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Home My WebLink About0044 MAIN STREET (CENT.) - Health 44 Main Street Centerville rA=228 - 01G i i SMEAD No.H1630R UPC 10259 smead.com • Made in USA ,4�CYC(8b �J C�+ 4Q ,pZ J 9c 1 4 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Main Street Property Address P"' 49 Kevin Griffin , Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms s� /aaa3 on the computer, �C use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections r� Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 r 03/30/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �0#6w Vs Y � \ Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 2 bedroom home has a 3 bedroom septic system installed on 10/06/2006 The system has a H-10 1500 gallon septic tank and a H-10 D-Box feeding two 500 gallon leaching chambers with appx. 4 feet of stone. At the time of the inspection the leaching was dry and there were no visible signs of past hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 , Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the.distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal 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 '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] El 0 The system is a cesspool serving a facility with a design flow of 2000gpd-' 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. Cityrrown 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 b the owner, occupant, or Board of Health ® ❑ P 9 p Y p , ❑ ® 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes No information in this report.) El Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: weekends Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No - Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r tN Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M10 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. Cityfrown 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: 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 10/06/2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28"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.): Septic Tank(locate on site plan): Depth below grade: 18"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: Standard H-10 1500 gallon Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness T. Distance from top of scum to top of outlet tee or baffle 35" Distance from bottom of scum to bottom of outlet tee or baffle 5" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local septic pumping Co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: . gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Main Street M Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. Cityrrown 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.): At the time of the inspection there were no visible signs of past hydraulic failure or leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working orders stem is a conditional ass. p p 9 Y p Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M ,•'`y 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the leaching was dry and there were no visible signs of past hydraulic failure. 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-3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 9 U1 14- t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 TOWN OF BARNSTABLE LOCATION 7 7 SEWAGE#N `VILLAGE ASSESSOR'S MAP&'�P,,AR��CEL�� INSTALLERS NAME&PHONE NO. 1V1k ,,+0J SEPTIC TANK CAPACITY /,SV 0 LEACHING FACILITY:(type) 6nO a- fit,(size) NO.OF BEDROOMS OWNER PERMIT DATE:A9 COMPLIANCE DATE: Separation Distance etween 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 A`1 A2 -73 132 � 1 A-3- �3'A7 3- �3 �35=5� 3 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show five plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 44 Main Street Property Address Kevin Griffin Owner Owner's Name information is required for every Centerville Ma. 02632 03/30/2017 page. Cityfrown 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 OTTOro F Ilfe S.A S o HZ � t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATIONy /� % SEWAGE `J;LLAGE (' l 47/— ,,/ ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. W1 JC//4-01 V/ '7/T 2 1 SEPTIC TANK CAPACITY /579Q LEACHING FACILITY:(type) �® 04 Gi (size) Z�20 NO. OF BEDROOMS OWNER PERMIT DATE: 129 COMPLIANCE DATE: Separation Distance etween 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 4 Q500".� • No. 3_5 r ' Fee ®� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS atlphratton for loiq;pozat i�pgtem C0115trurtioll Permit Application for a Permit to Construct( ) Repair(Vupgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. A14 A' 5 Owner's Name,Address,and Tel.No. /IRS Assessor's Map/Parcel via? .