURG OH 4668 330.866-435 naTiFicatina purposn Cit7NTowm State Zip Code Telephone r----- Name Authorized Signature Posiftru itla Date(MWDD/YYYY) Telephone RepresenOng 122 WILLOW ST CHELA Address Citvaown MA. ..._ 021so State Zip Code hittps://edep,dep.mass.gov/WebForms/Asbestos/BWPANF001.aspx M W2015 04/03/2015 06:57AM 5442 DAVE WALSH PAGE 06/06 AQ 04-Asbestos Removal Notification Form ANF-001-Transaction#729129 Page 4 of 4 D. Certification °I cbrfify that I have personally examined the foregoing arid am familiar with the information cattained in this document and all anachments and that,based on my Inquiry of thm iriclMduals . anmsdK ttly responsible for obtaining the information,I believe that the Information is true,accurate,and Corr-I6te.I am avrarB float Uwe aro significent penalties for aubrrlftUng false Information,Including posssmflnesancl imprisonment The undersigned hereby states that I have reed the Commonwealth of Wasechusetrs regulatlons goveming asbestos abatement(453 CMR 6.00 proirrralgated by the Depanmerttof Labor Standards and 310 CMR 7.95 promuIgQted by the Department of Emrironrttantal Protection),and Mail amawarethat 5tis permit application or nctIlImUon shag not be deemed varrq unless payment of the applicable fee is made." https:Hedep.dep.mass.gov/WebFonns/Asbestos/BWPANFOOI.aspx 3/19/2015 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 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. A. General Information �I (//pJ,. 1 030_r 1. Inspector: L - Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 Local Approving Authority 12-3-14 spector'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. lf0 5 I� t5ins•3/13 Title 5 Offic al Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. City/Town State Zip Code Date of Inspection B.'Certification (cost.) 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 is in good working order with no sign of failure. 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 m W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal Y P rY 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 El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than.4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ (A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ . the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes".to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been-determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form �m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2014 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 ,M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 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: N/A Was system pumped as part of the inspection? ❑ Yes ® No If ,es volume pumped: Y gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts = W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 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: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 30"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•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 M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Good condition with water at working level and no sign of back-up from field. 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 c Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4'M , 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-60'x4'x2' ❑ 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.): Leach trench in good working order with no sign of back-up into d-box or surrounding stone. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 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 �M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately s ' ._ f a 0 ' 4 ® { 3. 33 . �. 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 �M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 a e. City/Town State Zip Code Date of Inspection P9 P P D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 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: Original design plans show no groundwater at 12'. 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 fm - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °7M 34 West Terrace Property Address Fred Desimone Owner Owner's Name information is required for every Centerville MA 02632 12-3-14 page. CityTTown 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every 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. A. General Information 1. Inspector: j Shawn Mcelroy i= Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address iD E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification t � I certify that I have personally inspected the sewage disposal system at this address and thatathe _ - 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 onsite sewage disposal systems. I am a DEP approved system inspector pursuant to Section:1`5.340_of Title 5(310 CMR 15.000).The system: r- ® Passes El Conditionally Passes ElFaili :Dr ❑ Needs Further Evaluation by the Local Approving Authority L:T 5-7-08 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. 