HomeMy WebLinkAbout0031 WESTMINSTER ROAD - Health 31 WESTMINSTER RD., CENTERVILLE
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UPC 12534 5�
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HASTINGS, MN
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
- 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Westminster Rd.
u Property Address
Evan Perry
Owner Owner's Name /
information is Centerville ✓ Ma. 02632 11-6-20
required for 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. Please see completeness checklist at the end of the form.
Important:When A. Inspector.Information 50a.5
filling out forms
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites Path
r� Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S114430
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 -�kA OF Al
2. ❑ Conditionally Passes
MICHAELLn
3. ❑ Needs Further Evaluation b the Local Approving Authority
=o. SEARS �r
y pp g y S L No.SI14430 0
4. ❑ Fails
INS?
11-6-20
Inspector's Signatur 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 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�i; Subsurface Sewage Disposal System Form Not for Voluntary Assessments
t
31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is Centerville Ma. 02632 11-6-20
required for every
page. City/Town 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:
1000 gal tank, D Box, Chambers
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 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.
El Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection -Form
J- �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`C, � 31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is Centerville Ma. 02632 11-6-20
required for every
page. CitylTown State Zip Code Date of Inspection
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.
❑ 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):
3) 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.
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:
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. � 31 Westminster Rd.
u Property Address
Evan Perry
Owner Owner's Name
information is Centerville Ma. 02632 11-6-20
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont)
❑ 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
b. 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.
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
El ® 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
c Commonwealth of Massachusetts
�v ,p Title 5 Official Inspection Form
II Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is required for every Centerville Ma. 02632 11-6-20
page. City/Town 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 %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.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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.]
❑ ® y
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
❑ ❑ 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
A ........... 31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is required for every Centerville Ma. 02632 11-6-20
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
® ❑ 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?
® El 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
AN' Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name -
information is required for every Centerville Ma. 02632 11-6-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
Number of current residents: 6
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ 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? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 2018-137000 gal2019-115000 gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present .
Date
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i
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.......... 31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is required for every Centerville Ma. 02632 11-6-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes,,discharges to:
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 below):
3. Pumping Records:
Source of information: 8-7 19
Was system pumped as part of the inspection?. ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I -
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u—
31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is Centerville Ma. 02632 11-6-20
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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:
Tank-1977, D Box- 5-8-19, 2 Chambers-5-15-17
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
12"
Depth below grade: 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.):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
I
Commonwealth of Massachusetts
�u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is Centerville Ma. 02632 11-6-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan): \
2"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain),
1000 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth: 1
� 29„
Distance from top of sludge to bottom of outlet tee or baffle
`Scum thickness 0
811
Distance from top of scum to top of outlet tee or.baffle
Distance from bottom of scum to bottom of outlet tee or baffle 18
How were dimensions determined? Sludge judge, 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.):
1000 gal tank with inlet baffle and outlet tee, both covers at 2" below grade
T
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c � 31 Westminster Rd.
u-
Property Address
Evan Perry
Owner Owner's Name
information is required for every Centerville Ma. 02632` 11-6-20
page. Citylrown State Zip Code Date of Inspection
D.-System Information (cont.)
7. 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.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form Not for Voluntary Assessments
u 31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is Centerville Ma. 02632 11-6-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
f 9. 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.):
D Box is 16x16 with 2 outlet pipes, cover at 12" below grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
M1,,
Title 5 Official Inspection Form
5
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
I
`C � 31 Westminster Rd.
V
Property Address
Evan Perry
Owner Owner's Name
information is Centerville Ma. 02632 11-6-20
required for every
State Zip Code Date of Inspection
page. Cityrrown
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 chamber, 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:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t.
31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is
required for every Centerville Ma. 02632 11-6-20
page. Cityrrown 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.):
SAS is 2- 500 gal chambers chambers are clean and dry with no sign of 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 ❑ No
Comments (note condition of soil, signs.of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Westminster Rd.
Property Address — -
Evan Perry
Owner Owner's Name
information is Centerville Ma. 02632 11-6-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form Not for Voluntary Assessments
31 Westminster Rd. __—__--
Property Address
Evan Perry
Owner Owner's Name
information is Centerville Ma. 02632 11-6-20
required for every — - — — -
page. City/Town 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
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15insp.doc•rev.V2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
IISubsurface Sewage Disposal System Form - Not for Voluntary Assessments
I'
............. 31 Westminster Rd.
Property Address
Evan Perry
Owner Owner's Name
information is required for every Centerville Ma. 02632 11-6-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high round water:
p g g 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: 6-29-09
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:
No ground water per plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspe
ction Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` !% 31 Westminster Rd.
u—
Property Address
Evan Perry
Owner Owner's Name
information is required for every Centerville Ma. 02632 11-6-20
page. City/Town 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
O Gr �dt
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
No.r7V7 2 ___ q Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Disposal 6pstrm Construction Vrrmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Adividual Components
at n Add r L t No. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel /
Installer's Name,Address,and Tel.No. Designer' Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 4:;V , No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ` o gpd Design flow provided �/ gpd
Plan Date m X P i y Number of sheets ,/° Revision Date
Title
Size of Septic Tank �®®® Type of S.A.S. �l
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Pe4' .eA�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board qPWealth. 7
Si
Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. a Date Issued
--------_
j
No.C7-�7� i Fee Dv
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
. Yes
PUBLIC HEALTH DIVISION - TOWN-OF BARNSTABLE, MASSACHUSETTS
01ppliLAtion for Misposat-6pBtem Construction 3permit
Application for a Permit to Construct Repair Up'grade�'� Abandon( ) ❑Complete System Adividual Components
tipn No. O isy, Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer' Name,Address,and Tel.No.Uv
Type of Building: �y
Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 6;V4", No.of Persons Showers( ) Cafet
Other Fixtures
Design Flow(min.required) `3g� gpd Design flow provided ` y9. gpd
Plan Date S— -000y Number of sheets 001, Revision Date
Title
Size of Septic Tank fX�.l���J"�tO ,,000'40490 Type of S.A.S.
Description of Soil cr��zo"
Nature of Repairs orAlterations,(Answer when applicable) .P4,.e o:5;Pe.,eA1
Date last inspected:
Agreement: (t Or
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ealth.
Si e54R Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. l / '� �`r Date Issued 5
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )bylT /07 ,Pfr���'-Ti
at 31 �/�✓ �9�r-!'TE'G� Or.b «p`hA been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Nadated ��5 ,112
lnstaller . J�7 ���a /L Designer,®,
#bedrooms 3 Approved desi gpd
The issuance of 's pe it shall not be construed as a guarantee that the system wil r unctio design
Date (D Inspector k✓
No. 9}}--17� _ _ .. Fee .THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Bisposat 6pstem Construction j9ermit
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at ,A
and ,A .�
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be com�Ie wittithree ears of the date of this ermit.�// y p e
Date Approved b �
Town of Barnstable
prof, Regulatory Services
Thomas F.Geiler,Director -
'"�'ASS. ' Public Health Division
9 ��
o2.659.
