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0062 WESTMINSTER ROAD - Health
62 Westminster Road Centerville A=168-068 /// S M EAe No.2-1531AR UPC 12834 sn wd com • Made In UBA . AM 2p) t t ;>o i O I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1/I1 Property Address Owner ie J P✓'VG.I every Owner's Name ��� information is required for eve a Vr �/t ✓ Q 6 1 ? / page. City/Town State ZipCode p� J Date of Ins ectio Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms s/ on the computer, use only the tab 1. Inspector: key to move your cursor-do not use the return key. Name of Inspector � i,/, o �/ rao- Company Name n Company Address --- — -- _—_ reoai, �S �� �.✓L1 l�i� D� 6 � )) — Cityrrown o` Jro 0_,7�9 State�O Zip Code 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 systerns. I am a DEP approved system inspector pursuant to Section 115.340 of Title 5(310 C 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7 41nspectSignature J 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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 /o f 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments WeS�it'11hJ�� Property Address L Owner �2✓��"` T information is Owner's Name / required for every C�t/1 `I-2Vl/j 0.) � page. City/Town State Zip Code Date of I B. Certification (cont.) pec on Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) Syste asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by . the Board of Health, will pass. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name �evv�0 information is /� ,/ required for every C-e�►-�I Kt// 1l-e- �� �a 6 �� 3TIYT"),- page. Cityrrown State Zip Code Date of ingpectfon 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 ❑ ❑ Fd ❑ 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 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 Property-Address Owner Owner's Name information is / required for every iQ1il Me //�� �aG3� page. Clty/Town State Zip Code Date 41pe�P= 3- 2. B. Certification (cont.) System will fail unless the Board of Health (and Public water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or ❑ No clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters d e to an overloaded or clogged SAS or cesspool ❑ tatic 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner 6/ information is Owner's Name /Q0 required for every — („_ ✓VG �Npeon page. Cltyi I ownStateZip Code Dateof I 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: ❑ ,L—�/ 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 '11 ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privyis within 50 feet et of a private wafer 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.] ❑ he 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 follo wing, 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.doc•rev_6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M �a C✓�5�,�,H s�Q A Property Address Owner Owner's Name e rv,o information is required for every ✓i /��'/r/� ��.� 3 /2 C. Checklist page. City/Town State Zip Code Date of Ins ecti Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? ❑ u 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3�� t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M G� der Property Address �es 4//1,//�S Owner Owner's Name �49 �Q information is C //� required for every � !/(/ `( / / page. City/Town State Zip Code P Date of sp tion D. System Information Description: Number of current residents: — Does residence have a garbage grinder? ❑ Yes 2- -'No-Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes g--No Laundry system inspected? ❑ Yes ;No�10 Seasonaluse? El Yes Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address � C_ Owner v4information isOwner's Name s,� required for every t�� page. City/Town State Zi Code (X J P Date of Ins ecti n D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? I❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? --- —_ Reason for pumping: Type of Sy m: 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. El (describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. GRy/Town State Zip Code Date of Inspection U. System Information (cont.) Approximate ag of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): / Distance from private water supply well or suction line: A) I feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): ) �/ Depth below grade: �o feet Materi 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: j Sludge depth* t5ins.cloc-rev.6/16 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 t� 'es /�l✓I S r i2d Property Address Owner Owner's Name information is r_ required for every State A1,4 �/� m! \ page. City/Town � � vd rp r,L Zip Code Date of I D. System Information (cont.) pe on Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle v `/ Scum thickness i� Distance from top of scum to top of outlet tee or baffle /i Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition s liquid levels as related to outlet invert, evidence of leakage, etc.): tructural integrity, C0.1 d, �roN Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a "" (�✓�S�/"IidIS�e Property Address Owner S� a V1, information is Owner's Name required for every Cel/��err�� (� -6 ) 3 L / page. City/Town State ZipCode Date of spe lion 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 roust be pumped at time of inspection) (locate on site plan): Depth below grade.