34 west terrace•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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. j Comments: �O System is in good working order with no sign of failure. IL__ 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 byj 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 34 west terrace•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M a 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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)(6)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. 34 west terrace•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r t Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 'h 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. 34 west terrace-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection .Form Subsurface Sewage Disposal System,Form Not for Voluntary Assessments ,M 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 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. 34 west terrace-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Scott King Owner Owner's Name information is Centerville MA 02632 5-7-08 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"non 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)] 34 west terrace-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments. w 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 4-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): 34 west terrace-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner--not pumped 6 yrs 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): Approximate age of all components, date installed (if known) and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No 34 west terrace-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts I - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 36" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 30" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 Gal Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 0 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 16" How were dimensions determined? Tape 34 west terrace-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 u Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town 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.): Tank in good condition with baffles in place. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 34 west terrace-03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 4 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 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.): Good conditon. " Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes , ❑ No Alarms in working order: ❑ Yes ❑ No 34 west terrace•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments 'M 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-60'x4'x2' ❑ 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.): Leach trench shows no sign of back up or break out. 34 west terrace•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.)' 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 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.): 34 west terrace•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 •1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. G� 49 r 34 west terrace-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 West Terrace Property Address Scott King Owner Owner's Name information is required for Centerville MA 02632 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' 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: I ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: Town maps and original permit show no water at 10'. 34 west terrace-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 1HE Town of Barnstable Tp� Regulatory Services BARNSTABM ; Thomas F. Geiler,Director MASS. 9� sa3� Public Health.Division AlED��p Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWN BARNSTAB E SEWAGE -Ile �+SSS SSOTS NIA $G'LOT VILLAO j�s N mE&Ky/yy NO., SUS j)ER OR.6VfNE P + I'C�A' .�G'()Wjp all�.l`I S*eatiatt D;& t qv,thtv�e�E tk�e Nlnxnxtuml��Ijust ilGt.oaj JwaterTAgile(atlid'Bo tomaf X�:achi �?aciUt� � r 1?►ivaaa; "/ t4r Sug�l�!^j Vdc Rl �c9 Y,cn%i�aitt C?lcikty �Bl:'my�re19s ex(s't on site 0V..:within�(IA fent Uz l�deiiitr�kstrili�,) _. Eci {: 1iVtAanr�apt iLaacdtii►�r 1Cacili(y G!<I"any��etlaa►c!5 exis¢ zsc tidi9.lai�t:1(}(1 f�et Qf l0:ACjjj68.facility) urnls�ied by. �. . - ... ......... a I C— a A _j` ,336 TOWN OF BARNSTABLE LOCATTON 3 5� GJ 5 f g . C@ sewAc YBA.,Ml9i.DL' � ��/ ffe ASSGiSJOWS M1^Y.T & A..4J+1-.-^...,.,.