5s 16 Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 5 8-862-4644 Fax: 508-790-6304
r ,
Date: Sewage Permitn'�� ��� Assessor's 14Iap/Parcel
Installer&Designer Certification Form
Designer: 1�17 Installer:
Address: �� `��' G+-t�G '/ Address: ��
Ply
was issued a permit to install a
(date) ll (installer)
septic system at �j 1 ��� W 05 ased on a design drawn by
(address)
__))*,J IV' 0( dated 5 }�
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stnpout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than la' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local R '-tions. Plan revision or
certified as-built by designer to follow. Stripout(if r.- acted and the soils
were found satisfactory. �tN OF tijgS�
spy\
DAVID \.
B.
nstaller's ignature) o MASON li
U 9 Na.1066-3L 0
AJL
'``�� IS
est er s Signature) �� r �✓����
PLEASE RETURN TO BARNSTABLE PUBL. - f E
OF COMPLIANCE WILL NOT BE ISSUED UlN i ii, asv i rl i riia r l)RM AND AS-
BUILT CARD ARE RECEIVED BY THE_BARNSTABLE PUBLIC HEALTH DIVISION
THANK YOU.
q:loftice fonnskdesignercWitication fonn.do:
TOWN OF BARNSTABLE
LOCATION �� ������r���� -eI,EWAGE#-,)oJ->
VILLAGE Ce�,�G'tel--/'1"'ZASSESSOR'SMAP&PARCEL--,"�d—
INSTALLER'S NAME&PHONE NO.
E:'"Xi ®®® At
SEPTIC TANK CAPACITY ��"A" � � e
(size)
LEACHING FACILITY: (type)
NO.OF BEDROOMS
OWNER
PERMIT DATE: �'� /'�`�,� COMPLIANCE DATE: Jam,
Separation Distance Between the: 0 ii4,002 ✓ o�
M Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) �i _Feet
FURNISHED BY (-fJokV ZZ ® �J`"
G�/��
� � � � �. �
o�
� �
3 �
t
Town of Barnstable P#
Department of Regulatory Services
MUMSTABL : Public Health Division Date 0
�A 1639. �e� 200 Main Street,Hyannis MA 02601
JJr,,
Date Scheduled Time �r Y4 %11 Fee Pd: 00
Soil Suitability Assessment for Sewage isposal
Performed By: Witnessed By: ✓
i
_ LOCATION & GENERAL INFORMATION
Location Address L C�n�^� �n S,Da—� �7�, Owner's Name (� QtC i�r
e 'V � i k c k mot"`R Address z5cll�
Assessor's Map/Parcel: ) �'
Engineer's Name CAemjEtij JN• qy
NEW CONSTRUCTION REPAIR Telephone# 3((o(,p
Land Use 1AQXN_i CA. Slopes(40) . Surface Stones
Distances from: Open Water Body /V f[ Possible Wet Area ft Drinking Water Well
Drainage Way la=ft Property Line ! ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands 4n proximity to holes)
SN
� y
T,9;
I
Parent material(geologic) t 0+L..�zh Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: (� Weeping from Pit Fnce
Estimated Seasonal High Groundwater l\ tl-1 SS V�Q
DETERARNATION FOR SEASONAL HIGH WATER TABU
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level , Adj,Factor— Adj.Groundwater Level
_ PERCOLATION TEST lute- i241 Thne 11 -Q(
Observation
fr
Hole# Time at 9" _ULM
Depth of Perc � Time at 6" 1
Star[Pre-soak Time Time.(9"6") 4 m\n
End Pre-soak 8
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Pubic Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one (1)week prior to beginning.
Q:\SEPTICU'ERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.% ravel
S
eq la4 C � S 1 e2-Sy J-H
DE
EP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,% ravel
M�;/L
-C S 'Z
C r i he-
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders.
Consi ten °
z
Flood Insurance Rate Map,
Above 500 year flood boundary No.= Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious u�aterial exist in all areas observed throughout the
area proposed for the soil absorption system? � -
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on L (d I h ve sled the soil evaluator examination approved by the
Department of Environ tal tecti n an ha the above analysis was performed by me consistent with
the required training, perti and ex ie c de cribed in 310 CMR 15.017.
Signature Date
Q;GSEPTIMERCFORM.DOC
No. ZZitoSa --
,� Fee o
THE '".OMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH Dl%,iSION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rppliratior for Migogal �&p5tem Cow6truction Permit
Application for a Permit to Construct O Repair(�ade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location ASldress or Lot r . CC N 7 C/Z Owner's Name,Address,and Tel.No.
/ `�/ s7-y►r.vs EQ �� �..�Y fir✓e 2 4 j e z a
Assessor's Map/Par< ? �6 p 7 SP ✓" jr
Installer's Narre,Address,and Tel.No. Designer's Name,Address and Tel.No.
G '>7S >3 6� S'o SS.31 7266
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder (�
Other Type of Building f �_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures /
Design Flow(min.required) D 3 Q gpd Design flow provided gpd
Plan Date 7 / O ` Number of sheets Revision Date
Title
Size of Septic Tank rk 1-57 /O Q0 Type of S.A.S.
Description of Soil
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 the Environmental C e and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health
Signed Of Date r> v
Application Approved by e, Date 7^ IC ^
Application Disapproved by: Date
for the following reasons _41
Permit No. 0 0"\ /6 Date Issued & - 20�
L
1 n
No. b ,_. 'Fee
THE COMMONWEALTH OF MASSACHUSETTS Enteredin'computer:_
PUBLIC HEALTH 11, ISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
` Application for �
r igpogaY,,pgtPm Congtruction Permit
1 f,/ 1
Application for Pemit tonstruct( ) Repair( ade( )� Abandon.( )-y❑'Complete System ❑Individual Components
LocatioW" ddress or'L'ot,n F IV?EQ vi 7 P Owner's Name,Address,and Tel.No.
-'�t,/�•!�'E'sT iyt i ni.s 7 f� �^lX / v N% GU�' iL/Z r e� �
Assessor.'s'�Map/Parrel �6 o
Installer's Narrie,Address,and Tel.No. Designer's Name,Address and Tel.No.
14 441c ,y ro s- ` ( C,a a/'-, r- ��,a y
G(7 >7S )3'6 s oP' 5-3 7 �6
Type of B gilding:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder 611
Other Type of Building E No.of Persons Showers( ) Cafeteria( )
C ther Fixtures /
Desig,hlow(min.required) �3 Q gpd Design flow provided 36_3 , gpd
Plan Date � /��� Number of sheets Revision Date
Title —� 1!
