Loading...
HomeMy WebLinkAbout0354 WHITE OAK TRAIL - Health 354 WHITE OAK TRAIL, CENTERVILLE A= MOM IN UPC 12534 ` No.2�0R r NASTINot,UN e k Town of Barnstable OPINE r Regulatory Services Thomas F.Geiler,Director . Public Health Division BARNSTABLE, Thomas McKean,Director 1639. ,m� 200 Main Street, Hyannis,MA 02601 ATFD MA'1�` Phone: 508-862-4644 Email: health(cDtown.barnstable.ma.us Fax: 508-790-6304 Office Hours: M- O F 8:00—4:30 V December 9,2010 Ann Marie Sullivan RE: Underground Storage Tank 15 Village Green Drive 354 White Oak Trail,Centerville Mashpee,MA 02649-2293 Map Parcel: 192-244 Tank Number 1, Tag#00434 Dear Sir/Madame: The Barnstable Public Health Division(BPHD)is in receipt of a copy of the"Application and Permit' for storage tank removal and transportation issued by the Centerville-Osterille-Marstons Mills Fire District demonstrating that the underground storage tank was remove_d from the above referenced address on or about June 30,2000. The Public Health Division appreciates your attention to this matter and has updated its data base to reflect this fuel tank status change. Should you have any further questions.please contact Cynthia Martin of this office at 508-826-4645. homas A. McKean,RS,CHO Director of Public Health ` y OYA Y Town of Barnstable y'�P �•e Barnstable Y Regulatory Services 9B''MA�`E�" Thomas F. Geiler,Director All-America City 1639. Public Health Division TfD MA'S A , III r Thomas McKean,Director ')007 200 Main Street Hyannis, MA 02601 Office: . 508-862-4644 Fax: 508-790-6304 November 23, 2010 Ann Marie Sullivan Scow) 15 Village Green Drive Mashpee, MA 02649-2293 RE: Underground Storage Tank �354 WHITE OAK TRAIL, CENTERVILLE Map/Parcel: 192-244 Tank Number: 1 Tag Number: 60434 Our records indicate that your underground fuel (or chemical) storage tank exceeds thirty (30) years in age, and has not been removed as required by the Town of Barnstable Code Chapter 326, Section 3, Fuel and Chemical Storage Tanks. You are directed to remove this tank within sixty (60) days from the date of this Notice. Upon completion of the tank removal and within ninety (90) days of receipt of this Notice, please submit to this office a copy of the permit for storage tank removal issued by your local Fire Department. This copy of the removal permit serves as documentation that the underground storage tank was properly removed and disposed'Of. You may request a hearing provided that a written petition requesting same is received by the Board of Health within ten(10) days after this order is served. Per Order of the Board of Health Thomas A. McKean, PS, CHO Health Agent QAHazmat\Underground Tanks\let Undergmd tanks 30 yr Nov20l0.doc J Make application to local Fire Department Fire Department retains original application and issues dupiicate as Permit. �Q�LyYiYY%Qil'1rGl�2CtiG�f2 Q�����zJ�SCLCfZG�SE%� �I - ���f7,C�/I��/J'I2P/I'GCd��UIrP�.l P/Ir/!1(.CP/.l — ✓CJ4�/X� O�V'GJ�° �9rP/11P/I9i�G0�12 APPLICATION and PERMIT Fee:$25.00 for storage tank remcval and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 1A8. Section 38A, 527 CMR 9.00, application is hereby mace by: 0 Tank Owner Name(pk-�--se print) Thomas Jones X agnature i apllying(orpermit) Address 394 Wh;rP O k Trail Centerville MA 02632 Street City State zip 7" Company Name Advanced Environmental Co. or Individual r{ Print Print Address P 0 Box 472, 197 Great Western Rd. Address i< �� �'��s Print Print Signet Signatu (if appl cr= IFCI Cen:fie-_ Other IFCI Certified = T Other Tank Location 354 White -Oak Trail Centerville Steer Address ^1 Tank Capacity(gallcris. '100 Substance Last Store— #2 fuel Tank Dimensions(diar x length) Steel .•t � M' Remarks: F MV5083856100 ' Firm transporting was`: Advanced Environmental State Lic. #_ ca Hazardous waste mar:i�r= E.P.A. James G. Grant Co. , Inc. Tank yard 008 Approved tank dispcsai,/�� Y y Type of inert gas venting Tank and address Wolcott St, Readville, MA IC7ityorTown FDID# Permit# Date of issue Date of expiration Dig safe approval nurrbr n/a Dig Safe Toll -: Tel. Number-800-322-4844 Signature/Title of OfSc`r_ranting permit - After removal(s) send Fc 7-7:1-290R signed by Local Fire Dept. to UST Regulatory Complia.rr_--Unit, One Ashburton Place, Room 1310, Boston, MA. -38-1618_ FP.7g9 tra Ai P.i 9/961 THE T Town of Barnstable ti Regulatory Services Barnstable " '"MASSS A . ' Thomas F. Geiler,Director A"mericaCity 1639. �•� Public Health Division 11111.