- Material of construction: ❑ concrete U metal ❑ fiberglass ❑ polyethylene El 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Asssees�sments `M y Q W Property Address 'eS JAII N S�� Owner Owner's Name Se v �� information is required for every �� ^ page. City/Town s State Zip Ci Date of In ecti In D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert L , 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.): sa/,j Pump Chamber(locate on site plan): Rumps i��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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 4 h G Property Address Owner Owner's Name information is required for every Q v1 page. ` e /y ®.)6 7l / City/Town State Job Zip Code Date of I spe Ion D. System Information (cont.) Type 0 J o7 0- S W/ ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: --- --- ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 7— z . "` ✓1S D� vl ��wl, L �� l� 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / Owner K 7` Owner's Name information is required for every C�eL4 4/,"t Or) 6 l page. City/Town State Zip Code d Date of In pec n 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address `f�" `tof Owner ner's Nae � p✓VCL vt information is Owm ?� required for every 'e ll q Ile A �h/ J page. —"Y/Town 3 3 of In ecti n D. System Information (cont.) State Zip Code Date Sketch Of Sew ge Disposal System: Provide a view of the sewage disposal system, including ties to at least two ermanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately — - -3G''� 39, t5ins.doc•rev.6/16 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 a c Property Address Owner Owner's Name ✓t/a w information is ) required for every � 3 / page. City/Town State Zi Code P D. System Information (cont.) Date of Ins cti Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: _ 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 ❑ served site (abutting property/observation hole within 150 feet of SAS) Checked with local Boa d of Health -explain: lCvls 4- ❑ Checked with local excavators, installers -(attach documentation) ElAccessed USGS database-explain: You must d scribe how you established the high ground water elevation: / G y1 N t l'o to✓1 C(,v a c��j C w—�Pi sLf t), �V7 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M Property Address Owner v v N Owner's Name information is I required for every � Vj /4 page. City/Town State Zip Code Date of I E. Report Completeness Checklist pe ion [-;�Inspe tion Summary:A, B, C, D, or E checked 'Insnextion Summar y D(System Failure Criteria Applicable to All Systems) completed Xemof Information—Estimated depth to high groundwater Sketch Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 t i w . -► � � �,� M�ri� C��sI�Q, tll �� �. a(� ����i o�yC6 � �PLA tl,e - N DECK DN �- ENT ENT COUNTER 11' 7' 11' 5' 15' 6' 1s' a' --BATH— KITCHEN ^P BED DINING c ROOM c COUNTER I C 9' 2' it 10, 9' 27' 7' C o I LIVING �o BED BED zo m ROOM ROOM c rr ENTMA\IN —r C 11' 2' L—fk==11' J' FL❑❑R 1: 1379 SF -- - - - - _ - ---�-- � �----------- �� FOUNDATION 15' 8' �8` 1� 7' 5' 19. S. N �ITGVj N W LEDGE Nr aw C C t7w s rc W EO Z Q. O � O N UTILITY ROOM GARAGE W O "u W 27' 7' > U C] �W ur ELANTRI VHTER 26' 9' �� N W BASEMENT: 1323 SF N DECK DN r ENT ENT COUNTER 11' 7' 11' 5' N DN 15 8' AT KITCHEN BED DINING c ROOMLo e• l "2�-- 27' 7' 10 3' o c LIVING --j BED BED ROOM ROOM ✓ MAIN C ENT c 21' 3'- 11' 2' FLD11R 1 1379 SF FOUNDATION 15' 8' 7 5' _ 19' S' c Q U n��r5tk •�� o � o �a N N PROPOSED ST ' GE AREA W v LEDGE / oe LW c c W Z Q' a, D a UTILITY ROOM Q V iu GARAGE a O rl N W 27' 7' U_ W K 1 W O uW ECTRI VAT R W 26' 9' N BASEMENT: 1323 SE No. Z00 fj 6(k a * r Fee /00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitatioii for Bisposal 6pstem ConstrUrtion permit Application for a Permit to Construct( ) epair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No a Ev Owner's Name Address and el.No. 4 ,C/ " 1 C T f Assessor's Map/Parcel ///c e-t i C'•%?G 0,S�e��j�l� llp9, Installer's Name,Address,and Tel. o. f Stv Vr! Designer's Name,Address,and Tel.No. � �/ n is�' Ct)n st Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required gpd Design flow provided ��G/ gpd Plan Date �f /� �® t7 Number of sheets c2 Revision Date Title Size of Septic Tank P Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) e Gent dA 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 Healt Signed -� Date Application Approved by Date A Z 4 Vd49 Application Disapproved by Date for the following reasons Permit No. "1 ` Date Issued l I 241 Pe No. Z00,5 --l 6(` z n Fee /00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes - ftpYication for Vsposai 6pstem Construction permit Application for a Permit to Construct( ) epaP Upgrade( ) Abandon( ) ❑Complete System ElIndividual Components Location Address or Lot No, G a w Ps- /7)j4/S Owner's 7elddress.,andTel.No.. ivC�. �� "Yo/G TfAssessor's Map/Parcel Pry S ia� /�r /C.irF�C Q S/eJi�ji/� A/PIV. Installer's Name,Address,and Te1ANo. 7 S'e.of l/► a Designer's Name,Address,and Tel.No. /ado iS r, Sf / 19 Type of Building: r/ /�'a Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building C, -�. No.of Persons Showers( ) Cafeteria( ) Other Fixtures -.- Design Flow(min.required) ?.? gpd Design flow provided ��L� gpd � � Plan Date �� /�j / Number of sheets Revision Date Title - Size of Septic Tank /l..t�^9p') Type of S.A.S. 12 �lTifiG llw,14 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 Code and not to place the system in operation until a Certificate of y Compliance has been issued_by this Board of Health. Signed %i% a�s ��i Date �� y Application Approved by f/v Date Z L,/ ('j r , Application Disapproved by Date for the following reasons Permit No. 4 q k Date Issued 11 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Cornpfiarue THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by DLX L f- V 1Z ?�,A '4 1 L.