Size of Septic Tank Z-r< 57 /,0 0' Type of S.A.S.
Descriptio`n'of Soil
A�/�
Nature of Repairs or Alterations(Answer when applicable)
__ zt
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
�G
Application Approved by Date A
�^
Application Disapproved by: Date
for the following reasons
Permit No. Q — Z d Date Issued
———————————— ———---———————.——————————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( )
Abandoned( )by 6L G A
/� r
at �j vv_/A has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 210 dated 7-/&'
Installer Designer( 19 2 /"
#bedrooms Approved design ow gpd
The issuance of thi permit shall not be construed as a guarantee that the system wilY
ncti'bri as designed.
Date (1 Inspector Q
No. .————
Fee M0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
&!9p0ar *pgtem ConAtruction Permit
Permission is hereby granted to Construct ( ) Repair ( ✓) Upgrade ( ) Abandon ( )
System located at 3 G �-5- 7 Z y-57T 9 2
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 pe tt.
Date ( god I Approved by
TOWN OF BARNSTABLE
is )CATION, / lt/2ST�tnf5Te2 SEWAGE#o200 --Z./0
^� LLAGE C.t:.v7-G R i )1'0 ASSESSOR'S MAP&PARCEL J h X— y-76
INSTALLERS NAME&PHONE NO. 5-0 9F
SEPTIC TANK CAPACITY
/740id2
LEACHINGFACILITY:(type) (size), �,�/�, 2A 7J—
NO.OF BEDROOMS
OWNER
PERMIT DATE: � COMPLIANCE DATE: � O
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
rr
i
C.)k 41
90
° U
3_ 3.2
ry!
t ,
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM to 11
Address of property 31 Westminster Road, Centerville, MA. `°y'�
Owner' s name Thomas L. & Karen J. Boduch `►�
Date of Inspection 6/5/95 �4/
PART A r �. 8 Ig9�
CHECKLIST �l'!y
Check if the following have been done: `�. �ie'
�y1
Owner Pumping information was requested of the owner,' occupant, an S oaci of
Health.
yes None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system -recently or as part of this inspection.
yes As built plans have been obtained and examined. Note if they are not
available with N/A.
yes The facility or dwelling was inspected for signs of sewage back-up.
es The site was inspected for signs of breakout.
P g
yes All system components, excluding the SAS, have been located on the
site.
Yes The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
_ems The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
yes The facility .owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential"�1
3 -number ofjbedrooms
2 number�of- current residents
no garbage- grinder, yes or no
es laundry connected to system, yes or no
no seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
current Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
Owners Pumped 1989 and 6/5/95
s System pumped as part of inspection, yes or no
Y'''''' if yes, volume pumped
Reason .for pumping:
Sale of house
Type of system
yes Septic tank/distribution box/soil absorption system
n,� Single cesspool y
�_ Overflow cesspool
n/a Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
n/a Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
Tnitial 1 �170 • N w i 1987
Town of Barnstable Board of Health and Owner
_nD_ Sewage odors detected when arriving at the site, yes or no
I
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade: covers to grade
material of construction: X concrete metal FRP other(explain)
dimensions: To, 4161, x 8 ,16 ( 1000 gal.)
4" sludge depth
20" distance from top of sludge to bottom of outlet tee or baffle
411 scum thickness
9" distance from top of scum to top of outlet tee or baffle
20" distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
Gand rnndl i t i nn _ Pumt)Pd1 Normal Level T i q1]i d
RRrnmmPndai:inns • normal maintenance pumping average every 4 years
DISTRIBUTION BOX:
(locate on site plan)
Even depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
�11 nnnr9i �-inns normal
PUMP CHAMBER:
(locate on site plan)
N/A pumps in working order, yes or no
Comments:
(note. condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
i Q
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may .be
approximated by non-intrusive methods)
If not determined to be present, explain: N/A
Type
leaching pits and number Two 6 x 6 leach pits
leaching chambers and number n/a
leaching galleries and number , Ufa
leaching trenches, number, length n/a
leaching fields, number, dimensions n/a
overflow cesspool, number n/a
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
N/A
CESSPOOLS (locate on site plan) : N/A
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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY: N/A
(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, recommendations for maintenance or repairs,etc. )
• 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
SEE ATTACHMENT
DEPTH TO GROUNDWATER A1W-30; ZONE 4-5
apx. 34 . 8 ' depth to groundwater
method of determination or approximation:
Cape Cod Commission USGS Observation Data 4/95 and Hyannis Quadrangle
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
N Backup of sewage into facility?
N_ Discharge or ponding of effluent to the surface of the ground or
surface waters?
N Static liquid level in the distribution box above outlet invert?
N Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
_N Required pumping 4 times or more in the last year?
number of times es pumped
P P
N Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
N below the high groundwater elevation?
N within 50 feet of a surface water?
N within 100 feet of a surface water supply or tributary to a surface
water supply?
N within a Zone I of a public well?
N within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
N within 50 feet of a private water supply well?
N less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysis
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
t 6706a "
F
LE # J 3766 CENSUS TRACT #
IENT: Tel Workers' C.U.• DEED BOOK 6700 PAGE 235
NER : m s . & Karen J. Boduch PLAN BOOK 243 PAGE 97 LOT
PPLICANT: same ASSESSORS PLAN PLOT
MORTGAGE INSPECTION PLAN of LAND
I N
B A R N S T A B L E
SCALE: 1"= 40'
FEBRUARY 25, 1992
loo -oo
* LoT I a
16poo +S.F
a
g°�� I ISo.00
LOT 19 A
l 50.0o 131 LoT 17
i I STO R`(
I
I S'1"O�IEI
I DRIVEI
I I
100.00
32� INLET SGPric 'yak A 6
36' ourLEr . V�IESTMINSTER ROAD 35, D-eox Is '
43' � I ZI "
72 Z t 3(o'
itJLElr 10'
OUTLET 13'
.I CERTIFY :TO SOUTHERN MASS.ACHUSETTS TELEPHONE .WORKERS."..C.REDIT UNION, AN
I Ts
TITLE; INSURANCE- -COMPANY, `THAT THERE=-ARE NO VISIBLE ENCROACHMENTS <.;0
EASEMENTSEXCEP.T AS SHOWN AND THAT. THIS PLAN WAS PREPARED UNDER '..M
IMMEDIATE SUPERVISIONI
` ATTACHMENT
�; ;; NT;FROM PAGE #11 '
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector Gordon Bumpus
Company Name Ocean General Contracting
Company Address P.O. Box 659, Osterville, MA. 02655
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
X I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature �.
