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0133 ZENO CROCKER ROAD - Health (2)
133 Zeno Crocker Road Centerville . P A =_170 144 No. 42101/3 ORA PG R 90GE, 10 0 t ECO-TECH ENVIRONMENTAL. THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION (revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 133 Zeno Crocker Road RECEIVE® Centerville Owner's Name: Marcia E. Horne Owner's Address: 133 Zeno Crocker'Road APR 18 2002 Centerville ABLE Date of Inspection: April 16, 2002 TOWN OF BARNST HEALTH DEPT.. Name of Inspector:(Please Print) David D. Coughanowr, R.S. 3� Company Name: Eco-Tech Environmental - Mailing Address: 43 Triangle Circle MAP Sandwich, MA 02563 PARCEL ' i 44t Telephone Number: (508) 364-0894 LOT Z CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 CMB 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature Z C�l 4 &S Date: A-pP I zoo Z The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority NOTES AND COMMENTS InVector's Note=_> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ` ****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. Title 5 Inspection Form 6/15/2000 page 1 C. + Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 16, 2002 INSPECTION SUMMARY: Check A, B, C,D or E/ALWAYS complete all of section D: A] System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 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, or 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 breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. ND explain The system required pumping more than four 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 2 f Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 16, 2002 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 s failing to protect public health, safety and environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303 (1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System will fail unless the Board of Health(and public water supplier, if any) determines that the system is functioning in a manner that protects the public health, safety, and environment The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis, performed by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3) OTHER 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 1616, 2002 D) System Failure Criteria applicable to all systems: You must indicate either "yes" or "no" to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no —X— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. --X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. -X- Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. --X— Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped —X— Any portion of the SAS, cesspool or privy is below high groundwater elevation. �. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. —X— Any portion of a cesspool or privy is within a Zone 1 of a public well —X— Any portion of a cesspool or privy is within 50 feet of a private water supply well —X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form) No (Yes/No)The system fails.. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore, the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 16, 2002 Check if the following have been done* You must indicate either "Yes" or "No" as to each of the following• Yes No Pumping information was provided by the owner, occupant or Board of Health. _X_ Were any of the system components pumped out in the last two weeks? Has the system received normal flows in the previous two week person? Have large volumes of water been introduced to the system recently or as part of this inspection? jiLa _ Were as built plans of the system obtained and examined? (If they were not available as N/A) X Was the facility or dwelling inspected for signs of sewage back-up? X Was the site inspected for signs of breakout? X Were all system components, excluding the SAS. located on site? X Were the septic tank manholes uncovered, opened, and the interior of the septic 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 he facility owner(and occupants, if different from owner) provided with information on the proper maintenance of subsurface disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: _X__ Existing information. For example, Plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to part C is at issue, approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 16, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a-no plan on file at BOH Number of current residents_3 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system (yes or no): no :(If yes, separate inspection required Laundry system inspected (yes or no): n/a Seasonal use(yes or no): nQ Water meter readings, if available (last two year's usage(gpd):504 gpd: Sump Pump (yes or no): no Last date of occupancy: current COID&RCIALZINDUSTRIALe Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sqft/etc.): Grease trap present: (yes or no) Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy/use:- OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS source of information: System not pumped in recent past(Owner) Was system pumped as part of the inspection: (yes or no) No If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: X Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternate technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank_ Attach a copy of the DEP approval Other(describe) APPROXIMATE AGE of all components, date installed(if known)and source of information: -Age 3 years -according to owner's statement. No plan or as built card was on file at Board of Health Were sewage odors detected when arriving at the site: (yes or no)-m 6 I Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 16, 2002 BUILDING SEWER_(Locate on site plan) Depth below grade:_2_ft— Material of constructiowcast iron __X_40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints, venting, evidence of leakage, etc.) Sewer is vented through roof and appears structurally_sound with no evidence of leakage or backup into dwelling SEPTIC TANK: (locate on site plan) Depth below grader Material of construction: X concrete metal fiberglass_polyethylene other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(yes or no): (attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft Sludge depth: 8 in Distance from top of sludge to bottom of outlet tee or baffle: 26 in Scum thickness: 1 in Distance from top of scum to top of outlet tee or baffle: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 14 in How dimensions were determined: Probe to ton of tank Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Liquid level at outlet invert Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out. GREASE TRAP: none (locate on site plan) Depth below grade: 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: Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 16, 2002 TIGHT OR HOLDING TANK: none (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/day Alarm present(yes or no):_ Alarm level: _ Alarm in working order(yes or no): Date of last pumping: Comments:(condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: _ —(if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: at outlet invert Comments:(note if box is level and distribution to outlets is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.) D-box appears structurally sound with no evidence of leakage in or out Effluent level at outlet invert, No solids in tank. PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 r Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 16, 2002 SOIL ABSORPTION SYSTEM(SAS):---X—(locate on site plan; excavation not required) If SAS not located, explain why: Type: _leaching pits, number beaching chambers, number _leaching galleries, number I beaching trenches, number, length beaching fields, number, dimensions overflow cesspool, number innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Soils above leaching_gallery aMeared unsaturated. No evidence of surface ponding, breakout lush v g a ion, or other evidence of hydraulic failure was observed. Observation hole dug into stone of leach pit showed no sending wa r CESSPOOLS: none (cesspool must be pumped at time 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 or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: none (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 16, 2002 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' (Locate where public water supply enters the building) LOCATIONS 3 ❑ D-BOX LEACHING A B GALLERY SEPTIC 1 14 f t 16.5 f t 2° ° TANK 2 19 ft 14 f t 3 22 ft 18 ft B A 3 BEDROOM DWELLING W Z J d' W I i 3 ZENO CROCKER ROAD NOT TO SCALE 10 a Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 133 Zeno Crocker Road Centerville Owner: Marcia E. Horne Date of Inspection: April 16, 2002 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater: 12.8+ feet Please indicate(check) all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed _K_ Observed Site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: Checked local excavators, installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. According to Barnstable GIS doartment database, groundwater is below elevation 35jeet. The flat to is at elevation 53.1. A groundwater adjustment of 5.3 was calculated and added in(Index well SDI*1-252, zone D, level = 48.0 for March 2002,adjustment = 5.3 feet) Doth to groundwater-5 1-( 5+5 ) — 12.9. 