-,,- at to'I w V-ST M\ N S' f f '=17 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoZc, t-4l j datedhZ411 P 00$ Installer la►D G t�ll S l 4J S-T 12 u(-'I 1 U Designer #bedrooms 3 Approved design flow A gpd / The issuance of thEnm construed as a guarantee that the system ill c�tion�as designed) Date Inspector No. Z0441-1% 41�( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS 30isposal *psteu—t oustruction 3permit Permission is hereby granted to Construct( ) Repair(✓) Upgrade( ) Abandon( ) System located at (� (it,r�C�'T �1 1 �'�(1,(, �� j L L 09- 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 completed within three years of the date of this permit. Date 1 ' 2 I -U y �� Approved by '� W Town of Barnstable THE Regulatory Services I/ Thomas F. Geiler, Director 1• YARNSf UL. "SAS Public Health Division '0lenty. Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 503-362-3644, Fax: 503-790-6304 Installer & Designer Certification Form p Date: Sewage Permit# 2009- 1 ( Assessor's Map\Parcel Designer: �'i Ir/� t'✓!C.l� Installer: Address: PO PO 6)1/ � � address: -7 ( t a 4 Sa k r)w l L S3� � O2 S3 On d� 2`1!v g � � �A'�U��S was issued a permit to install a (date) / (installer) �y septic system at _(�2 W IES` -MIA15Mk PO, based on a design drawn by (address) f'r' dated (designer) 1 certify that the septic system referenced above was installed substantially y according to the design, which may include minor approved changes such as lateral relocation of the distribution box an6'or septic tank. l certify that the septic system referenced above was 'Installed with major changes (i.e. greater than 10' lateral relocation of the SAS or am: vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF MAss9c VVo� orl M. s -s ignature) " No. 1140 'PF6/S1E � c' S01 TWP� �-H �5 (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU Q: Health/SepticiDesigner Certification Form 3-26-4.doc TOWN OF BARNST,yABLE P,..._ LOCATION 6 2 CJ�/� f !/�jOl,�^�G�Ov SEWAGE#' k � �1 �t VILLAGE C&Ojc' o //` . ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. J-,Ts4d/Ig-P i?, SEPTIC TANK CAPACITY �O LEACHING FACILITY:(type) '-,3� r f (size) 9 IrK �[ / NO.OF BEDROOMS i OWNER PERMIT DATE: COMPLIANCE DATE: b 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 L7:�07 k d4 3 i '70 13 s 3 )�v SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A Signature ,,��/( item 4 if Restricted Delivery is desired. X l ewgent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. _- g. R eived by Print N e) C. Da of Delivery ■ Attach this card to the back of the mailpiece, 4 ( � ; or on the front if space permits. i��GG�� !�u wf'[ (., 1. Article Addressed to: D. Is delivery address different m item 1? Yes If YES,enter delivery address below: ❑No D A-L6- •¢i(Ol�f? I fir y��r �lf c��T4. .�,��,t��M i�'1 ervice Type Certified Mail O f;.�ressMali ❑Registered ❑Retum Receipt for Merchandise ❑Insured Mail ❑C.O.D. Restricted.Delivery?(Extra Fee) ❑Yes 2..Article Number -- � (TiansferfmmseMcelabeq Ili _�7006 0810 0000 3525 3695 f PS Form 3811;February 2004 Domestic Return Receipt (,Z (��S�y1jA to ss-o2_pa-ts4o i UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.GG10 • Sender: Please pdnt.your name, address, and ZIP+4 in this boxCD • C) cm ill, fill,l,li,ill,,,,,,ll,1„lll,,,O,„W.71M I At ,., C Town of Barnstable Barnstable AN-Am , Regulatory Services Department mica j BARNSTABM , �$ 69. ,� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geder,Director FAX: 508-790-6304 Thomas A.McKean,CHO 4?.t5s zoo August 5, 2008 $' 4-0 Dale Urbanik ,f r 62 Westminster Road �l° i5 �C � `f'l i Centerville, MA 02632 ()sE �% - /-�— a � CQ,CAP11-n Njf;/ 9- 7c�O 4- OS/0•-6000-- 5- 3 C9� ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 62 Westminster Road, Centerville, MA was last inspected on July 29, 2008,by Brad J.White, a certified septic inspector for the State of Massachusetts: The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Leaching pit has one pipe entering and one pipe exiting leaching pit. Liquid was sitting on outlet line %2 way. Second leach pit is completely overfull. System needs to be upgraded. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER CIRWR OF HE BOARD OF HEALTH f A avid Stanton, R.S. Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 7590 Q:\SEPTIC\Letters Septic Inspection Failures\62 Westmonster Road.doc oyPtESPosryc F Town of Barnstable _ Public Health Division 05.32° era a 200 Main Street o 2 1 A Hyannis,MA 62601 MAILED FROM ZIPA CUOGD 1E 3 0226001 7006 2150 0002 1041 7590 N �CEIPT Dale Urbanik ` \ RC-iURN� \ � .K�Qs1Ea 62 Westminster Road e�N m Centerville, MA 02632 v H NIXIE 029 SE i 0200y 25/-O£1 t RETURN TO SENDER UNCLAIMED UNABLE TO FORWARD BC, 02601400.200 *0969-01859-18-37 q Ara�F I I X-1 Logged In As: arc i Thursday, September 4 2008 Parcel Lookup Parcel Info Parcel ID 1 168-068 Develo er SOT 7 Lot _:.. _ _ _...._ _.. _ ....�..._..r.. ........ .. ......._._..........._.._.._ .. ....I. Location 62 WESTMINSTER ROAD Pri Frontage 100 Sec Road ROUTE 28 Frontage .....115 99 Village CENTERVILLE Fire District _._,_ Sewer Acct Road Index 1816 Asbuilt Septic Scant P Interactive 168068 1 k — Map Owner Info _ Owner[URBANIK, DALE TRS Co-Owner'URBAN REALTY TRUST - Streeti 1153 HICKORY HILL CIRCLE Street2 CityOSTERVILLE State MA Zip 402655 Country USA Land Info Acres j0.38 use Single Fam MDL-01 zoning €RC Nghbd 0106 _... .._ _ __._... .. _ ............. ...... Topography 11-evel Road €Paved ........ .... ......... ............... utilities;Septic,Gas,Public Water Location Construction Info Building 1 of 1 Year _ Roof i .__.,,,.,. M_.�._. Ext in _� 1971 -Gable/Hip Wood Shgle Built .-. __._ Struct i Wall .. Effect 720 - Roof As h/F GIs/Cm� AC None Area Covert P P Type 3 Int Bed �....... .... ..... ... R Style:Ranch Drywall 3 Bedrooms Wall I -- - _. _...� Rooms. Model;Residential Int 9 Batn ;2 Full Floor Rooms 3 . Heat +Total ' r Grade;Average ry. Type Hot Water Rooms 8 Rooms j Stories 1 Story Heat IG __. _ Found- ;T Typical Fuel las ._ _._._ ation; Yp ,� Permit History.......,., _.....