-- 011 Installer's Name,Address,and Tel.No. 041-1*i)l 121ACEA Designer's Name,Address and Tel.No. . f� D AD/ U' RV 9,?/ c 5;,*/V0ttJc4 (. cu?'� Type of Building: Dwelling No.of Bedrooms _ Lot Size 141 99F sq. ft. Garbage Grinder ( ) Other Type of Building � ,G s No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 36 gpd Plan Date Number of sheets Revision Date Title q " Size of Septic Tank � �JdC3 Type of S.A.S. coac w�l76',✓' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sialred Date 0 Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Y 3 5 Date Issued t� G No. 4?C 6 ,-— 3,5 L, I s• Fee a Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN,O0 BARNSTABLE, MASSACHUSETTS Y S ZIppYication for, 33igpo.5d1 Qpp5tem Construction Permit Application for a Permit to Construct( ) Repair(1/ Upgrade,( Abandon( ) l l Complete System ❑Individual Components Location Address or Lot No. c� / //V 57 Owner's Name,Address,and Tel.No. E' �I�A o 5,-a 114 AkY I (C)EW4AIVE Assessors Map/Parcel d�O2 7 — 0 Installer's Name,Address,and Tel.No. `1//�L��'{Y� �/�6= Designer's Name,Address and Tel.No. 5T /� 6 �� P°' 1301Y Type of Building: Dwelling No.of Bedrooms _ Lot Size A 99-� sq. ft. Garbage Grinder ( ) Other Type of Building ,.S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) e3 30 gpd Design flow provided 3d gpd F Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of.S.A.S. 9f-1 U,Fla,-n V Description of Soil v� Nature of Repairs or Alterations(Answer when applicable) . Date last inspected: e Agreement: d The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. f. Date Y Application Approved by\ Date ,/00l+ Application Disapproved by: N Date for the following reasons � hh � Permit No. 00 61 L/3 Date Issued 11016 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On•site Sewage Disposal System Constructed ( ) Repaired ( I,<) Upgraded ( ) E Abandoned( )by � at l/y ,4/111//V ST /(4,/(has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. cps(n 413 .5 dated'`, /,ate Installer C/V�L //a �j� �l 1(/CI r A? Designer �,� 4�ar ,/v I_ I—` Y 5/C bedroorns Approved daS -R"�w�, 3 gpd The issuance of this�pe.r shall of be construed as`a guarantee that the system wil functinrs�desig e Date ( 1 1 tD Inspector �' No. )6 /G r' l Fee_,,. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS W45po al i§psstem Con$truction Permit Permission is hereby granted to Construct ( ) Repair (r✓') Upgrade ( ) Abandon ( ) System located at y A/ /I Z,11V c % �/'/1/T: l�//l T� I A A- U :-4 S` and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. . Provided: Construction must be completed within three years of the date of this pe it. Date /-� / l Approved b Town ®f Barnstabl' Regulatory Services Thomas F.Geiler,Director + sARNSJ'a�BLE. a Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Designer: �J - �V'� /"� ' i� Q G Installer: _/�� Address: . FL-,' UX l �( Address: '— j On issued a permit to install a (date / (installer septic system at- 4+ M.oI q ST. CeAiv") 1 • � based on a design drawn by (address) r � M �- dated (designer) certify that the septic system referenced above was installed substantially accordingto the design, which may include minor approved changes such as lateral relocation of he distribution box and/or septic tank(ptr t✓�s f a!le Gh t, 7°�V,,,,g�,�� ,�,,c_p n,t c�e tv I certify that the septic system referenced above was installed with major changes (i.e. greater-than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. OF (histaller's Signature) REYE,4 No. 1 t 40 II 1 �< C21 ` l STE VL s�'fYtrAR0'' . (]designer's Signature) - (Affix Designer's tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTNICATE OF COMPLIANCE WRJ, NOT BE ISSUED UNTH, BOTH -THIS FORKS AND AS- BUILT CARDARE RECEIVEDBY THE,BARNSTABLE PUBLIC HEAL' 'HD M- ,v,1 l.�T. THANK YOU. Q:Health/Septic/Designer Certification Form TOWN OF BARNSTABLE - LCCATION '� A.t�x, SEWAGE'# < N,U,.LAGE ASSESSOR'S MAP A LOTS l SEPTIC TANK CAPACITY LEACHING FACILITY (type) NO OF BEDROOMS B R-GR OWNER PERMITDATE: -%XV" COMPLIANCE DATE: Separation Distance Between tfte: 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 1�'%Furnished by _° '� w f l _ : r.r r Town of Barnstable Ell Y`tio Regulatory Services. sivsrneLec Thomas.F..Geiler,Director 9� .� Public Health Division Thomas McKean,Director r 200 Main Street,Hyannis,MA 02.601 Office: 508-862-4644 Fax: 508-790-6304 October 4, 2006 Ms. Rosemary McErlene 21 Keane Road West Roxbury,MA 02132 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 2 c a L The septic system owned by you located 44 Main.Street,Centerville,MA was last inspected May 22"d,2006 by, Robert A. Paolini, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: A single cesspool automatically fails in the Town of Barnstable You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Hdalth Department. N .BLE HEALT DEPARTMENT aSsTAAMcKean,R.S., C.H.O. Agent of the Board of Health K C—Q L-th DATE 5/22/06 PROPERTY ADDRESS 44 Main street Centerville MA 02632 On the above date, the septic system at the address above was inspected. This system consists of the following- 1. 