11 COMPLETE •N COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3. A Si u e f ■ Print your name and address on the reverse X r ❑Agent so that we can return the card to you. ❑Addressee ■ Attach this card"to the back of the mallpiece, P. Received by(Printe me) b. Date of Delivery or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below. ❑No w . 46O II��III'I I II Ili I III II II III II III II I I II I I II III V103d ull S egnatreRestricted Delivery O Regis red Mail Restricted9590 9402 5225 9122 5464 65 rtified Mail® Delivery ❑Certified Mail Restricted Delivery ❑Return Receipt for ❑Collect on Delivery Merchandise . 2_AMtr_tc_N.v.... •.[r.�-��--------' - 'ect on Delivery Restricted Delivery ❑Signature ConfirmationTM 4 7[1`0 8 3 2 3 0 0 0 0 2' 517 7 818 6 .red Mail ❑signature confirmation•. 4 —red Mail Restricted Delivery Restricted Delivery (over$500) t PS Form 3811,July 2015 PSN 7530-02-000-9053 �` r D'otfiestiaReturri.Receipt f USPS TRACKING - +`I .EN'CE P first-Class Mail Postage&Fees Paid LISPS } Permit No.G-10 I 9590 9402 5225 9122 5464 65 United States •Sender:Please print your name,address,and ZIP+4®in this.box* Postal Service -- Ot Town of Barnstable Health Division 200 Main Street Hyannis,MA 02601 f I r Certified Mail:7008 3230 5177 8186 Town of Barnstable Inspectional Services • BARN9FABL& f 39. Public Health Division a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 October 28,2019 JPL Reality Trust 416 Main Street West Dennis,MA 02660 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION The property owned by you located at 133 Zeno Crocker Road, Centerville MA, was inspected on October 25, 2019 by Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted in accordance with Chapter 170 for Town of Barnstable Public Health Division. The following violations of the State Sanitary Code were observed-: 105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements Observed chipping paint on the 1st floor bathroom ceiling. Observed missing cabinet doors in the kitchen. 105 CMR 410.280- Natural and Mechanical Ventilation: Second floor bathroom fan not functioning properly and mold like substance on the ceiling was observed. You are directed to correct the violations listed above within(30)days of your receipt of this notice by installing a new fan in the second floor bathroom; by cleaning mold like substance on the ceiling; repairing the chipping paint in the 1" floor bathroom; by installing cabinet doors. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10)days after the date the order is served. However,said violations must be corrected within twenty four hours regardless of any request for a hearing.Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations,please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH R.S.,CHO Director of Public Health Town of Barnstable \\toa\depts\HEALTH\Order letters\Housing-Motel Violations\244 north street 4-31-17.doe . Date: Time: y D=30 Inspector: � Building/Zoning Approval Meet WI E ✓i LA IAZ&A. Date Town of Barnstable Barnstable Pd 711V,I � Inspectional Services Department ���A�� � p P 1111, sc A` Public Health Division 2007 200 Main Street, Hyannis MA 02601 Email: Barnstable.Rental.Registration@town.barnstable.ma.us OFFICE: 508-862-4644 FAX: 50 -790-6304 Thomas A.McKean,CHO Date: 9 � Time: .ICATION FOR RENTAL REGISTRATION In spec r: Date: 60119 /19 Meet /% Fee: $90.00 Per Unit-Plus$25 for rr� /� each addtl.unit on the same parcel Property Address: j 3 3 �0 �l'C�G k oo-d l im Y —� Unit# If Applicable,.Building# �• wf� Assessor's Map and Parcel: 1 7 Q t S e*(-\14-4r Total Number of Rental Units You Own At This Property (including this unit) Owner's Name: .0 , L Telephone Numbers (Daytime) bU 'b '3 - .5 (Home Phone) A,-b (Cellular) Owner's Address: n w• -D,- ? Mailing Address: (if different than above) + -p /S Email LJ:P-,, '-w-s O Co),.� UVy\C0--S-i-r ytej ' Owner's Representative's Name (if Apica ): Address: ,� c�.S6=�- �V V : ,e._ Telephone Number: 1�U q) -7 3`i - 7 F Tit �({� Occupant's Name: i-etv..wc- "I Daytime Phone Number: Cellular Number of Bedrooms: Check One: Is this a single family dwelling unit? [ ; accessory structure or unit'%❑, studio'?❑duplex? ❑ condo?