__........... .. i IIIAue D'd'te I Purpose Permit# I Amount I Insp Date I Comments II Visit History ..... . ... Date Who Purpose 6/11/2008 12:00:00 AM Paul Talbot Cyclical Inspection 9/20/1999 12:00:00 AM Donna Dacey 3rd Visit-2nd Notice Left 9/9/1999 12:00:00 AM Donna Dacey 2nd Visit-1st Notice Left 18/23/1999 12:00:00 AM Donna Dacey Meas/Est - Sales History Line Sale Gate Owner Book/Page Sale Price 1 11/15/1986 URBANIK, DALE TRS 5386/294 $128,900 2 LEBEL, JOHN S 3287/16 $0 - Assessment Historyr _... Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2008 $153,900 $10,900 $0 $151,700 $316,500 3 2007 $153,000 $10,900 $0 $151,700 $315,600 4 2006 $139,000 $10,900 $0 $155,300 $305,200 5 2005 $129,000 $10,700 $0 $123,900 $263,600 6 2004 $104,800 $10,700 $0 $92,900 $208,400 7 2003 $101,300 $10,700 $0 $41,400 $153,400 8 2002 $101,300 $10,700 $0 $41,400 $153,400 9 2001 $101,300 $10,700 $0 $41,400 $153,400 10 2000 $75,600 $9,900 $0 $31,100 $116,600 11 1999 $75,600 $9,900 $0 $31,100 $116,600 12 1998 $75,600 $10,700 $0 $31,100 $117,400 13 1997 $90,500 $0 $0 $28,000 $118,500 14 1996 $90,500 $0 $0 $28,000 $118,500 15 1995 $90,500 $0 $0 $28,000 $118,500 16 1994 $83,000 $0 $0 $19,600 $102,600 17 1993 $83,000 $0 $0 $19,600 $102,600 18 1992 $94,400 $0 $0 $21,800 $116,200 19 1991 $97,500 $0 $0 $55,300 $152,800 20 1990 $97,500 $0 $0 $55,300 $152,800 21 1989 $97,500 $0 $0 $55,300 $152,800 22 1988 $67,700 $0 $0 $24,800 $92,500 23 1987 $67,700 $0 $0 $24,800 $92,500 24 1986 $67,700 $0 $0 $24,800 $92,500 Photos ........................... ......................... ......... .. ...... ......... ......... ......... ` ` 8 'VIA, Y J , 711 suite k £: .. .V. �. 'Ma@e WJ c � Zoo 97�.- �f91 i . I '.Gown of Barnstable. P# o`er Department of Regulatory Services : Public Health Division 0 Date ITO . Mnse e$ 200 Main Street;H annis MA 02601 . t6J9. ♦ Y'. 1 Date Scheduled 0 Time Fee Pd. ,foil Suitability Assessment fog- Sewa a Disposal . Performed B;Is� /l�/� �� Witnessed By: J i LOCATION & GENERAL INFORMATION Location Address �qj `1�15'i tn/�l�STD V.dtD Owncr's Name I�e U t213 �e `i1Q S IS3 tfiK.k_r-?.tj 1jrkLC1k6LE WA Address 05T•E�2V l Ll.� Mk6ZG Assessor's Map/Parcel: 16 I Engineer's Name NEW CONS' U0nON REPAIR Telephone# n oZQa Land Use t'�t D111 f�li Slopes Surface Stones Distances from: Open Water Body 2 00 ft Possible Wee Area a ft Drinking Water Well > ft i > d fi Other ft Drainage Way ft. Property Line SKETCH:(street name,dimensiod6f lo4 exact locations of test holes&perc tests,locate wetlands in proximity to holes) �� P�D� SLR � � • � rri c•� ra _( • S i "5 ��.,.g1 ��—gam: NM i i F 1 Parent material(geologic)=Water Depth W Bedrock Depth to Groundwakec St ! Weeping from Pit Price Estimated Seasonal;"igh Groundwater DtTERMINATION FOR SEASONAL HIGH WATER TADLE Method Used: I in, _in. Depth to sail mottles: in Depth dbperved standing in obs.hole: i in. proundwnter Adjustment Depth to(weeping from side of obs.hole: , — Adj {actor,,,,.....-.._ Adj.Orvundwaler l.eVpl,,,e Index Well# Reading Date Index Well 1eve1 - - PERCOLATION TEST Date�...�. '�>uc_ Observation ' Time at 9" N Hole# �-- Time at 6" .....----- • Depth of Perc Start Pre-soak Time.C& - End Pre-soak ' � � I ]fate Min./Inch Site Suitability Assessment: Site Passed�_. Site Failed,' Additional Testing Needed(YIN) Original:.Public He$Ith Division Observation Hole Data To Be Completed on Back--------- ***If percolafiitin test is to be conducted within 100' of wetland,You must first notify the Barnstable C6ijtservation Division at least one(1)weak prior to beginning. 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 sk 3Z 124 C 2.5 �/j 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) , -41- N A t24" G a•^d 2•S 7ly DEEP OBSERVATION HOLE LOG Hole# _, Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. - Cons istencv.%Gravell I DEEP OBSERVA HOLE LOG Hole# -P Depth from Soil Horizon Soil ture . Soil Color Soil Other Surface(in.) (USDA (Munsell) Mottling (Structure.Stones,Boulders. Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No X Yes Within 100 year flood boundary No X Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material 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 I D (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 3.10 CMR 15.017. Signature Date ll-h QASEPTIMERCFORM.DOC Darren M. Meyer, R.S. P.O. Box 981 E. Sandwich, MA 02537 (508) 362-2922 Contract Prepared for: Richard Murphy Date:. 08/20/2008 C/o Cox and Cox . 60 Dedham Street Needham, MA 02492 RE: Residence— 62 Westminster Road, Centerville, MA Septic System Design Scope of Work: Town of Barnstable Percolation Test Fee .......................................:. $ 100.00 Backhoe for perc test ............................................................... $ 225.00 Soil Evaluator for Soil Evaluation/Percolation Test................................ $ 225.00 Topographical Survey ......................................................:.......... $ 325.00 Septic System Design/8 Copies ....................................................... $ 500.00 Total Job Estimate: $ 1,375.00 If Board of Health variances are necessary, there will be an additional charge of $100.00 (Administrative Fees) and$ 65.00/hr for preparation of paperwork and possible representation at a Board of Health hearing. Payment Schedule $ 700.00 retainer, to begin work $ 675.00 upon delivery of plans Please make checks payable to: DARREN M. MEYER and mail to address above. Exclusions Price does not.include field layout of septic system for installation (usually done by contractor), wetland flagging/conservation fees (if necessary), design for innovative/alternative septic systems, pump system design (if necessary), retaining wall design (if necessary) that may be required or fees associated with obtaining local or state variances. Agreement to Terms Signatures: **-If you have any questions regarding this estimate please contact me at the number above. Estimate is good for 30 days from date above. NP Christiani Proposal DATE September 1, 2008 PO Box 247 