Date 6/5/95
Original to system owner ; Thomas L. & Karen J. Boduch
31 Westminster Rd . , Centerville, MA. 02632
Copies to:
Buyer (if applicable) Jerold & Davida Gilmore
Approving authority Town of Barnstable Health Department
fib:•t'c.1°F5 1:; .36 FROM Town of Barns tab 1; =b F.02
TOWN OF SARNSTABL$
LOCAILDiy
ASSESSOR'S MAP&LOT�,�y1�
WSTAr LZR'S DAME& PHONE No.C�
SRPMC TANK CAPACa Y Cj
42-
LEACMNG PAcnz�:( 5. (6Joao
NO OF.:BEDROOI[S PRrYATB WELL OR MBLiC WAM&L
DATE I!SR=IS U D: .
DdTB }�,LPLtgNCE�SU$O -12
-
VARIANCE:GRAWRIN Yea No i
l31�,h'
3-3 S y, r
3 �.Q
�fi
wr. DATE:10/20/99____
PROPERTY ADDRESS: 3l_Westm m-t.Pr-- .UJL___
Centerville2Mass ______
02632
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following: O r�
1 . 1-1000 gallon septic tank . Ono
2 . 1-Distribution box .
3 . 2-1000 gallon precast leaching pits .
Based on my Inspection, I certify the following conditions:
4 . This is a title Five Septic System. ( 78 Code )
5 . The septic system is in proper working order
at the present time .
6 . Both of the leaching -pits are presently dry .
SIGNATURE:f
a
Company: Jose_ph_P . Maco.mber_& Son , Inc . �
Address: Box 66 GF _
Centerville , Ma__--632-0066 °w`� `9`919 I
Phone ...5,08_775=3338 "7'
9
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
v VWA__
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachfle Ids
Pumped & Installed
Town Sewer Connections '
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775.6412
f
DATE:10/20/99____
PROPERTY ADDRESS:_ 31_WestmnsteraQ•L,d-___
Centerville.LMass .______
02632
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon septic tank .
2 . 1—Distribution box.
3 . 2-1000 gallon precast leaching pits .
Based on my Inspection, I certify the following conditions:
4 . This is a title Five Septic System. ( 78 Code )
5 . The septic system is in proper working order _'
at the present time .
6 . Both of the leaching pits are presently dry .
SIGNATURE:
Name:_,, � a�ombgr
Company: Joseph_P . Macomber &—
Son , Inc .
---- ---------
Address:_ Box_66 ___________
Centerville , Ma . 02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
" COMMONWEALTH OF MASSACHVSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor - Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:31 Westminster Drive Name of Owner Jerald Gilmore
Centerville as 02632 AddressofOwnw: 22C Pilgrim Drive
Data ofhupection: I6720��39 Westford ,Mass . 01886
Name of Inspector: (Please Print) Joseph P.Macomber Jr .
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
c«npanyNar„e: J. P .Macomber & Son Inc .
MarTingAddress: Box 66 Centerville Mass . 02632
Telleptx"Number: 5 0 8_7]S_4 4 4 S2
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The Inspection was performed based on my training and experience In the proper function and
maintenance of on-site sewage disposal systems. The system:
_✓ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
-�I C
Inspectors Sig Fails nature: v z 1 Date: �e
The System Inspect shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department ofrEnvironmental Protection. The original should'be sent to-vw
system owner and.copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 P2ge1of11
iJ Printed on Recycled Paper
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CERTIFICATION (cwn ued)
PropertyAdcir.:31 Westminster Road Centerville ,Mass .
own«: Jerald Gilmore
Darts of Insaec.Kion:1 0/2 0/9 9
WSPECTTON SUMMARY: Check A. B, C, or D:
A. SYSTEM PASSES:
I have not found any Information which Indicates that any of the failure conditions described In 310 CMR 1-6.303 exist. Any failure
criteria not evaluated are Indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
!U� 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of daterminatlon In all Instances. If 'not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance (attached)Indicating that the tank was Installed within twenty (20) years prior to the date of the Inspection; or
the septic tank, whether or not metal, Is cracked, structurally unsound, shows substantial Infiltration or exfiltration, or tank
failure Is Imminent. The system will pass Inspection If the existing septic tank Is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pips(s)
or due to a broken, settled or uneven distribution box. The system will pass Inspection If (with approval of the Board of
Health).
broken pipe(s) are replaced
obstructlon Is removed
•``,, distribution box Is levelled or replaced
The system required pumphiq•mory than'foLvdmas i•yeardus to broken or obstructed pipe(s). The vyrmm will-j"=--
Inspection If(with approval of the Board of•Hes(th):
broken pipes) ms replaced
obstruction Is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:31 Westminster Road `Centerville Mass .
owner: Jerald Gilmore
Date of Irupection: 10/2 0/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
.t! Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and 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.YALL.PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENV=ONMENT-
Cesspool or privy is within 50 feet-of 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 AND SAFETY AND THE ENVIRONMENT:
Q 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance A14 (approximation not valid).-
3) OTHER
A
AA
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(contirwed)
PropwWAddrass: 31 Westminster Road. Centerville ,Mass .
own«: Jerald Gilmore
Date of Inspxction: 10/2 0/9 9
D. SYSTEM FAILS:
You must indicate either "Yes" or'No" to each of the following:
�i AD I have determined that one or more of the following failure conditions exist as described In 310 CMR 16.303. The basis for this
datermination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No '
�I Backup of•sewogs into feci{ityror•r/stem component-due tto an overloaded orcbgQsd•Sf1Sor-casspool.
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 bo/ bove outlet Invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in.4c&szpass�oel is less than 6" below Invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 60 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic-compounds, ammonia natrogen•and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system Is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No i/
�/ the system Is within 400 teat of a surface drinking water supply
the system•Is-witWo 200 foot of a H+butary to o furtaoa�rkilclr+q w+torsupp7y ... _ . . ._—. .. _
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)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further Inforinatlon.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAda.e>s; 31 Westmihster Road Centerville ,Mass .
Owner: Jerald Gilmore
Date of inspection: 10/2 0/9 9
Check If the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by theEnDioccupant,or Board of Health.
.None of the systemcompoaants.hamaAmen pup►ped4os`a4least<twoaweakeaad-tbe'system hasbaaaaaceiwwgwasial flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,**c luding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on-the site has been determined based on:.-
Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at Issue,approximation of distance Is unacceptable)
(15.302(3)(b))
_ The facility owner.(and.occupants-if differaW from owcnerl.waraptlutided.wi2h lnfntmatioann thA Prnpar maintasmaca 4f
SubSurface Disposal Systems.
i
1
r
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Pr.wtyAddr.ss;:31 Westmikster Road Centerville ,Mass .