[j apartment building? ❑, renting a room?❑ Private Drinking Well? ❑ If applicable, describe where accessory structure or unit is located Will there be any children under the age of six who will be occupying the rental unit? (circle one) Yes No ❑ Was the dwelling constructed prior to 1979? ? Yes ❑ No I certify that the information provided above is true: *Inspections Done Annually. Applicant's Signature . e M t (d sA'* r�i•..rub ¢a�'w .. .«...+- - +• • a TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date �6 — 57 Time: In Out Owner Tenant Address p Address 1 Compliance Remarks or (7�z� n 4 Regulation# Yes Recommendations NO 2. Kitchen Facilities 3. Bathroom Facilities d9 i1 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities �j J 7. Lighting and Electrical Facilities yrl� 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART 11 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicl d (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date % Time: In Out Owner -7(� L Tenant Address Address t� A A�� AIS4 n A v v Compliance Remarks or! Regulation# Yes NO/ Recommendations 2. Kitchen Facilities V 3. Bathroom Facilities V iV _ C•--L_ 4. Water Supply 5. Hot Water Facilities Ci�- Ilj 6. Heating Facilities A 7. Lighting and Electrical Facilities V 8.Ventilation �✓ 9. Installation and Maintenance of Facilities 10. Curtailment of Service w 11. Space and Use 12. Exits 1'3•.,-Installation and Maintenance of Structural Elements 3 YAK j 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal r ,, 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition_ Number oflBeddroo& Number of Vehicles Allowed (max) Number of Persons Allowed (max) jv Person(s) Interviewed Inspector' If Public Building such as Store or Hotel/Motel specify here w , rJ � THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................... .................o F... . ,. ri.l.�,� t ..................... Appliration for Dispoii al Works Toutitrudio t Prrmit Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal ystem at: f..(2 .. . .. C*.* ti t..L ................................................ LIVI;0 VIA, 5�J.. LocationAddress to L Lot ......................: . ...:... --.........------...-? - �� 1- �f Ate. r 0.............--..........--.------------- Owner ;r ..--- ......... ��. ...r`.�! ------------- -f 4 Address UType of Building Size Lot. �: .�; ...Sq. feet Dwelling—No. of Bedrooms..........47).............................Expansion Attic ( ) Garbage Grinder Other—T e of Building a —Type g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------- -------------------------------------------------------------------------------------•--•--•-•--..........-•-- W Design Flow.........ii.5?..........................gallons per person per day. Total daily flow.......... � ................gallons. WSeptic Tank—Liquid*capacitvW.—gallons Length`1V.... Width................ Diameter---------------- Depth................ x Disposal Trench—No..................•.. Width..i................. Total Length...... _.__. Total leaching area....................sq. ft. Seepage Pit No.___.____t....______. Diameter----- Depth below inlet.... Total leaching area..?�_.4_...sq. tt. z Other Distribution box (VI0,) Dosing tank ( ) aPercolation Test Results Performed by-LjAR-W-V-V---.:..A65��• ��........... -: - Test Pit No. 1_... ..minutes per inch Depth of T st Pit-__-__.V-___--• Depth to ground water..... v�%J...__. fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_---•-__-__--__-__-._--. P4 --••••......-•-...._' .....................................••••-.__...'...1-_---- ------------------------------------------•-..._...:._..:....... Description of Soil----••• "" � ``'� �-•---G '�'t. I S ti? .. .... .-•2,`------.M.IQ......5-- v � A: ' .........------------------------------------------------- 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 of TITS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Ce ifi to of Compliance has e issue by oard of health. Signed.. . •• --- -----------------••--......•----•-••-••-••-•-----• � ....................... ��1r to Applica ' Approved BY (rr' ......... ......... - ate -......-- Application Disapproved for th llowing reasons:.............................................................................................................. .--••------••--•---------------------------.--•••--------•------•-------------•------------..... .-------• •----•-----...------•----•--- Date Permit No......... 7�. ..�t_ ------------------ Issued_.............4- ---•+_gs..ate...... ' ate No..........;j._....... s...... 0.D•.9 I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....