Forestdale, MA 02644 Phone(774)392-0187 f Bill To: Richard Murphy Cox & Cox 60 Dedham Street Needham, MA 02492 RE: Septic Upgrade, 62 West Minster, Centerville, MA .. �escr�pt� ;n AMOUNT .. .. _ _. ... Provide engineering, permitting, perk test and installation of new soil absorption system as per plan prepared by Darryn Meyer. Work will include tree work to gain access and backfill to grade. Loam and seed can be provided for an additional cost of $750.00. Total engineering, labor and materials $$8,500.00 Note- it is assumed that soil conditions will permit a standard installation. If after perk test it is apparent that unsuitable soils will have to be removed and replaced, this quotation will be adjusted. If you have any questions concerning this invoice please call Nick Christiani, 774-392-0187 THANK YOU FOR YOUR BUSINESS! Postal o, CERTIFIEDRECEIPT ,a (Domestic Mail OnP..A,-,No!insurance Coverage Provided) For delivery Woi�ation visit our website at www.usps.corna m Postage. $ / p Certified Fee p Return Receipt Fee Here (Endorsement Required) ` Restricted Deligery Fee ��r r9 (Endorsement Required) srf s J Cc M Total Postage&Fees o Sent To Yr'F�C: Street,Apt.No.; C%ty,State ZIP+4 O �� s Certified Mail Provides: asiansal aooa eunr`ooee wao�sd ■ A mailing receipt 6 A unique identifier for your mailpiece +'►— m A record of delivery kept by the Postal Service for two tears Important Reminders: is Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. a Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain ReturnReceipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse maiipiece"Rehim Receipt Requested".To receive a fee waiver for ,a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. O For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailptece with the endorsement"Restricted Defivery". is If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post.office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. 'MPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. k Town ' of Barnstable Barnstable Regulatory Services Department n® m;cac , * BARNSrABLE, MAC i639• Public Health Division �� ` 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO August 5, 2008 41i 40 l�G� �c LE Dale Urbanik 62 Westminster Road 153 Centerville, MA 02632 0 /Y?f' A-Z 651;-- ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 62 Westminster Road, Centerville, MA was last inspected on July 29, 2008,by Brad J. White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00),due to the following: Leaching pit has one pipe entering and one pipe exiting leaching pit. Liquid was sitting on outlet line %2 way. Second leach pit is completely overfull. System needs to be., upgraded.. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. - Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER O R OF HE BOAARD OF HEALTH avid Stanton, R.S.. Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 7590 Q:\SEPTIC\Letters Septic Inspection Failures\62 Westmonster Road.doc F Town of Barnstable �'O O Z Public Health Division PITNE BOWES Y i MARNSrnaM 1 02 1 A $ 05.320 � s6!gg. �0g 200 Main Street 111111111111111?entity+° Hyannis, MA 02601 0004606238 AUG 1 3 2008 MAILED FROM ZIP CODE 02601 c 7006 2150 0002 1041 7590 � n N l X y' TURN` �E1PT Dale Urbanik \ TED 62 Westminster Road TM Centerville, MA 02632 z. RETURN TO SENDER UNCLAIMED UNABLE TO FORWARD � .� rFL SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent• I I ■ Print your name and address on the reverse ❑Addressee I so that we can return the card to you.. B. Received by(Printed Name) C. ate of Delivery ■ Attach this card to the back of the mailpiece, I or on.the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No I I I I env��� 1� oac�3a 3. Service Type I ` Certified Mail ❑Express Mail \ ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. I �\ / 4. Restricted Delivery?(Extra Fee) ❑Yes 2. ArticleNumberT-- T 7006 2150 0002 1041 7590 i (Transfer from service label) PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 \� O F _ �1HE IpN, Town of Barnstable D Z 5 Public Health Division � Q nG y 0 200 Main Street - 0004606238 A�53? B FD(eAED� Hyannis,MA 02601 - E MAILED FROM ZIP CODE 02601 7006 2150 0002 1041 7590 a io T � N REIURN` �EIPT Dale Urbanik .nEQ1Eo 62 Westminster Road o Centerville, MA 02632 . N NIXIE 029 ESE 1 02 09J25JD's RETURN TO SENDER - UNCLAIMED UNABLE TO FORWARD BC: 052601400.200 *0969-01OS9-13-37 r Town of Barnstable Barnstable regulatory Services Department NAMMicaeft sn st:E. MA9_pQ0 i639: Public Health Division 1Vr� • 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO August 5, 2008 Dale Urbanik 62 Westminster Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 62 Westminster Road, Centerville, MA was last inspected on July 29, 2008,by Brad J. White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Leaching pit has one pipe entering and one pipe exiting leaching pit. Liquid was sitting on outlet line %way. Second leach pit is completely overfull. System needs to be upgraded. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER O R OF HE BOARD OF HEALTH avid Stanton, R.S. Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 7590 Q:\SEPTIC\Letters Septic Inspection Failures\62 Westmonster Road.doc t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Westminster Road Property Address Dale Urbanik �I Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 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. 