► ATED MA't A Thomas McKean,Director 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 November 23, 2010 Ann Marie Sullivan 15 Village Green Drive Mashpee, MA 02649-2293 RE: Underground Storage Tank 354 WHITE OAK TRAIL, CENTERVILLE Map/Parcel: 192-244 Tank Number: 1 Tag Number: 00434 Our records indicate that your underground fuel (or ch6ii ical)`'storage tank'exceeds thirty (30)years in age, and has not been removed as required by the Town of Barnstable`Code Chapter 326, Section 3, Fuel and Chemical Storage Tanks. You are directed to remove this tank within sixty (60) days from the date of this Notice. Upon completion of the tank removal and within ninety(90) days of receipt of this Notice, please submit to this office a copy of the permit for storage tank removal issued by your local Fire Department. This copy of the removal permit serves as documentation that the ' underground storage tank was properly removed and disposed of. You may request a hearing provided that a written petition requesting same is received by the Board of Health within ten(10) days after this order is served. Per Order of the Board-of Health 4Thomas'A''NlcKean -PS,CH0 Health Agent .... .;=fir.; . . QAHazmat\Underground Tanks\let Undergmd tanks 30 yr Nov20I O.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 354 White Oak Trail — Property Address Tom Jones — Owner Owner's Name information is Centerville MA 02632 July 15 2010 — required for State Zip Code Date of Inspection every page. Cityrrown 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell — cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. — Company Name 189 Cammett Road — Company Address Marstons Mills MA 02648 run Cityrrown State Zip Code 508.428.1779 SI 12855 — Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority W 4 m a- July 15 2010 Job# 10-179 (4 M(la J- In ector's S gnat Date c The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or Co cn has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the o report to the appropriate regional office of the DEP. The original should be sent to the system owner z and copies sent to the buyer, if applicable, and the approving authority. 3 � 0 0 ...,� H o This report only describes conditions at the time of inspection and under the conditions of uPe C`.j 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 1 of 17 t5ins-09108 �v c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 354 White Oak Trail — Property Address Tom Jones — Owner Owner's Name information is Centerville MA 02632 July 15, 2010 — required for State Zip Code Date of Inspection every page. City/Town — B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching pit had T of standing water at time of inspections. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 354 White Oak Trail — Property Address Tom Jones — Owner Owner's Name information is Centerville MA 02632 July 15, 2010 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing t6protect 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 l5ins•09/08 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 354 White Oak Trail — Property Address Tom Jones — Owner Owner's Name information is Centerville MA 02632 July 15, 2010 — required for State Zip Code Date of Inspection i every page. Cityrrown B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: -- The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: — **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 354 White Oak Traii Property Address Tom Jones Owner Owner's Name information is Centerville MA 02632 July 15, 2010 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feel: from a private water supply well with no acceptable water quality analysis. [Thlis system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,. or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �( 354 White Oak Trail — Property Address Tom Jones Owner Owner's Name information is Centerville MA 02632 July 15, 2010 required for every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 — l5ins•09/08 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 yr 354 White Oak Trail _ Property Address Tom Jones Owner Owner's Name information is required for Centerville MA 02632 July 15, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No ,000 gal. _ Water meter readings, if available(last 2 years usage(gpd)): 1 13232 gpd. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 354 White Oak Trail — Property Address Tom Jones — Owner Owner's Name information is required for Centerville MA 02632 July 15, 2010 - every page. Citylrown State Zip Code Date of Inspection — D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped every 2 years. — Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 354 White Oak Trail Property Address Tom Jones — Owner Owner's Name information is required for Centerville MA 02632 July 15, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Overflow pit installed 11/14/90. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' _ 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.): :Ian site Septic Tank(locate on plan): 3' _ Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. _ 3" Sludge depth: t5ins•09108 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 354 White Oak Trail — Property Address Tom Jones — Owner Owner's Name information is Centerville MA 02632 July 15, 2010 — required for every page. Cityrrown State Zip Code Date of Inspection — D. System Information (cont.) Septic Tank(cont.) 27" Distance from top of sludge to bottom of outlet tee or baffle — 1" _ Scum thickness 6" Distance from top of scum to top of outlet tee or baffle — 13" Distance from bottom of scum to bottom of outlet tee or baffle — How were dimensions determined? Measured — Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert. Tees were intact and clear. Tank is not in need of pumping at this time — 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 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments '< 354 White Oak Trail — Property Address Tom Jones — Owner Owner's Name information is Centerville MA 02632 July 15, 2010 required for — every page. Citylrown State Zip Code Date of Inspection — D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 354 White Oak Trail _ Property Address Tom Jones Owner Owner's Name information is required for Centerville MA 02632 July 15, 2010 - every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 354 White Oak Trail,p - Property Address Tom Jones — Owner Owner's Name information is Centerville MA 02632 July 15, 2010 required for — every page. Cityfrown State Zip Code Date of Inspection — D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits. — ❑ 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.): Original leaching pit had previously failed, overflow pit had 3'of standing water with a high stain line 2"above current level. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts 01- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 354 White Oak Trail Property Address Tom Jones — Owner Owner's Name information is required for Centerville MA 02632 July 15, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 354 White Oak Trail Property Address Tom Jones Owner Owner's Name information is MA 02632 July 15, 2010 re Centerville 9 CityfTown State Zip Code Date of Inspection wired for every page. D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ .drawing attached separately . r r . r r r r rrr r'r-r'r-r'r'r r rrr r r r rrrrrr rrr r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r • r r r r r r r r r r rrrrrrr r r r r rr r rrrr r r r r r r \r\r♦i r\r\r\ \ \ ♦ r rrrrrrrr♦ \ \ \ \r r r\ ♦ \ \ r r r r r r ♦ ♦ ♦ \ \ \ ♦ ♦ \ \ r♦rrr r\i r♦r♦rrr\rrr\r\r \r♦r\r♦r\r\r r \ ♦ \ \ ♦ \ ♦ \ ♦ ♦ \ \ rrrrrr r r r r r r r r r r r r r r r r r r r r r r r r rrr r r r rrrrrrr rrrrrrrrrr r r r r r . . . . .. 25 1 26 4 46 0 33 White Oak Trail i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 354 White Oak Trail _ Property Address Tom Jones Owner Owner's Name information is required for Centerville MA 02632 July 15, 2010 - every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20+ 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: pate ® 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: Low point at rear of property is considerably lower than bottom of leaching pits. _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 el 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 354 White Oak Trail Property Address Tom Jones Owner Owner's Name information is Centerville MA 02632 July 15, 2010 required for every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION _ �1 dww t e�kar• #-s7w, 'VILLAGE r-6y.1 L# ASSESSOR'S MAP&PARCEL INS NAME&PHONE NO.,-;26 r,C,(L(kod1m SEPTIC TANK CAPACITY ICc o LEACHING FACILITY: (type) i?� (size) NO.OF BEDROOMS ? OWNER :5�0f,,QS PERMIT DATE: "1 115 I IO 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 t 4 \ 4 4 t 4 ♦ t 4 \ 4 4 4 4 4 \ 4 4 t 4 4 4 4 ♦ \ 4 ♦ ♦ 4 4 { J { { f { { { f J { { f { { ! { { J f { f l f { { f J { { f { 4 \ t ♦ t ♦ 4 4 4 t ♦ O t t 4 \ t \ \ t t 4 \ t 4 4 l f l 4 f l { J l { f J F f { J f ! J f F l f ! t{4f\JJ♦ftJ♦ \ 4 4 4 4 4 4 4 4 4 ♦ 4 4 \ 4 4 \ ♦ \ \ \ 4 \ J♦! itf4J !♦f4J4f\f4f4J4f♦f4l t \ t.♦ t ♦ 4 t 4 t t t op 4 4 \ 4 4 ♦ t t ♦ 4 \ 4 ! f f F f F F / f f l f J f f •• 4 4 4 ♦ 4 4 \ 4 4 ♦ \ 4 4 4 4 4 \ M 4 t t 4 t t \ t t \ \ t t \ t ♦ \ 4 4 \ t 4 ♦ t 4 ♦ ' 25 1 .. . 26 46 40 33 d .z a, � 1 White Oak Trail No..._90.= ....� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Uispwial Works Tons rn.r#inn rami# Application is hereby made for a Permit to Construct ( ) or Repair k"I an Individual Sewage Disposal System at: .