-•-- ...............:- ---.---..---OF.... - ApplirFatiou for Disposal Works Ti vustrurtioaa Prrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at yy Location_Address or Lot No. ...:.i .-. C7...� vv. ....i�..` �....��...-.-_..'�r '-•----........�`..�. �-$-----•--•• ------------------ •------------- c Owner e d&r s Installer Address Type of Building Size Lot__�!`_1_E_��.�_ __Sq. feet a Dwelling—No. of Bedrooms............. ___.._____�____________________________Expansion Attic ( ) Garbage Grinder (� a Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow_.__..__.S_�1__________________________gallons per person per day. Total daily flow..............�d._Z__�_._.__.________gallons. WSeptic Tank—Liquid capacity�0 5�gallons Length��____ Width________________ Diameter__--__________ - Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length..... _____._._ Total leaching area....................sq. ft. Seepage Pit No __________ __________ Diameter.....t2, ..___.._. Depth below inlet..._4........... Total leaching area__?%_ ...sq. ft. Z Other Distribution box (✓) . Dosing tank ( ) Percolation Test Results Performed by-_) 2�utG - _.. ___._____. Date__tf?_f _ _� :... Test Pit No. 1.....!•: ._minutes per inch Depth of T t Pit_.__..1_�.__.__. Depth to ground water__-__ham°' . G=, Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ -=------- ---- ---------------------------------------------•---•---............................................................................... 0 Description of Soil---------4� � � �_ 1 � ------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----C-t�__Nl._���1--�-�----�'-<=�'-�--�-7-----• 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 TITLE 5 of the State Sanitary Code— The iindersigned further agrees not to place the system in operation until a Certificate of Compliance has 46—th issue by board of health. � Sign( .........................................- r='' /T,��r� •�e.�-..-�M- ����.�'` ---•-------•--------------•--- � - ---__• Application Approved BY .. !`'. ----- - •-------•......................... .. -•--- ..1_-7. Application Disapproved for thej b lowing reasons--------------------------------•----•-------•-----------------------------------------•-------------•--------- 4 V �SDate Permit No----------�esn... ---------------. Issued_---------•- ---,6 --..................... ate THE COMMONWEALTH OF MASSACHUSETTS �- BOARD F HEALTH TrrtifirFatr of TompliFaurr TH S I,S' TO (7ERTIFY,.jr That the Individual SeNva e Disposal System constructed ( or Repaired ( ) by......... Lam= "t�; -'1 °�{ '..................................................... -------- ---- ' - astaller � j� at � �*---------- 'r'd' ° ' - .j--... - '` ': -................................. has been installed in accordance with the provisions of TITS 5 of The State Sanitary Coe s d cribed in the' application for Disposal Works Construction Permit No_______-1_ __..�;."`i._______. dated---.-_ ___ __ :_ - THE ISSUANCE OF THIS CER IFIC TE SHALL NOT BE CONSTRUE® AS A GU RAID EE THAT T;NE SYSTEM WILL FUNCTION SATI F CT O Y. DATE...... ........................... ... ........ .� --- Inspector_..-...---------------------------•---------------------------••------.....----•--- TH CO MONWEALTH OF MASSACHUSETTS --"'' BOARD F HEALTH 49 771TP.. ..... No.......... :-------- FEE........................ Disposal prkp,uManotrurtion r mi# Permission is her granted '. ' _ ;- 13 ,1 ................to Construct (� or Repair ( ) an Individual Sewage Disposal System Street p- as shown on the application for Disposal Works Construction Permit No. '_.3.AjDated....... : ___9__ .1............. LW ---------------------- -------- ----------•-•--------------- Qoa -t Health DATE....... - C•� ---------------------------•-•------•-_----•- FORM 1255 HO') BS & WARREN, INC.. PUBLISHERS LEACHING BASIN SECT/ON NOT TO SCALE Shcc>� 2 of Z 24"C.I.MN COVER BRICK Am MORTAR COURSES AS'RE0'O• TO BRING COVER TO GRADE 4 B"FLOW L/NE IN L_ _ __ 2'=,B"TO "WASHED PEA STONE FREE. OF IRONS, FINES AND OUST/N PLACE /4" TO I%2'WASHED CRUSHED STONE FREE OF , OPENING W/TN 4%B" IRONS FINES AND DUST IN PLACE S OUTER 0/AMETER ANO /3/4„IN5/0E ' DIAMETER :: • . I. CONCRETE TO BE 4000 PSI 28 DAYS 2. REINFORCED WITH 6%roll NO. 6 GA. W.W.M. 