1-6Xll��&eock CeZZR061., Based on Inspection, I certify the following conditions: Z.- 7h.iz .ins not a 7.it P.e Five .6e12t.i�',ZV,-5'tem.. 3.� Sewage zyzt-em .is .in ;'Pa.ieuze a-t' Ah.iz time., .0,z2y .1 ceazl2ooP ex.iztz on /22o/2e2ty. %r SIGNATURgdw— Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. 0. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped &.Installed Town Sewer Connections P.O. Box 66 Centerville, MA 026.32-0066 775-3338 775-6412 • i \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE'OF ENVIRONMENTAL AFFAIRS ` DEPARTMENT OF ENVIRONMENTAL PROTECTION � d TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ..44 Main Street Centerville MA 026-4 Owner's Name: Rosemary McFarl ena Owner's Address: 21 KPanP Road trot Roxhurv' Mn 021 Z2 Date of Inspection: 5/2 2/0 6 Name of Inspector: (please print] Robert .A Pao:lini Company Name: g_ P. Raconlea .& S::o.n Inc. Mailing Address: Cen e2vT e, 413.6. 02632 Telephone Number: 5 0 8-7 7 5-3 3 3 8 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.15:3'40 of Title 5(310 CMR I.&000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority �XFa' s Inspector's Signature: Date: — The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""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 game or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION:FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART A CERTIFICATION(continued) Property Address: 44 Main Street Centerville MA 02632 Owner: Rc)GPmarj Mr-P.arl Pne Date of Inspection: 5/2 2 f 0 6 Inspection Summary: Check A,B,C,D or.E/ALWAY' ,omplete all of Section-D A. System Passes: NO I have mm 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: Sewage zyz em .ie .in �eai&�ze., B. System Conditionally Passes: NO One or more system components,as described in the"Conditional Pass":section need wbe.replaced.or repaired.The system,upon completion of the replacement or repair,as apjlrovedjby the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. NO 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: NO. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection-if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: NO The system requited pumpingg more than 4 times a year due to broken or obstructed pipe(s)..The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: ;a 2 I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAC E SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 44 Main Street Centerville MA 02632 Owner: Rosemary McEarl ne Date of Inspection: 5/2 2/0 6 C. Further Evaluation is Required by.the Board of Health: NO. Conditions.exist which.require further evaluation by the.Board.ofHealth.in order to determine if the system is failing to protect public health,.safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: no Cesspool or privy is within 50 feet of a surface water no Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Bo A..and of Health(and Public Water Sit. pier;if any)determines that the system is functioning in a manner that protects the public health,safety and environment: no The system has a septic tank and-soil absorption system(SAS)and the SAS is within 100 feet.ofa surface water supply or tributary to a.surface water supply. no The:system has a.septic tank and SAS and the SAS is.within a Zone 1 of a public water supply. no The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. no 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 v.izua p "This system passes if the well water analysis,performed at a DEP certified laboratory, for colifonn 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 r" PART A CERTIFICATION(continued) Property Address: 44 Main Street Centerville MA 02632. Owner: Rosemary McEarlene Date of Inspection: 5/2 2/0 6 D. System Failure Criteria applicable to all systems: You must indicate"yes":or"no"to each of the followingfor all inspections: 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'h.day flow 7- 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 ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface wgter supply or tributary to a surface water supply. r _ X Any portion of a cesspool or privy is within a Zone I 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 at 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.] N0 (Yes/No)The system