9 Important: A. General Information ` When filling out � cv forms on the computer,use 1. Inspector: G �� only the tab key to move your Brad J. White cursor-do not cri t f I e of use the return Nam ci� Tl 4a key. Bluewater = _, Company Name 350 Main Street _ Company Address r1, West Yarmouth MA 02673 City/Town State Zip Code (508)775-2800 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ❑✓ Fails ❑ Needs Further Evaluation by the Local Approving Authority f 7/29/2008 Inspector's ature Date The syst m 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. i t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 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: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed t5insp.doc•03108 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 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 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)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: El 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. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 every page. Clty1rown 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 ❑ E? 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 ❑ [Ere Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 2 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ d Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts. W Title 5 Official Inspection r p on Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville reg uired for MA 02632 07/29/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes N�o/. ❑ L1d' 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. ❑ ER"' 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 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. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 every 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 L�1 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? LI ❑ 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) Li' ' ❑ Was the facility or dwelling inspected for signs of sewage back up? E ❑ Was the site inspected for signs of break out? Lf ❑ 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: L_r1 ❑ 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-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 ,M 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 every page. City[Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown Number of current residents: �; 4 Does residence have a garbage grinder? ® Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ® Yes 0 No Laundry system inspected? ® Yes ® No Seasonal use? ® Yes No Water meter readings, if available(last 2 years usage(gpd)): 11,534 Sump pump? ® Yes ® No Last date of occupancy: Current Date CommercialAndustrial 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): t5insp.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: After Inspection Was system pumped as part of the inspection? 15 Yes ® No If yes, volume pumped: 1,000 gallons How was quantity Tank Size q y pumped determined? Reason for pumping: Check tanks structural integrity, Maintenance Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ (i46) 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: bo System was installed in 1983 per as built plan on file with board of health Were sewage odors detected when arriving at the site? ® Yes 0 No t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts H u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is required for Centerville MA 02632 07/29/2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 38 11 feet Material of construction: ❑ cast iron ❑40 PVC other(explain): Orangeburg Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Building sewer is orangeburg pipe. Recommend replacing inlet line. Septic Tank(locate on site plan): Depth below grade: --610 30" feet Material of construction: 0 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 t---------------------------------------------- Dimerisions: 1,000 gallons Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15° How were dimensions determined? Measured t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 I Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is required for Centerville MA 02632' 07/29/2008 every page. Cityrrown 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.): Inlet baffle appears to be structurally sound. Inlet and outlet line should be replaced. No evidence of leakage in or out of tank. Inlet cover has risor within 12"of grade. 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): t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 / I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ® Yes ® No Alarms in working order: ® Yes ® No t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 . commonwealth of Massachusetts TRW 5 OfficW Mspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ^M 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 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: Ty,ppe: bd leaching pits number: 2 @ 6'x 6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching Pit A is orignal pit and has one pipe entering and one pipe exiting leaching pit. Liquid was sitting in outlet line 1/2 way. Pit B is completely overfull. t5insp.doc•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 every page. Cityrrown 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.): I t5insp.doc•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 every page. Cityrrown 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 ent rs the building. I t2 i • I + .T f � + + + I I e 6 A a t ® At - �3� (pn) 2,- 1 A4 23 g2 zes �33 34 C q e� Na., o 0 6cAL6 t5insp.doe•03/08. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 n1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Westminster Road Property Address Dale Urbanik Owner Owner's Name information is Centerville required for MA 02632 07/29/2008 every page. Cltyfrown 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: 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: ❑l Checked with local excavators, installers-(attach documentation) L� Accessed USGS database-explain: pw Well Al W 230/Zone D/Level 22.9/Adjustment 3.2 x 12"=38.4" You must describe how you established the high ground water elevation: Deepest leaching pit is leaching pit a which is 102" below grade. System is in hydraulic failure and needs to be upgraded. i t5insp.