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR . GREATER DEPTH REQUIREMENTS 4'0" �`-- --'--60 ---�— 3�--� 4. NUMBER OF PITS REQUIRED vNC i M/N. ' EFFECTIVE DIAMETER NOTE: EXCAVATE TO ELEVATION�OR (Nor ro ExcEED 3 TIMES EFFEcrivE oEPrH) LOWER AS REQUIRED TO REMOVE ALL WArER rABLE - LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN TYPICAL PROF/LE GRAVEL TO DESIGNED GRADE. F L:EL.52.y /B"STD LT WGT. C./.MH COVER 4"C.I.PIPE 4"8/r.FIBER PIPE OUTLET LEVEL OWELL/NG FLOW LINE T/GNT ✓O/NT I T �" TO flRST ✓0/NT - 47.z 14" �to7 00 1 Io(�po C./. TEE (O8 1 0 11 4a•� 4G.9 'STD. PRECAST CONC. T. BOX TO Bf q O : :1 0 0 00 1 1 D/S .'.; • ; II k�GAL.SEPTIC TAN INSTALLED ON LEVEL, I 1 100 O 0 0 1 } STABLE BASE i i j 100 0 0 ,1 `SEP /C TANK TO BE 11 100 O 0 1 11 1 /NST L 0 0 LEVEL, 11 f 100100 1 1 '.� STABLE•BASE. 1 1 1 10 0 0 , 1 LEACH/NG BASIN i i 1 0 Q O 0 0 0 1 BASE rO BE LEVEL 1 1 O SOIL AND PERC. DATA PERC. RATE MIN. /IN. a,� TEST PIT NO. r ���� O' TEST PIT NO. 2 Tvp 5Li00 L TEST BY. A lr--L-2 .,,_.�, Z' G O M p,a,L-r e p WITNESSED. BY: orJ (^tG,r-ojr_p .4 SA�n �0 M eD, 6A\QD TEST PIT GR.. EL. A 1�.I p URA-4i,- DATE: I o / ?) 17. I:LF-V tJo �ZoUNDwA-C 4- 0ESION DATA GENERAL NOTES BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL tiaQ65 SEPTIC TANK, DIST.. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL 3 3o GPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK toff GAL ALL ,SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE . TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIpEWALL AREAGAL/SQ.FT. MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA I'4" GAL./SQ,FT, SANITARY. SEWAGE EFFECTIVE ON JULY I , 1977. LEACHING REQUIREDZ�SQ.FT,. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING AREA OF HEALTH. E l ;= t�Q;FT. .-',..,AT -COMPLETION OF CONSTRUCTION, PRIOR TO BACKFIIIING, THE h=1126-UJA .: ►35•�s E x z.,_y �3.9 gel -.BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. ►aot`fo :�:;,113;j s�.,, a o 113. 1 9a 1 PITCH ALL SEWER LINES I/4� / FT. UNLESS INDICATED OTHERWISE. SFWAW DISPOSA-4 SYSTEM o�* . .MARTIN tiN L l3 o i E. v MORAN <y Z.>C�10 GP�G 1b •� �F f23417�Q ¢ ' -------. � �°•� �/��•��``� G'�NT���1 11.,L.t� MAC 5 s SCALE AS /NCICATER DATE ►!M. AG WARWICK. @ ASSOC., INC. 8OX 801. - •NORTN M4 MOUTH ` MASS. OZ"6 t f m 565-Z658 PROFESSIONAL ENGINEER C SITE PLAN sHEEr I of 2 SCALE: /"= Zv' , l l 67, oo' F¢EGAh? COUG• (ova ewAi, t715T b�o�c. T►G. TA. -jv: O O So � 4%x 8 SOx�j �vx-v PROF, 8l Dw1; _ s � � -• �.' b"1 ..,.'` �,,r� .. p'±;�`°t� tiw.�c'ern 7"?.'" `..-� r�&, _.-ys a �'' ^. - r—n, •�;a 'wn;n -�,�...., q, _,r,.;, ,. - ® ' I NO ZIP ff v OF WILLIAIiA �,- WARWICK ti ' No. 19771 s0 /STERN � -Q L0d' • FOR REGISTERED LAND SURVEYOR ZONE iZ G �' IJ-1' �!l t_l- , NA A,�a . PLAN REF. GATE �' � J ¢mil 17��5 BENCH MARK DATUM WM.. M. WARWICK 6 ASSOC., INC. DOMESTIC WATER SOURCE Tow I'"T -J -- BOX 80/ - NORTH FAL MOUTH FLOOD ZONE. NC'`ti ' 1-\ MASS. 02556 - (617) 563 -263B 7 LEACHING BASIN SECT/ON NOT TO SCALE 24 0.L MH COVER EARTH f/LL BRICK AND MORTAR COURSES AS REDO. TO BRING "• _.r•,y_ COVER TO GRADE - 4.. FL INLET L/NE INLET 1_ _ __ _ 2= ll8"TO "WASHED PEASTONE FREE. Of IRONS, PIPE : FINES AND DUST IN PLACE q 1 OPENING W/TN 4%8" �4 TO l%p WASHED CRUSHED STONE FREE OF l7 �� 7 OUTER DIAMETER IRONS, FINES AND DUST IN PLACE • . ANO 1314"INSIDE ' DIAMETER I, CONCRETE TO BE 4000 PSI 28 DAYS ' 2. REINFORCED WITH 6%61' NO. 6 GA. W.W.M. 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR .I GREATER DEPTH REQUIREMENTS 4'0" 4. NUMBER OF PITS REQUIRED /N� MIN. I 1ET NOTE: EXCAVATE. TO ELEVATION ' f- OR j (Nor TO EXCEED 3ET%MES DIAMETER FFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL WATER TABLE — LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN TYPICAL- PROF/LE GRAVEL TO DESIGNED GRADE. FL+EL.SZ•j 18"STD. LT WGT. C.I.MN COVER 4"C.1.PIPE 4"8IT.FIBER PIPE' */GNT JOINT OUTLET LEVEL DWELLING T LOW L/N£ TO FIRST ✓DINT00 T C.I. TE I I 0 10 0 1 1 44•0 I i10oQ 01 I 1 11 ' !�8, 'STD. PRECAST CONC. 13, �. 0/ST. BOX TO Bf t)(p p ( 0 0 0 O 0 1 1 i I�GAL.SEPTIC TAN III 100 00 0 1 1 I LINS AON LEVEL, "" STABLE BASE 1 1100 00 I'll 11 1 it 100 00 11 1 1 �SEPTIC TANK TO BE 1 If 600 00 1 oil INS* LL 0 0 LEVEL, 1 11100 10 0 1 1 '. 1 STABLE BASE. 1 1 1 0 0 0 0 0 1 1 i , 111100 001111 : LEACH/NG BASIN , 1 t e 0 00 0 1 if BASE TO BE L EVEL 110 0 1 1 if I 4:_L 4z. SOIL AND PERC. DATA PERC. RATE `2. MIN. /IN, TEST PIT N0. i' ���� „ TEST PIT NO. 2 0 0 z TvP 5v13tiolL TEST BY: — t GOM p�,.Gt p WITNESSED. BY: w�� �i�-© 4 sA1.�n M rr.D. sA%uD TEST PIT OR. EL. A 0 p C-RA--/,4 DATE: I o /z Iz1 tJ v c-t.ovlJ P`4-c 6� 4- e DESIGN DATA GENERAL NOTES BEDROOMS NO.HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL No,at-5 SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL 3 kl GPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC .TANK 1"f GAL ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL AREA LGAL./SQ•FT. MINIMUM REQUIREMENT$ FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA.�. .,.GAL./$Q,FT, SANITARY, SEWAGE EFFECTIVE ON JULY to 1977. LEACHING REQUIREDZaSQ.FT... ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING AREA. OF HEALTH, .SQ,FT •':r.,AT -COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. _. ►�a o ,- ;,1 I3:.1.s K I'.'o 113, 1 ga-1 PITCH ALL SEWER LINES 'A" / FT UNLESS INDICATED OTHERWISE. o� oe Esc � SEWAGE DISPOSAL SYSTEM . .MARTIN 13, MORAN `�» ad SCALE AS INDICATED WU. M. WARWICK. 8 ASSOC., INC. - ; 8OX 801 -NORTH M4 MOUTH ` MASS. OZ,566 f17) 565-Z638 PROFESSIONAL EN61NEER uo L0CATI N SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS e U I L D E R OR OWNER �d DATE PERMIT ISSUED 4 DATE COMPLIANCE ISSUED — L — ,y v .37 tl 4 CO,m,-%,10,.\7N%7ALTH OF MASSACHLSETTS ExECU TIVE OFFICE OF ENN IRO\MENTAL AFFAIRS F- DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE tCINTER STREET. BOSTON NLA 0210c t61,i 292-550v TR ii DY C OXE Secre:a--c ARGEO PALL CELLUCCI DAVID B STR .-z-?S Governor Commissione- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:13 3 Zeno Crocker Rd.. , Name of Owner T im D e L ong C e t o ry i t le , MA Address of Owner: Date of Inspection: 15—,Zj— ? S Name of Inspector:(Please Print)Wm. E . Robinson Sr . 1 am a DEP approved system!inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) m Copany Name: WM. E . Robinson Septic Service Mailing Address: PO Box 1089. Centerville,yA Telephone Number: 7'7 — 7 7 0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sevyage disposal systems. The system: /✓_/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer-if applicable, and the approving authority. NOTES AND COMMENTS a � Vim' t� V revised 9/2/98 page Iorll h i� ,r!ed on Reaycfrd Pane SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'ropertyAddress: 133 Zeno Crocker Rd . , Centerville Jwner' Tim DeLong Date of Inspection: r 3- INSPECTION SUMMARY: Check C, of D: A. SYS PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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 s stem, upon Y completion of the replacement or repair, as approved by the Board of Health, will pass. Indicat yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined', explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. t Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 revised 9/2/98 Page 2ofII !r' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) P►opertyAddress: 133 Zeno Crocker Rd . , Centerville owner: Tim DeLong Q Date of Inspection: C. FURTHER EVALUATION IS REOUIRED 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 the ublic health, safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). OTHER revise.^'. 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddress: 133 Zeno Crocker Rd . , Centerville Owner: T im DeLong Data of Inspection: D. SYSTEM FAILS: You mr indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N Backup of sewage into facility or system component due to an 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 112 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARG SYSTEM FAILS: You must i idicate either "Yes" or "No" to each of the following: e following criteria apply to large systems in addition to the criteria above: he system serves a facility with,a•,design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public ealth and safety and the environment because one or more of the following conditions exist: 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) The own r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of he Department for further information. revised 9j2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Prop"Address: 133 Zeno Crocker Rd.. , Centerville ' Owner: Tim -DeLong Date of Inspection: /a7_ Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. , As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. V _ All system components, excluding the Soil Absorption System, have been located on the site. v _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)) _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintenance_of SubSurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Iroperty Address:133 Zeno Crocker Rd.. , Centerville Owner: T�'m DeLong ' Date of Ins on: j X,3_ n 1+ 7 j FLOW CONDITIONS RESIDENTIAL: Design flow: ZZY0 g.p.d./bedroom. Number of bedrooms(desjgn):.T Number of bedrooms(actual): Total DESIGN flow 