Owner: Jerald Gilmore
Date of Ir,specd-10/2 0/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: d/_g.p.d./bedroom.
Number of bedrooms(des' Number of bedrooms(actual):
Total DESIGN flow-
Number Number of current residents:
Garbage grinder(yes or no):_
Laundry(separate system) D3 or®:_; If yes, separata.inspection.required
Laundry system inspected or no)
Seasonal use (yes or no): 1y /+a 7(/i
Water meter readings, if available (last two year's usage (gpd): f�Q/ LGCJl'il�� W7 T`� (o��Y'
Sump Pump (yes or no):
�t7
Last date of occupancy: t�l7yl /_ ^,
COMMERCIAL/INDUSTRIAL: /1�!
Type of establishment: W-4
Design flow: 414 gad ( Based on 15.203)
Basis of design flow WA
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)A&
Non-sanitary waste discharged to the Title 5 system: (yes or nou&
Water meter readings,if available: AV
Last date of occupancy: 44
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS ardoylrya of irL ��:����
System pumped as part of inspection: (yes or no)_3
If yes, volume pumped: gallons
Reason for pumping:
TYPE O SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
AX
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank W,4_Copy of DEP Approval
Other �!¢
APPROXIMATE AGE of all components, date installed{if known)•and source oftinforrnation:
Sewage odors detected when arriving at the site: (yes or no)la
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ProopertyAddress: 31 Westminster Road Centerville ,Mass .
Owner: Jerald Gilmore
Dau of tn�:10/2 0/99
BUILDING SEWER:
(Locate on site plan)
�I
Dept below grader
Material of construction:_cast Iron�40 PVC_other(explain)
Distance from private water supply well or suction line A,t
Diameter
Comments: (condition of joints, venting, evidence of f"kage,•etc.)
Joints appear tight . No evidence of leakage.
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: onct/retq/-)AMetal4J�i Fiberglass A/APolyethylenoVAother(explaln)
If tank is [natal, list alga A&1s.age.confirmed by Certificate of Compliance (Yes/No)
Dimensions: Pit; 'Ai7A1!] V'& /JeA
Sludge dept?�
Distance from top o ludge to bottom of outlet teeortraffle-
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet to or baffler
How dimensions were determined: G
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level In relation to outlet invert, structurekntegrity,
evidence of leakage,etc.) Pump seDtic tank every 2-3 years: Inlet & outlet tees are
in i 1 are The ttanlr i e structurally* sound aAd ShbiWB P.9
GREASE TRAP: e_
(locate on site plan)
Depth below grade: 1W
Material of con3tructionconcreteIJAmetal.f�4Fibergl83s0l9 PolyethyleneN.�other(explain)
Dimensions: IN
Scum thickness:
Distance from top of scum to top of outlet tea or baffler e
Distance from bottom of scum to bottom of outlet tee or baffle:)',
Date of last pumping: AM
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert, structural Integrity.
evidence of leakage, etc.)
Grease trap is not present .
• 4
revised 9/2/98 Page 7of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Addresa:31 Westminster Road Centerville ,Mass .
Ownw: Jerald Gilmore
Date of Inspection: 10/2 0/9 9
TIGHT OR HOLDING TANK:Ajl&!f (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:-AM-
Material of construction:aconcrete4Ametal4/AFiberglass/&Polyethylene*Aother(explain)
A -- -- -
Dimensions: A/A
Capaci
gallons
Design
anon
Design flow: gallons/day
Alarm present
Alarm level:Alarm In working order:Yes414 NoR�1Q
Date of previous pumping: A14 —
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
lignt or noiding tanks are not present .
DISTRIBUTION BOX:z
(locate on site plan)
Depth of liquid level above outlet invert: 41211)
Comments:
(note-if level and distribution is equal, evidenoe of solids carryover, evidence of leakage into or out of box, etc.)Distribution box has two laterals .No evidence of solids carry over .
No evidence of leakage into or ortt of the hnx
PUMP CHAMBER:-A�we
(locate on site plan)
Pumps in working order:(Yes or No
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
Pump chambpr is not =rPsPnt -
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
_ PART C
SYSTEM INFORMATION (coritinuod)
PropertyAddr—:31 Westminster Road Centerville ,Mass .
Owr-w: Jerald Gilmore
Dau of lnsp.cdo :10/2 0/9 9
SOIL ABSORPTION SYSTEM(SAS):,,,
(locate on site plan, If possible; excavation not required,locadon may be approximated by non-Intruslve methods)
If not located, explain:
Type:
leaching pits, number:,
leaching chambers, numbs(:O
leaching galleries, number:,
ff
leaching trenches, number, length:
leaching Maids, number, dimensions:
overflow cesspool,numb r:n
Alternadve system: q n
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vagetation, etc.)
Loamy sand to merl; ,,m send No signs of hydra tl i _ fa; 1 nrp
or ponds nQ 4oi 1 s are dr. Veasta��el;e Ufa �6���' -
CESSPOOLS:
(locate on site plan)
Number and configuration:
Dapth•top of liquid to Inlet Invert:
Depth of solids layer:
Depth of scum layer: AM
Dimensions of cesspool:
Matsriais of construction:
Indicadon of groundwater: Iva
inflow (cesspool must be pumped as part of InspecUon)
Cesspools are not irPRPnt --
Comments:
(note condition of soil, signs of hydraulic failure,.level of ponding,condition of-vegetation, etc.)
--Cesspools are not present -
PRfVY:
(locate on site plan)
Matarjals of constru tign: AIR Dimensions:
Dapth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE=PO4AL SYSTEM INSPECTION FORM
PART C -
SYSTEM wr-oa.xnon (cortdrx►aC)
Prop*nZyAddt—: 31 Westminster .Road Centerville ,Mass .
o..^e, Jerald Gilmoze
D eu of Vupoc`ion: 1 0/2 0/9 9
SKETCH OF SEWAG
E DISPOSAL SYSTEM:
Includs Iles to at Fast two permanent te)srencs landmarks or banchmarks
locete all wills within 100'(Locate whirs public watsr supply comas Into house)
O
0 iY
i
i
i
i
W
/ C!J e S 7' A /T 4, gxt u R b
revise
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:31 Westminster Road Centerville ,Mass .
Owner: Jerald Gilmore
Date of kupection: 10/2 0/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
served.Site(Abutting propert observation hole, basement sump etc.)
,(/Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
__;ZChecked local excavators, Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map .
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page 11of11
I
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•n.lnr�T-n.9T+-tTr-\TRra.n•nTPrr�'•1.n rwr+s*1fltT+tr�rr1RA.1nn�TSYu 1T�11t7•rt ll+ns.vTlfsAas+► T'R1T��.�+TR....1..1'�
TOWN OF Barnstable DOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
1
�•Tf'I�T•:::f-T.111t�.T1TTT.1.1'q.'R1T�RlRITP'1RT.T�.t'I TI VIR`�11'TR�"�RP�Iw.1�9R\ nR11. .+tip T'R'1r •-.