--«.......,,«a....».. INSTALLERS NAM PHONE NO. SEPTIC TANKCAPACITY (LEACHINC P'A.CII...TTX: ( ) �� .. .,(size) NO,OF'BEDROOMS___ .._.... BUILDER OR (' "separation Distau ice Between that Maximum A.djus cl(;rau dv�ater"l' ble to iltc 13c►uam of Z aGh%ng Iwru ility �, l Private WAter SQpPIy Well acid LcacWng Facility (If any twens exist on SW or within 200 feet of!caching fmcility) f'Age of Wedand and Leachl"S l:acility(if any wetlands exist Within 300 feet ["lcac.;iung facility) I7 cl, C. T J �GK , ' Q 4�SC4A Q b r A-0-qo A - F- y3' A F 336 J, F- /° F- 33, No. C Fee_6�2 / THE COMMONWEALTH OF MASSACHUSETTS /Entermedn computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Xkgozal *pMem Construction Vermit Application for a Permit to Construct( )Repair(6,l pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. , e r,W E-C Owner's Name,Address and Tel.No. v2 8' 4'O Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 5/7%— O14117 Designer' Name,Address and Tel.No. el9 7 O3 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) f y04P /=X/J/"idiCZ Gsysspools c'/eiim Ti�rbrrr¢// -oo (gam/, X�r1c T?Jrk d Ln_.SrC4/;71, 17 �OX41x2 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date 3 — /— 9 7 Application Approved by Date - 7 Application Disapproved for the ollowin reasons Permit No. Z Date Issued ,.yr 'A C•.w.�nr.r_ `. 1 V � t J �+ , r... .-. ._. ... ' •'n,�`.'.a F,« � � 1 ' y No. �_ ` i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for -Migpogar *pgtem Congtruction Permit n Application for a Permit to Construct( )Repair( pgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. y� r,-14C *�OWner's Name,Address and Tel.No. Assessor's Map/Parcel 2 7 2 Installer's Name,Address,and Tel.No. 4/7 7— 03 Cl Designers Name,Address and Tel.No. 4177 t Jo L3.� Jas t: Z)e 9J�rra Type of Building: i Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank .4 r Type of S.A.S. ' Description of Soil nz _ Nature of Repairs or Alterations(Answer when applicable) f yo4 P /;X ljrl h U Gi�,s's pao/s A aw/4 C 1 eon .S-oh',/ r4sr*ll /5'DO 6Qa 11 edTiC Twee e r-I.F 4 �0Xyx2 I Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-,a' cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date 4- 7 Application Disapproved for the ollowing reasons .w Permit No. - 7 Date Issued - i————————————————————————————————-—— — i 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(G-)Upgraded( ) Abandoned( )by J05e-pLi 22=e os at 141 -l/Y:"S 7"" Ed y e'w e - has been constructed in accordance with the provisions/of Title 5 and the for Disposal System Construction Permit No. dated 2 - � Installer k/r7 s-cam Designer 5 ftrs1 e- The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date '1 - )n - 1 -7 Inspector , i ————————————————————— ———————— —— No. ! 7 Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS�'�p 7 ligogar *pgtem Congtruction.Permit zo F Permission is hereby granted to Construct( )Repair(4o, 'Upgrade( J Abandon( ) System located at 3 4 'ui/=s 1"` x and as described in the above Application for Disposal System Construction Permit._ The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date:__ �, - t-/ - ? Approved by r"elw D— (2ax i t Sao G e 4t 3� �v 1s.5 NOTICE: This form is to be used for the )repair of failed septic systems only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAI; WORKS CONSTRUCTION PERMIT MITHOUT DESIGNED PLANS) 1, J0,5eP4 0,— l34rr03 ;hereby certify that the application for disposal works construction permit signed by me dated 2 — y--47 ; concerning the property located at 3 y ( l,5:'r Tr_- meets all of the following criteria: ,I 1 *' There are no wetlands within 300 feet of the proposed 'septic system t/ There are no private wells within 150 feet of the proposed'septic system •/ 'The observed groundwater table is 14 feet or greater below the bottom of the leaching facility vl There is no increase in flow and/or change in use proposed 6/There are no variances requested or needed. SIGNED: DATE: — 77 LICENSED SEPTIC SYSTEM INSTALLER IN T14E TOWN OF BARNSTABLE NUMBER 3t [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert TOWN OF BARNSTABLE LOCATION 3y 66/gS1- //=lry l4C/: SEWAGE # 97- y7• VILLAGE (/�NTFi'✓/��F ASSESSOR'S MAP & LOT ,�0,7 - /20 INSTALLER'S NAME & PHONE NO. JosepP D.v lYwe ^o S Y77- 0:?el SEPTIC TANK CAPACITY /500 LEACHING FACILITY:(type) Rene 4 (sue) 6 X 9 X 2 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 7wh BUILDER OR OWNER_( DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i(/a 71� TOWN OF BARNSTABLE LOCATION 3y G�EsT / f-1�ge SEWAGE # I7- y7 VILLAGE ASSESSOR'S MAP & LOT ,�O7- /ZO INSTALLER'S NAME & PHONE NO. ),Step 177-03y9 SEPTIC TANK CAPACITY ISoO ( 41 LEACHING FACILITY:(type) T&nr.ti (sue) CD X 4 X 2 NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATER. love BUILDER OR OWNER_�� � DATE PERMIT ISSUED: -7-97 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �D �ti�� ��r� �� .-� k �lC 33� 36�.2! I . . . ��. 3' �: . . EXISTING DECK REMOVED VANITY MIRROR AND COVERED HOLE WITH l8'Xl8' PIECE OF SHEETROCK BACK DOOR j BATHROOM BDRM 82 * ' KITCHEN SUN ROOM r-r rr "CLOSET D r O v N F I LIVING ROOM R �• E BASEME L BDRM M3 A C E MASTER BDRM CLOSET CLOSET COSMETIC CHAIR RAIL MOLDING WAS FRONT DOOR FRAMING A COSMETIC MANTEL REMOVED AND SHEETROCK WAS CUT BACK AROUND THE EXISTING FIREPLACE, 2FT AND REPLACED WITH NEW SHEETROCK, EXISTING WALL WAS MODIFIED 3 W. TERRACE BY CREATING AN OPENING CENTERED ON THE WALL APPROXIMATELY 4' HIGH X 9' LONG. L R P L A N (2) 9 1/2' LVL BEAMS WERE PLACED AS HEADER SUPPORT, NEW SHEETROCK WAS INSTALLED. N.T.S. ALL EXISTING ELECTRICAL WIRING WAS NOT MODIFIED ONLY THE RECIPROCAL BOXES WERE REPLACED, DRAWN BYi FPD