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 �� I : l , - ` 10. I V I I I I j I _! I • •- - - ---,' .--.,____.L.__ -=----I -__ _I __ .-� --I---: ....-�- --� -- - ' !- �- - --�-I ----I-_- ' - --�-• ------- -I -- - -[- - - - --- I-_ i -I i I I I i j I '^�� - , . 1 _ -i- -. . I I 'i I i r I ...I � ---...._ ' � ' � ' i- I l J i.•_ i � .� i. I I_ .� I.. - ; I... i i_,._. _ ..I ._. I I _...-'...._ i .. _'-_._. '__-j I 1 I i I I : • n ! " j I : , _. I ' f..•:. I_.. _.i._ I J._.._ ..1._ � I f I ' i ! t i i I ' -' I ; i ! .._�._ ._..i_, -�-._..--j-- - I'-- . I_..._ j._.. ..�---.�•. _-.f.._ ! J Town of Barnstable �p I E 1p� Regulatory Services aaxsrnsie Thomas F. Geiler,Director 9� 039. per Public Health Division plED MA'S s Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER 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 or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations 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 Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. 1 QASEPTIODisclaimer Private Septic Inspections.DOC N .. ............ Fss. 1..Q:.00...... THE COMMONWEALTH OF MASSACHUSETTS ' y�BOARD OF HEALTH .................C/.h J.......0 F.1'( ............................................... Appliratiun for Uiipuiial Worse Tunstrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (K) an Individual Sewage Disposal System at: ------------------•-••----.....------•----.. ...........-----.--------...........---•-- Location-Address or Lot / ..... ...... . ........... ................. a s S� W Owner A ess - --_6..- ..... ,� .•. . ----•.... ..........................•••-••Y.. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................. __ .....Expansion Attic ( ) Garbage Grinder ( ) p`,, Other—Type of Building ............................ No. of persons----------K-_ ( ) Cafeteria ( )_____________ Showers — cw Other fixtures ----------------------------•--- . d •---------------------•--•-------------.---.-••---.. 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--_-----___-_-__---___-. Gt4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil. . ........... x c, UW -----•-----•----------------•---•----------••-•---••-----------------•-•••-••......_.._...--••••-•-•------•-••---------------••------•-•-•---------------•••------•---•-•-•••--••-----•--•--•---------•. Nature of Repairs or Alterations—Answer when applicable..,d,� ---ROL._,.__.�_ o Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code-The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha e i sued"by the b - d of alth. .................. ...... ..............................4.�...(Zi... .. d"!....... Dat ApplicationApproved By------ ---•-. .---•-• --•=••••----•-•--•--......---•------••--••-----•-•--•--•---.._..-• ••-•--••-•• ...... Date Application Disapproved f t following reasons:................................................................................................................ ---------------------------------•--•-------•--.......-------•-•----......-------•------•--------........._...........---------------------•••..............................--•------ --•......••--- Date Permit Nodp_3'-............................................... Issued......... ---•----------------•--- Date `7 'w THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH G•...t�iG OF...f4=lJ,_,Lrrt'4leA.Cc__ _................... ...----........------------......------_.......................... Appliration for Biiivoiial Works Tomitrttrlion Errant Application is hereby made for a Permit to Construct ( ) or Repair (V,) an Individual Sewage Disposal System at: Location-Address ' f GC,G�'r Lot#o<G%C-r✓L_------ .(.::�-�- ......... �- .... �......G✓.-_ S s_ W Owner ...- _ l' Ad'1Ls.......... ... / ...._. : Installer f-__ Address ff dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms................. .............•--__-_--Expansion tic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.......__. ............... Showers ( ) — Cafeteria ( ) a' 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................ ►a -------------- 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............._.......... D Description of Soil. ,--- .'__', �= x V •••-•-••---••••-•-•---•--•-••--•-.....-•-•-•---.....•-•---••••••-----.......•--•-••-•--•------•••-•-•---•---•••-•-------•-•--•-•--•-----••----.....•................................................... W x ---------------------------...................................................................................................................=......................................................... U Nature of Repairs or Alterations—Answer when applicable...,_.,Z �Z77 :-----/ 61-, ,,-. �} Cf 4? ...... = .......... ...----------------------------------------------------•------- (/Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha �Ihar iealth. Si/ ...---•-------••--•-----•••---- G(� Dat ApplicationApproved B -•--- =----•-•-•••.•--•------•-•••...._--•-•---...-•--•-----•--•--•........................... ........................................ Date Application Disapproved for the following reasons:.............................................................................................................. .......••-•-•••--••---•----•-----...•---•--•--•••-•------•---------••••----•-••-•----...--•-------•--•----••-••-•------•---------••--- ---------•-••--•-------------•--•--------•......-•---•-----•----- Date Permit No. .................................................. Issued-•-----/-=fir`"'l D •---•----------•-•--•--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD--OF HEALTH OF. '...........1-Tz. ... .......................................... .................................................... Trr#ifiratr of Tompliattrr THIS IS TO-CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�) r ...................................