—TYPE OR PRINT CI.EARL1'—
PROPERTY INSPECTED
STREET ADDRESS 31 Westminster Road Centerville Mass .
ASSESSORS MAP, DLOCK AND PARCEL #
OWNER' s NAME Jerald Gilmore
=sue
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J.P.Macomber & So-f 'Inc .
COMPANY ADDRESS Box ,66 Centerville ,Mass . 02632.
Street Town or Clty State LIP
COMPANY TELEPHONE ( 508 ! 775 - 3338 FAX (508 1 790 -1578
w
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa'1 system at
Dtomplete
his address and that the information reported is true , accurate , and
as of the time of4inspection . The inspection was performed and any
ecommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
�Systeoi PASSED
The inspection which I have conducted has not found any informat
ion
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have con acted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
icaio copy of this c rtiftn must be provided to the OWNER, the BUYER
DFne
Where applicable ) and the BOARD OF HEAL711.
* If the inspection FAILED, the owner r or""� ` oator shall up
grade pgrado ' tho system
within o'ne year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 , 306 .
partd .doc
TOWN OF BARNSTABLE
-%TION 5l 4 SEWAGE # _
ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)�� /4)6�f (size) AV
NO.OF BEDROOMS /�
BUILDER OR OWNER�� 4)iLWJ
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)- Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet o 1 mccility) Feet
Furnished by
731
Q /-C
a �
-e I �� Iu-
W
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No..je `��.6 7
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
Appfiration for Disposal Works Tontrnrtion Upumit
Application is hereby made for a Permit to Construct ( ) or Repair '><) an Individual Sewage Disposal
System at:
^^ Location-Address or Lot No.'
.................. ........................ ..........------......•.................... .-----....------_.._..........................
Owner Address
W
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ..
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_.__________---____-
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ...••----••-•••--••••••----•-••••--•....-•-•••••----•--------••-••-••-----•-•---•-----•............................•-------•••......--•--•-•-..........•-•--
0 Description of Soil.................................
x '
U ----•-----••---••------•---•---------•••-•-•-•-•-••••-....•••••.....-•-......---••-••-------•--••••••-•-••-------•••--•--••----•-----------•-•-•••---•--•-------••---•••••••----•------••---•-......•.--
W
U Nature of Repairs or Alterations—Answer when applicable.......... '°'____.-___ .-•...-_ ...............
-----------------------------------------------------------------------------------••-----.....--------......------------------------...•--••-••••-•-•••....-•-•-•-•••-••....-•••-••----•-•-•-----•-•••.
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of TTTv..=i 5 of the State Sanitary Code——he undersigned further agrees ntt to place the system in
operation until a Certificate of Compliance has b n issue yjtbqAr� of health.
Signed_. , r -.-rr.. .!....... .................... ................................
Date
Application Approved By.......... ......��r "l �= ..:..............
,f' �" ........................................
Date
Application Disapproved for the following reasons---------------•-------------•-----------------------------------------------------------------------...---_...
--------------------------------------------•------•------------------.....-----•--.....---•------------••--••-•••.....••-•--••••---------•-•--•-••-•-----•--••-•••••-----•--•••-----•--••--------•-•---
Date
Permit ------------------------- Issued.._........-•------------•-•- .............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... -c-Ic-......OF.............. ^c�?c� :1 r............................
Tnrtifiratr of Tontplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired"f�-}
it�± ..--- '�- =----'..`.- '—---------------------•---------------------•-------.-•---•-••----•--------------.--.---------------•----------------------.--
by--------------_---i� - _
n
Installer
at--------------� ................. y...
has been installed in accordance with the provisions of T I TIE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit NO----E.7.____ dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..............6.......�. ._-_.� ?................................ Inspector--- ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r: .............CGr�:.-�. OF. .....................................//11
........... FEE..�.�'"?......�..
Disposal Works TUonotrurtion rrutit
Permission is hereby granted.........L_. ................ E- --
to Construct ) or Repair � an Individual Se tag Disposal System
at No•---_-----2;L...I-------- === "-Q`�
Street
as shown on the application for Disposal Works Construction Permit
�No 1':. �_ . Dated..........................................
Board of Healthw�~
DATE.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
rA
ki� �' TOWN OF BARNSTABLE
OG. TION SEWAGE #
ASSESSOR'S MAP LOT "
INSTALLER'S NAME PHONE NO 36d`CO �
SEPTIC TANK CAPACITY Z a o
e `aa 0
LEACHING FACILITY:(type) (size)
�
/7111
NO. OF BEDROOMS,2 PRIVATE WELL OR PUBLIC WATER /�.
BUILDER OR OWNER ���'1 �v�� c �a
I '
DATE PERMIT ISSUED:
DATE . E ISSUED: —T COZLPLIANC � —
VARIANCE GRANTED: Yes No ..%
4cs/
31p _ i
32
0
oca Lt.-
O'd ��
2-1W DIAM. ACCESS MANHOLES �1 ,
VENT PIPE ((®Least 24 inches tall) ;Fe�. :,�:•,�•'.��,r�`_:' y'_e;_:'^�' , '
*NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.Y.C.10' min. from Schedule 48 PVC w/Charcoal Odor Filter
`r
Existing Foundation house to septic tank ESTABLISHED VEGETATIVE COVER •� P-
TOP OF FOUNDATION ELEV. 100.00 Septic took cows must be D-@0x .over meet be `I T
within a in. of finished grade with 5 In. of finished grade
Grade over Septic Tank_• 99.00 Grade over D-Box - 99.00 over SAS-99.00
4' ';( `., .•. ,• ,• BACKFILL MITH CLEAN SAND INLET
:�'' . :,.. ,.: ;: '•'i'•' (NATIVE OR PERC SAND) OU 1�'see.«wru
.:•1.