6 0 Number of current residents:y Garbage grinder(yes or no):�G� Laundry(separate system) (yes or noLiti 6; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):_,�,, O Water meter readings, if available (Iasi two year's usage (gpd): 1998 73 , 000 gal. Sump Pump(yes or no): Ao-0 Last date of occupancy: / '2.,A - % 1997 62, 000 gal. COMMERCIAL/INDUSTRIAL: Type of est lishment: Design fr d 1 Based on 15.2031 Basis o1low Grease ent: 'yes or no)_ IndustriHolding Tank present: (yes or no)_ Non-sanste discharged to the Title 5 system: (yes or no)_ Water mdings, if available: Last datpancy:OTHER: e)Last datpancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1r'i/if System pumped as part of inspection: (yes or no)-/, CJ If yes, volume pumped:/66 U gallons Reason for pumping: TYPE O 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: - 3 - Sewage odors detected when arriving at the site: (yes or no) revised c/2/9S Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyAddress: 133 Zeno Crocker Rd.. , Centerville ' Owner: T im DeLong• Date of Inspection: d Q y BUIL ING SEWER: (locate on site plan) Depth elow grade:_ Materi I of construction:_cast iron_40 PVC_ other (explain) Distan a from private water supply well or suction line Diamet r Comme ts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: I ✓t / � �_� Sludge depth:_ i Distance from top of sludge to bottom of outlet tee or baffle:�� Scum thickness:_ v Distance from top of scum to top of outlet tee or baffle:' L! ) Distance from bottom of scum to bottom f outlet tee or baffle: Now dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet tees gr baffles,,depth of li d level in relation to utlet invert, structu inte9t'/L�•�/) evidence of lea Mg , etc.) ��j 0 Vie' 1 /f •L !i`` , w �A iO /'✓�-G GR E TRAP: (locate site plan) Depth bel w grade:_ Material o construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensio s: Scum thickness: Distance tom top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Com ents: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to.outlet invert, structural integrity, evidenc of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION(continued) 'ropertyA eas: 133 Zeno Crocker Rd.. , Centerville OWE: im DeLong Date of Inspection:,-*� TIGHTR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate site plan) Depth bel w grade:_ Material o construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimensio s: Capacity-_gallons Design ow: gallons/day Alarm resent Ala level: Alarm in working order: Yes_ No Date previous pumping: Comm nts: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Q Comments: (note if level and distri tion is qg ual, vidence of solids arrYover, evidence of leakage into or out of box, etc.) - !L o '7'V PUMP CH BER:_ (locate on s to plan) Pumps in w rking order: (Yes or No) Alarms in w rking order(Yes or No) Comments: (note condit on of pump chamber, condition of pumps and appurtenances,etc.) ,reviser 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continudd) 'rop"Address:133 Zeno Crocker Rd.. , Centerville Owner: Tim DeLong Date of Inspection: ) X—A 3 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;exca tion not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: — leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, sins of hydraulic f it level of ponding, d p soil, c nditio7of vegetation, etc.) � l� IF CESSPOOLS:_ (locate on site plan) Number and'configurati n: Depth-top of liquid to let invert: Depth of solids layer )epth of scum layg Dimensions of cesspool: Materials of co struction: Indication of roundwater: i ow (cesspool must be pumped as part of inspection) Comments: (note condition f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PR/construction-: (lote plan) Ma 5 n Deids: Dimensions: Co(noon of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revise- 9/2/9C Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1ropertyAddress: 133 Zeno Crocker Rd.. , Centerville , Jwner: Tim DeLong Jate of Inspection: y _� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where ublic water supply comes into house) J a i /36 revised 9/2/98 Page 10ofII U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) ropertyAddress:133 Zeno Crocker Rd.. , Centerville owner: Tim DeLong Date of Inspection: G NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater eet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions ' / `� Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how( established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page.llorn