� --i.?... �. ......... ........ =--•--d d� < / — Installer at . .................................7 ,t ..- _.l r...... . :_ t c<_%`= ..r..? �,' 1 = 'L ..... ....................................... has been installed in accordance with the provisions of TIT 5 of T i State Sanitary Code as described in the application for Disposal Works Construction Permit No:`_': 9............................ da.ted_..../.- �"l'�'_3___....... THE ISSUANC OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM W11 FUCTION SATISFACTORY. DATE..../....1. --•�......•--•----••-------------------------------•-•-•---. Inspector-•--- --. ........................................................................ ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Y ,.�� ' ............................................... a No....:.................... FEE........................ �i��rrr��1 , �rk�, ��att��rtuorn err i# Permission is hereby granted :6/....__u=,c a�....-r------=r=L...... .................................. <' to Construct ( ) or Repair ( b,.) an Individual Sewage Disposal System r at No... =j`L!}':%_ e_ �, /L s. rj.r. .........==-.'' mil,& -z�r =' , l�G........ Street as shown n th pplication for Disposal Works Construction Pe Dated... 'r.l:............. '' l .� -_-•-- ...--•-- DA E............................................................................... Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS LOCATION SEWAGE PERMIT NO• VILLAGE I N S T A LLER'S NAME & ADDRESS sl BUILDER AR'- OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED31-F- N ' ra W J V S S l,v- ► 0 a 5" 767 DECK DN f4 ENT ENT - a COUNTER 11' 7' 11' S' 15' r e✓�� DN 15 8' BATH � KITCHEN O BED DINING c ROOM C COUNTER I C 9' 2' ll 27' 7' 10' 0 C LIVING \0 BED BED M ROOM ROOM MAIN C ENT 21' 3' 11' 2' FLOOR 1: 1379 SF ' FOUNDATION �``p�jN F'AZgs, 15' 8' 7' 5- 19' S' �� VE T PORTER 0 0 oaa 0 4 WAD (U i` N .� H ~ W �b 62 � b 02 QJ G TZ NA( LAND LEDGE d '2 -u C C W X W a o Existing Floor. Plans UTILITY ROOM GARAGE Q N N 62 Westminster Street 27 WW Centerville, Massachusetts ELECTRI AT' WW PANEL MET R NF 26' 9' Scale: 1"=10' October 3, 2008 Verne T. Porter Jr., PLS BASEMENT: 1323 SF Land Surveyors Civil Engineers 354 Elliot Street Newton, MA 02464 i f v`? 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II (J) w w LoI \ \ \ U � oQ � i cn \ \ I / 00 z Z Q t!i _ W �O > Z Lj Q U -1 Q ! \ \ N m w m ! \ \I I Q- EXISTING 5 ! q) Q) z OfDWELLING W� 6 j TOP OF FNDN I� I I r6 0 I EL = 41 .60 w I \ \ \ > 0 i, w o I vi LLJ 1 I I -7i z \ \ I I I I w \ II o L___�- - - - -- - - - --- - - - _ 1 1 2. 23 ft D w _ m EDGE OF PAVEMENT V) V) z ROAD w STM z � � ui W w z w z � ¢ O Q� 6 LLI ELEV. TOP I FOUNDATION NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS (Existing) INSTALL RISERS W/IN 6" OF FINISH GRADE FINISH GRADE= 35.0 = 41.60 F.G.EL: 38.0 F.G.EL: 38.0 F.G. EL: 35.0 Try A f MAINTAIN 2% MIN SLOPE OVER LEACHING AREA a COVERS TO WITHIN 6 " OF GRADE 6" INSPECTION PORT `•' ±! W/IN 6" OF FINISH GRADE L 25 > 6" 4" SCH 40 PVC L = 5' I = ° t0"I :INV.S3.60 S= 1% (MIN.) TEE'S ARE TO BE 14" (MIN.) 6 © S= 1 - (MIN.) q_...p 4" SCH 40 PVC I NV.33.0 ° ° ° ° ° ° ° ° ° ° ° ° A- l INV.32.8 GAS PROPOSED DB-3 ° H H. ° ° ° ° ° EXISTING OUTLET BAFFLE :.._•. H=10 DISTRIBUTION BOX I 25' _I INV. 33.85 EXISTING 1000 GALLON SEPTIC TANK NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INVERTS PRIOR TO CONSTRUCTION fXW�?r 9" MIN. sax 2) D-BOX SHALL BE SET LEVEL AND TRUE TO PER TI TLE 5 OF GRADE ON A MECHANICALL COMPACTED SIX I �Ass9 INCH CRUSHED STONE BASE, AS SPECIFIED IN BREAKOUT EL = 32.8 4 !'y 310 CMR 15.221(2) INV. ELEV.= 32.3 D N 3) REPLACE EXISTING 1,006 GALLON SEPTIC 314•_ -r�i• 24" J.5' R TANK WITH 1500 GALLON SEPTIC TANK DOME wAsrity STOW No. 1140 IF FAILED, DAMAGED, OR UNDERSIZED. INI/ERT cis SEPTIC SYSTEM PROFILE 4) INSTALL INLET & OUTLET TEES AS REQUIRED �48" Jr0" 48" I BOTTOM EL.= 30.3 SANITAR�P� 1 ' •v SEPARATION 5.63 FT. 146" _ I PTION SYSTEM INFILTRATOR 3050 SPECIFICATIONS BOTTOM OF TH-1 EL: 24.67� SOIL ABFIL RATOR 3050 UNTECTION� SOIL LOGS DESIGN CRITERIA NUMBER OF BEDROOMS: 3 BEDROOOM DATE: NOVEMBER 14, 2008 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) SOIL EVALUATOR: DARREN MEYER. R.S., CSE DESIGN PERCOLATION RATE: <2 MIN/IN WITNESS: DONNA MIORANDI DAILY FLOW: 110 G.P.D. HEALTH AGENT DESIGN FLOW: 330 G.P.D. i GARBAGE GRINDER: NO (not designed for garbage grinder) INLET END Elev. TH- 1 Depth Elev. TH-2 Depth SEPTIC TANK: 330 gpd x 2 = 660 gpd USE EXIST. 1,500 GALLON SEPTIC TANK (OPEN) 35.90 A LOAMY SAND 0" 35.00 A 0" LEACHING AREA REQUIRED: (330) = 445.94 S.F. 2.10YR 4 LOAMY SAND 74 / 1OYR 4/2 4.5'D/A ACCESS PORT FOR /NSPEC770N. 35.23 B 8" 34.33 B 8" USE THREE (3) INFILTRATOR 3050 UNITS WITH 4 FT. STONE LOAMY SAND I LOAMY SAND ON THE SIDES & 1.3 FT. STONE ON ENDS: 25' L x 12.16' W x 2'D 10YR 5/8 1 10YR 5/8 BOTTOM AREA: 25 x 12.16 = 304 SF 33.23 C1 32" I' 32.33 C1 32" SIDE AREA: (25 + 12.16) X 2 X 2 = 148.64 SF TOTAL SQUARE FEET PROVIDED = 452.6 vs. 445.94 REQ'D PERC®31.83 DESIGN FLOW PROVIDED: 0.74(452.6 S.F.) = 334.95 G.P.D. vs. 330 G.P.D. req'd MEDIUM MEDIUM PROPOSED SEPTIC SYSTEM UPGRADE PLAN SAND SAND INFILTRATOR 3050 2.5Y7/4 25Y7/4 62 WESTMINSTER ROAD, CENTERVILLE, MA Prepared for: Dale USCALE Trs. NOMINAL CHAMBER SPECIFICATIONS Engineering by: Surveying by: SCALE DRAWN JOB. N0. 25.57 124" 24 67 124" DARRENM.MEYER,R.S. Eco-Tech Environmental N.T.S. DMM SIZE (W X H X L) 51 X 30 ' X 85.4 PO BOX 981 (508) 364-0894 WEIGHT 80.0 LBS. PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) E4STSANDWICH MA02537 DATE CHECKED SHEET NO. NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED 508-362-2922 1 1/18/08 DMM 2 Of 2