- •Y" i^+ .ti A• :., t'.i• »'.;•J.. ,,'' ;y.. i. ''i'
5 Q02 '!• ','•t. '4•. ''L" .:q,:.A'• ,' .., 'y' '.y: 4 •""'•
B HOLE H-10 w. .i,. i':: t a..S`
';y' ",,:.�:.;:' THE ACCESS COVERS FOR THE SEPTIC TANK, .- ✓, A ra<`
s-o. IST. BoxF TOP OF UNIT ELEVATION 96.00 , : "�:, ;> •�' "<.'`w`. ti•� :: � �* t
EXISTINGico Ot 3' Maximum Cover i,i: :v �. " t•'+'»: t�',•..• ., I DISTRIBUTION BOX AND LEACHING COMPONENT i ( �J
12' 4"PVC CAPPED INSPECTION PORT TO BE T' ��f r"/
EXIST, ( ) :;. :.: o,.: tr +r'S '"f"'4:*•t�!' T� r '-+• SET DEEPER THAN a INCHES BELOW NISHED +
i�T. viog u� 1000 GAL. »1 a; ;.::,.. ,e w., t ,y
Ss INSTALLED AND lO BE 1MTHIN 8' OF GRADE �� : qq +j ++�,
n O 40 0.01' :,': .y ; GRADE SHALL BE RAISED TO W11HIN 0 OF i ter'
FROM EXIST, FOUNDATION Per foot INV. ELEVATION 95,7 ` �` -" "`)• ✓
SEPTI TANK a 5 :,, •'',f.: \
$ C ,,� y' ,;`,: STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE.
CONCRETE WALK-OUr-1 11 H-10 ,rj way r" J'
a, an e.rw p m 1S' n�• P N VIEW INSTALL 1UF-TITS CAS BAFFLES OR EouALS
MEWMMBOTTOM ELEVATION - 95.00 :tit• ;'w "
u B In.of 3/4"-1 1/2" m II b 26. 3-24" REMOVABLE COVERS .
I i
4J compacted stone c p �, 4 OWS OF l!UNITS AT 4'
tt /LLMIT i 2 END CAPS. 2e.00' •�' GENERAL NOTES
y - - e 5' MIN ABOVE BOTTOM OF " : .,
? SYSTEM PROFILE > c > TEST PIT OR GROUND WATER B 4 3 min. clearance :~
° -Epp. iIIDTE f2.yo` Ex1371NG suITABLE MATERUL INLET m� r min. Inlet to outlet I
r LNIET
Not to scale Bottom of Test Hole 1 Elev.= 88.50 Lq�ld?ewe °"mLn.
5 mpa led stone
1/2" GROUNDWATER NOT OBSERVED OUTLET ; 1. Contractor is responsible for Di safe notification, VERIFICATION
compacted .tone GROUNDWATER NOT OBSERVED O 126" o'm'" +•• ' and protection of ail underground utilities and pipes.
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE BOTTOM OF TP-1.: - 88.50 S❑IL ABSORPTION SYSTEM (SECTION) 5 -� � 5 -�" 2. The septic a distri Dion box shall be set
ESHWT s NO GROUNDWATER OBSERVED 0 126" 4•-D" min. level on 6 of 3f4 -1 1/2 stone.
INFILTATROR QUICK 4 (H-10 LOADING)/ GEORGE O'BRIEN .; §s °iMi^"` Llqutd depth 3. Bockfill should clean sand or grovel with no
stones over 3 in size.
(OR EQUIVALENT) 4. This system is subject to inspection during installation
NOTE: OVERALL HEIGHT OF INFILTRATOR IS 12' :'• ` t'- •'1 by Carmen E. Shay - Environmental Services, Inc.
W-D" 4' -10" 5. The contractor shall install this system in accordance
CROSS SECTION END-SECTION with Title V of the Massachusetts state code, the approved plan
and Local Regulations.
6. If, during installation the contractor encounters any
TYPICAL 1000 GALLON SEPTIC TANK soil conditions or site conditions that are different
NOT TO SCALE from those shown on the soil log or in our design
installation must halt & immediate notification be
made to Carmen E. Shay - Environmental Services, Inc.
7. No vehicle or heavy machinery shall drive over the
PERCOLATION TEST septic system unless noted as H-20 septic components.
8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
Date of Percolation Test: JUNE 29. 2009 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes.
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. 10. All solid piping, tees & fittings shall be 4" diameter
Results Witnessed By DAVID STANTON - Barnstable BOH
EXCAVATOR: Shay Env. Svcs. Schedule 40 NSF PVC pipes with water tight joints.
Percolation Rate: 2 MPI 0 30" 11. MUNICIPAL WATER IS AVAILABLE TO THE SITE and Surrounding
Test Hole Test Hole Properties. NO PRIVATE WELLS WITHIN 150 FEET of PROPOSED SAS
No. 1 No. 2
DEPTH SOILS ELEV. DEPTH SOILS ELEV.
.00 0 99.00 0 99 NOTE-
THE PROPERTY LINES ARE APPROXIMATE AND
Sandy Loam Sandy Loam COMPILED FROM THE PLAN BY DAVID H. GREENE,'RLS
10 YR 3/2 10 YR 3/2 MA, ENTITLED *WOODBRIDGE SUBDIVISION IN CENTERVILLE, MA"
D 0"-6" 98.50 0"-6" 96.50
DATED AUGUST of 1872, PLAN BOOK 235 PAGE 55
E S' T'1V-j�lV AS ?'ER l� OA� Loamy Sand Loamy Sand AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
-- -- - (40 FOOT RIGHT OF WAY) - 10 YR 5/e 10 YR a/o
THE SEPTIC SYSTEM INSTALLATION.
_ _ 6"- 36" 8, 96.00 6"- 36" Be 96.00
j
T - Mod-Coarse Mod-Coarse
Sand Sand NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
100.00' I ( 2.5 Y 7/4 2.5 Y 7/4 FROM THE EXISTING LEACH PITS TO BE DISPOSED
1 I 36"- 84" C, 92.no 3e"- 84" C, 92.00 OF AS PER BOARD OF HEALTH SPECIFICATIONS.
N 82D 05' 10 E i i e um
Medium
Sand Sand EXISTING LEACH PITS TO BE PUMPED DRY &
I I 2.5 Y 7/4 2.5 Y 7/4
W 84"- 126 5 FILLED IN PLACE
88.50 84"- 126 Ce 88.50
� 1 1
ASSESSORS MAP 168 PARCEL 076
I EXIST. I ZONING - RESIDENTIAL
I DRIVEWAYi ._, Perc #1
Depth to Perc: 36" to 54"
a I I Perc Rate= 2 MPI
I 1 1 NO Groundwater Observed ® 126"
I I PROJECT BENCH MARK ADJUSTMENT = NONE
EXISTING I I TOP OF FOUNDATION No Observed ESHWT NO WETLANDS ARE LOCATED WITHIN A 200' RADIUS
3 BEDROOM I I OF THE PROPERTY
HOUSE I I ELEV. = 100.00 (Assumed)
31 ALL L-----U DISTRIBUTION PIPES E ION E BOX SHALL
SET LEVEL FOR AT LEAST 2 FT. 12" CONCRETE COVER
"... ,: 6 - 5" OUTLET •; • r.,•.r•.. ..�:.. 2" LEGEND
KNOCKOUTS
64 4- 15.5" OUTLET I t ' 12" INLET 8X0 DENOTES PROPOSED
SPOT GRADE
EXIST. R ., .•;, ..I,,: 2 DENOTES EXISTING
LOT #17 0 1000 gal. 15.5" 4" - SCH. 40 T " X 104.46 SPOT GRADE
O Septic Tank Failed O 1.75
PLAN-SECTION CROSS SECTION
y 42.6' LEACH PIT "pO LOT #19 PL PROPERTY LINE
A LEACH
FailePIT ko 6 HOLE DISTRIBUTION 'BOX - [ED - PROPOSED CONTOUR
0y � A NOT TO SCALE '
OD 97- - -- - -97 EXISTING CONTOUR
> esian Calculations
20' 26, DEEP TEST HOLE &
- PERCOLATION TEST LOCATION
TEST HOLE #2 Number of Bedrooms: 3 Equivalent to 330 Gal./Day
f2 7' ELEV.= 99.00 Garbage Grinder: No
D-Box Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) FENCE
Septic Tank : - 2 x 330 Gal./Doy • 660 USE EXIST. 1,000 GAL. Septic Tank.