�.Z5.. .._-- .<. C-T !�... ? � ............. ............................................................-.................................... Lo tioii-Address or Lot No. --•...�`..........-O--� .........•......-•.................................. .........�.................. ._..................................................._..... Owner Address i_ ................................•-----------... •-- ................................ Installer Address Type of Building Size Lot----------------------------Sq. feet V Dwelling—No. of Bedrooms---------------------------------...........Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building ..... No. of persons............................ Showers YP g ----------------------- P ( ) — Cafeteria ( ) 04 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.-.-------------__. --- fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix ------------------------------------------------------------------------•-•---------------....-------- ---- ---... ------- •------ 0 Description of Soil.....n:::Z._......... ----------------------- ...............-�------•�----.........:5!r�A V --------------------------------------------------------------------------•------•------••.....---------•••---------------------••--•------- W UNature of Repairs or Alterations—Answer when applicable............................................................................................. ----�Q--------�'�G ����0--------G sr�`o�J--------1-�'..... ------ -----'7`.,.P------ ....................... Agreement: / The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certific of Compliance has been issu by the oard of health. � �� Signed :'-----------'' -' ------' � ce - ....... Application Approved BY .. Application Disapproved for the following reasons- -----------------------------------.............................................................. 1e ......................... ............. Da.e PermitNo. ----------_--_-------------.................................... Issued ..............................................................." Date = a� No....g� _ 9 FEE..::., ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFI—HEALTH` TOWN OF BARNSTABLE i Appluation for Uhipagal Work.5 Tnnstrnrtinn "amit Application is hereby made for a Permit to Construct ( ) or Repair S ,an Individual Sewage Disposal System at: / ) ,f c %i4 L--.�.... .............................................. -................................ t y. Lo ation Address �,, w ( or Lot No. ...................wti t. ....................................................r '' ....------•-- -----c-C`"t -"`�I 1 .`.' +` .............................................. ��11 �y / Address--- ddres tl�....... ...�5 .... ....... L i C� - ��--!�'? � 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 ( ) 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._F'------------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box' ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-___-----____-_---_;--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ x -----------------------------------------------------------------------------------------------------------------------------------•-•----•-•••-•••-•....---- 0 Description of Soil......0.�:_ ........... .......----•------•---7. .V_...-----<?C ffiU------ ....... A ...................•----....-----•--•------...._......----------------------....--••-----------•--------......---•--------------........----------...----•-----••---•-------••-•-•.......-•---........... x -•••••-•--••----------------•------------•••••-•-- ----•---------•---•---••............-•-•-• -- -•• .I. • ......... J Nature of Repairs or Alterations Answer when applicable J 1. t t 1 t ' .I .r .. ......... .. .� . tt(�'r Lls�tiJ •r1 ti%\lb0 �'^:�w4s QI--, L1,Ar'l(.�:t�t* .� - -drl_A�cg_, s7/z_ 1 ...-•--••.---• ---•••---------- Agreement: I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeri issue by the(board of health. - g Application Approved By .... r.7,t` � ... ...................................................--- -------- Gn.. ., A lication Disapproved or the following reasons: ........-- pp PP f f g ............................... ..........................--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ........................................ Date PermitNo. ..... ........................................................... Issued .........................................-----...................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Trrtifirnte of Tontlatia tce THIS IS TO CERTIFY; That the Individual Sewage Disposal System constructed ( ) or Repaired ( ROT by......... ---- rC-tcK --1....