Pepe SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch
P Bottom Area: 0.74 gal/sq. ft. x 490.88 sq. ft. - 363.25 gallons - PRIVATE DRINKING WATER WELL
TEST HOLE #1 LOT #18
ELEV.= 99.00 Sidewoll Area: NOT USED REVISIONS
28 S'- - 16,000 Square Feet ,f/- _ Providing: - 363.25 gallons
2. .Use: 4 ROWS OF 6-QUICK4 STANDARD CHAMBER JNITS WITH NO NO. �" DATE: DEFINITION
STONE FOR AN SAS HAVING THE DIMENSIONS: 12.7' x 26.0'
100.00' Bottom Area: (General Use Approval for 4.72 SF/LF of INFITRATOR
6 UNITS + 2 END CAPS per ROW as 26.0 FT
S 82D 05' 10 W 4 ROWS x 26.0 x 4.72 SF/LF = 490.88
DESIGN FLOW PROVIDED: 0.74(490.88 S.F.) = 363.25 GPD
PREPARED FOR : PRO-POSED
LOT #15 LOT #16 SUBSURFACE SEWAGE DISPOSAL SYSTEM
OF
ANTHONY GUERRIERO #31 WESTMINSTER ROAD
#31 WESTM I NSTER ROAD CENTERVILLE, MA
CENTERVILLE, MA 02632 PREPARED BY:
Of A$
c MEN , RHEYV E, SHAY
E.Y "' NVIRONMENTAL SERVICES, INC.
0 20 40 50
No. 1 81
III
85 ASHUMET ROAD
�GlST��
sANITAVk\ MASHPEE, MA 02649
SCALE: 1 "=20' TEL/FAX : 508-539-7966
SCALE: 1 "=20' DRAWN BY: CES DATE: JULY 16, 2009
PROJECT#SD-1148 ILENAME: SD1148PP.DWG SHEET 1 OF 1
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i
ASSESSORS P : r I1 -
TEST HOLE LOGS
PARCEL ,
-1"6 _ -- - --- t) The installation shall cornp� wvitll `Title V and 'Town ol'�wftiloard of
u 28 FLOOD ZONE: �`-t� __ SO I L EVALUATOR: I fealth Itegulations.
WITNESS : shall verily the location of utilities, sewer inverts talc) Septic
!1 2) The installer
�G WFllq - REFERENCE:��, ,..� - --�1C� C► ��
s� .... DATE. 17210011. components prior to installation and setting base elevations.
�S � ? I (� PERCOLATION RATE: e.. '21N)1 1 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
Q two l'eEa out of the d-box to the leaching shall be level.
yr Env.q�,D� �' b lob g
TH- I TH-2 4) This plan is not to be utilized for property line determination nor any other
purpose other than the proposed system installation.
,f\ 5) All septic components must meet Title V specifications.
6) Parkin shall not be constructed over H10 septic components. 1
g p p
&40 7) The property is bounded by property corners and property lines.
10 b , 8 The property owner shall review design considerations to approve of total
LOCATION MAP � ;b Epp > , p p y g pp
�jIQ �jb design flow and number of bedrooms to be considered for design. Receipt
of payment for the plan and installation based on the plan shall be deemed
C� 9 61 bolo
approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material
oK Awl ? per Title V abandonment procedures. Those within the proposed SAS shall
i G Z {� l✓Z be removed along with contaminated soil and replaced with clean sand per
4 i' 2, Title V specs.
U ,
Q� 10)System components to be 10 feet from water line. Sewer lines crossing the
AD L40. Wifla, water line shall be sleeved with 4 inch SCI 140 PVC with ends grouted if
E S 77MI1V s TER R OA applicable. The proposed SAS is being installed below the water service
7-7
-�(, line. The line is to be sleeved as aforementioned and maintained in place.
- (40 FOOT RIGHT OF WAY) S E P I C DE-S I GN 11) If a garbage grinder exists it is to be removed and is the responsibility of the
------------------- ------- -,-- - - owner to ensure such
-----------1------- T- .
FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such
100.00' i i exists.
N 82D 05' f0" E ,�BEDROOMS AT GAL/DAY/BEDROOM -�GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer
tij lines exiting the dwelling'Prior to the installation.
SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting
i i ► Title V requirements.
' GAL/DAY x 2 DAYS Welt GAL
EXIST. ; USEI= GALLON SEPTIC TANK
., » iDRNEWAr ---�'IGIV�I��
Sk01L' ABSORPTION SYSTEM
IEXISTING
9 BEDBOON r r ,. i
BousE .....; � .u�\ 'O2t� � 1�-1oW V� ��N aFa�gss4
SIDE AREA: ZX �� o� DAVID �y
*sr C.
BOTTOM AREA: x Qw �, ?�� MASON m
roo.loss
N04 P
SEPTIC SYSTEM SECTION
e EXIST. \ R
o - 1000 gal. R
O Septic Tank
O filed
tt C LEACH
Failed
LEACH PIT w�
o A q 10"
0
20' -
J
TEST. �I GAL
'1 I
tz y. ELEV.- 99.00 SEPT I C TAD Box
0
a l �3
Von
y
Pipe HOLE LOT #18 � x,
ELEV.e 99. 1 16,000 Square Feet /—
foo.00 SITE AND SEWAGE PLAN
nr
S 82D 05 10" li � 1 � -KC R)4
I LOCATION :
3&4ftyn NA
PREPARED FOR : -41 G
SCALE: I
DAV I D B . MASON R!), DATE: lZ
DBC ENV IRONMENtTAL DESIGNS
DATE HEALTH AGENT .
EAST SANDWICH . MA
( 508 ) 833- 2177