�C' `'�5� .k , �X ............../..................................... .......................... Installer � b '�� f� f " f° 1 E�v(�Y6 V 1�( .. ... ....... f f t t ! at 3 ...... �, .... O ` f � .... ................... .......................................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the,application for Disposal Works Construction Permit No. .......N....... ..y._z dated -//..-Z�Tl �_------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... ��. ....q.1 .-- -----. --- ------ ......... .................... Inspector ..... �(,""---...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9d S� TOWN OF BARNSTABLE No......................... FEE........................ Dish osial°Worko T.Fncnstrnrtion "permit . t Permission is hereby granted...::. li)+ ;fk! `tf_x ............... .••... ...... ...............---............•-•........ ............ to Construct ( )-or Repair s( { )''an Individual Sewage Disposal System d at NO. t ''� �i t ( `_'.�-f4+,�t ! �L.. ��'4 C'�',u("ttlCl!+�C _" ` •. ••--•...._..-•••-•••••........ ..............................••-...... !.- Street as shown on the application for Disposal Works Construction Permit No. Ul- /Dated.....!/_.rl ------------------ -------------- ...................•......--.------------ .:.,,,�,• -• / ;! Board bf�Health DATE-----��-z��--�� U FORM 38308 H�BBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LsOCATION 3S�/ w��'�� �cGe ice«. / SEWAGE # 5 CO VILLAGE C'P�r{✓y.��r-P ASSESSOR'S MAP & LOT/9o� v3Y INSTALLER'S NAME & PHONE NO. �� L6, e-a 3:; 7� l -Z/' SEPTIC TANK CAPACITY LEACHING FACILITY:(type) f'Ye Co-4 (size) /000 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: /�/�- 90 VARIANCE GRANTED: Yes No oar 5 r ,33,6" OIJ �eJ LOCATION SEWAGE PERMIT NO. V'lLLAGE I N S T A LLER'S NAME i ADDRESS B U I L D E R OR OWN ER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 1_3 ,O + ass+! �� �^ F �+� ��r ��? �� �� �, �/ �gi �" � `��. �� Fus............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH . 1✓..................oF....... « -, 1. ....................................... Applira#ion for Uiiipoii al Workii C outitrurtinn famit Application is hereby made for a Permit to Construct wl or Repair ( ) an Individual Sewage Disposal System at: 7_.l.6...... .. ?1 , .... ..............• Location-Address / or Lot No. ._..... �d�L lPlee!�[_a?... ------•----------•------------- ��Ld.S .�?� .... ............ Owner Address 14-1 a •.... .................................................... ................... ........•-•----------•-•-------- Installer Address Type of Buildin� Size Lot............................Sq. feet U Dwelling�3—No. of Bedrooms......../._!! ......._...............Expansion Attic Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures .................................. W Design Flow..............................%�5 _ _-_gallons per person per day. Total daily flow......................3.7 10.........gallons. W Septic Tank—Liquid capacity!.M. ..gallons Length................ Width................ Diameter---------------- Depth............. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.J.,.apvc------- 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----/_le,,......... Depth to ground water________________________ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x _ _ ---------- -- 0 •Description of Soil �� �Q .. �� `== 5 � ----3 �. � +� c r x . W ---••------•--------------------•----•---•------•-•----•-------------•-----------------••••--•••-•-•----••-•---------------------------•-----•------•------•-•----....-•--•----••----.................. U Nature of Repairs or Alterations—Answer when applicable----------------------------------------....................................................... -----------------------------------•--------------------------------------------------------------------•------------------------------------------------------------------------------..._..•---•...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LIT?:" 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has br is by the board of lie;ilth. Sign G ................... .... J-�-Ace....&.... Application Approved By............ �. ` Date Application Disapproved for the following reasons---------------------------------------------- ............................................................ ....••••••-••--••-•-------•---•••------------------------------•------•-------••--•..........------•-•---------------•----------------- ............................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -.-_---Tezz:�o•;,' _................OF........ ,/� . Apptirtt#ilin for Bi,gpuiitt1 Works Tunti#rur#iun Remit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ,e, , �.... „=� r.:.. `--•--1p''::. .... .s:ra.sl.M---•-•------------•-------•---------- --+�''r3:t-._7 ? G.......,�..*_ ....fr'-?::,s ..., `.:c«.«,; . ............... Location-Address or Lot No. ............................................................ * Owner Address s ............................................... ............•---------------..._........_...__....._.....----._..........__..._._............. Installer Address U •Type of Building Size Lot............................Sq. feet a Dwelling 4 No. of Bedrooms....... "_t>........................Expansion Attic (4�--j Garbage Grinder ( ) p-I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------------------•--• . W Design Flow............................. .............gallons per person per day. Total daily flow.................... ��L�_:_....-__gallons. WSeptic Tank—Liquid'capacity e"....gallons Length................ Width................ Diameter................. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___--__-_--_-------sq. ft. Seepage Pit No._j_,:c rv..._..__.. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (✓`)' Dosing tank ( ) aPercolation Test Results Performed by-----•--•-----•••...................•---••-------.�...._•---.........---- Date:................................... Test Pit No. I...._ -------minutes per inch Depth of Test Pit..../ __._.__._. Depth to ground water________________________ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x --• --- -••••.................•---•-• ---------.......- ••. ---- -- . ... ------. O Description of Soil `` !� ` �-:.. r...a V ........... --•.........................•j....--•-------------...................------------------••-------------------------------------------------------•-•-•-^--------•-----------^--------•------ W ----•••---------------------•..........•-•---•----••--•••••--------------------------....••-•-•--••-----•----------------••----•---•-•----•---------•-•-••••-----••--•-•••---.......................... UNature of Repairs or Alterations—Answer when applicable.....................................:......................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions'o'f:TIT L;. y g g p y S of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. Sign , G r1 /lI .�• . p '..._ Date Application Approved By--••- 41524, -----jo....�714444-r ............. ............. Date ;Application Disapproved for the following reasons:------••---•--•--•---------•--------•••--------•-----•....----•----------•------•---•--••--------•-------------- ........................•-•----------•--............----•--•-------^----••--------------------......•••- Date PermitNo.......................................................... Issued_....................................................... Date rTHE`COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �pr#ifirtt#� of f�unt�rli�nrr THIS IS TO C R,T FY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) + nst Iler has been installed in accordance with the provisions of Tf m r j of The State Sanitary Code as desc ibed in the application for Disposal Works Construction Permit No..- - "t�---------- --- dated___ ----- . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........4 . -_._ r>......---•.............•--------•---. Inspector < C ..--- ......................................... THE COMMONWEALTH ,,MASSACHUSETTS ' BOARD OF '* ry EALTH r- , .........OF................ .. -:....:.......... FEE_ N ........ .�.. Permission is hereby granted. L..... :...... to Construct �( r/Rep�airf, � an,; div dual Sewe >s s� S tern �;.......... Street as shown on the application for Disposal'AArks Construction - mit o___ ___ _______ Dated-__ �'~�_ y............................ ��­"` r Bdard of Health DATE-----I ..........................--------------•- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA l/b < 4-9 CC 6.P.U. 1i�P+�►,lS�a `�°1 t� � t-�t'f evaP -to 1 SF �c 2. = CIS G.P.U. QQ� rl. TA►_uc. co , i Sim'. � t .c� SO C�.R D. / �p.,�r{} \: ,� �-• ; �25 vt_�Ttc�►..J t2&Ti= l t►.f 2M I u� 02 L>:SS. a VIC I y r wm F G —I ToP awn L ' t.n j 4 yP,-- per-, 5 Jx1aL71 e. 'box 6,(,6 SEPTIC IWV. r ,-ASK G A t_. LEAc N a �.0 krZSl: FT s . r WAS1.11Eb ` , �,�2iW1E�,. STsotifz ,� C,ttitlp11-4� T(-1 C-G °V►,ILA ri O h� 5 t�o.�v kJ L. L>t.l i-i= �' t7L�t.l �r ,v�('t_�lS ��/ iT►-d Tt-i ytL�� Lt►-IE GG f Lei' AktC:P °>C-I-L-,AC1:: C CuiQGAA TI; of T►at -To vJ LJ o f= %©QJ-4-ST W: ,' C ��A+.b t.o JRT 'PL-A ►.l i�A'CC'i a•"�r"_ `'f"" �� ;,.f I .�C,���...--=._ g/�'y�T L k. C;. 411r 1:= t!`� �i`�' I-4k) it m—I 42CGlS 1l-i�i_t� i /��u 'Sc�' 4 t_IUT {_'.Q7CL7 AAA z '. . � 1,