fails.I have determined that one or moret,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 101000 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 X the system is within 400 feet of a surface drinking water supply X the system is.within 200 feet of a tributary to a surface drinking water supply _ X 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 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 INSPECT,I N O FORM PART B CHECKLIST Property Address: 44 Main Street rentprmill.e l4A 02632 Owner:_ Rosemary McEarlene Date of Inspection: 5/2 2/0 6 Check if the following have been done.You must indicate"yes"or"no"alto each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks ? X _ Has the system received normal flows in the,previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X 14 Were as built plans of the system obtained and examined?(If they were not available note as N/A) e.. X _ Was the facility or dwelling inspected for signs of sewage back'bp,,! X _ Was the site inspected for signs of break out? `' X _ Were all system components, excluding the SAS,located on site? X _ 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: Yes no X Existing information.For example,a 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)] '4 5 Page 6 of 11 OFFI:CIAL INSPECTION FORM. NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL::SYSTEM;INSPEETION FORM PART C SYSTEM INFORMATION Property Address: 44 Main Street Centerville MA 02632 Owner: Rosemary McEarlPnP Date of Inspection: 5./2 2 0 h FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 - Number of current residents: 2 Does residence have a garbage grinder(yes or no): a o Is laundry on a separate sewage system(yes or no):rz o. [if yes separate inspection required] Laundry system inspected(yes or no): 2 00 Seasonal use-(yes or no): n0 2004=33,. 000gai.eorn6 g10D=90.41 Water meter readings,if available(last 2 years usage(gpd)):2 0 0 5 2 9., 0 0 0 g Q e o n z g%D=7 9.4 5 Sump pump(yes or no): n o Last date of occupancy: /z 2 e s e n t COMMERCIAL/IN" USTRIAL N/A Type of estab".}rent: Design flow( d on 310 CIv1R 15.203): gpd Basis of dbsign''flow(seats/persons/sgft,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):_ Watenmeter readings,if available: Last date of occupancy/use: . OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 5/5/06 RumRed ee'3zRo0i Was system pumped as part of the inspection(yes or no): nQ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption.system 7—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) —Tight tank _Attach a copy of the DEP approval _Other(describe): ApprT�nate a,ze of all components,date installed(if known)and source of information: f t�ea2.6 Were sewage odors detected when arriving'at:the site(yes or no): a 0 6 I Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 44 Main Street Centerville MA 02632 Owner: Rosemary McEarlene Date of Inspection: 5122106 BUILDING SEWER(locate on site plan) Depth below grade: 18". o ce a n ge k u 2 g- o Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): aoirzt6 appeal right No eeakage v rziod fhnnijgh hn,i.to ,ion,;. SEPTIC TANK:NO(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 a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage, etc.): — Septic tank iz not 2eaent GREASE TRAP:NO(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.): gaeaae .taap iz not paezent 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: 44 Main Street Centerville MA 02632 Owner: RncamAr)4 McVnrl ane Date of Inspection: 5.19 2,/0 6 TIGHT or HOLDING TANK: NO (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: Co t (condi 'on f ajanm arld float switches,etc. 'g 02 ho � zag tanks ate not /22ezent DISTRIBUTION BOX: NO (if present must be opened)(locate.on site lan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence.of solids carryover,any evidence of leakage into or out of box,.etc.): D,i.61-2.ifHuion goz iz not /22ezent PUMP CHAMBER: N0 (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Rmm�ts�(note�condition of puipp chamber,c.Tndition of pumps and appurtenances,etc.): inn c am ea .cis no 2eaen 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: 44 Main Street Centerville MA 02632 Owner: Rosemary McEarlene Date of Inspection: 5/2 2/0 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS.not located explain why: No Te c iy��ng. eW ce��sjzoo Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields;number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.): CESSPOOLS: /J"(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert o v e 2 Depth of solids layer: no '6 o e ids Depth of scum layer: no cum — Dimensions of cesspool: 6 'X ' Materials of construction: aio ckz Indication of groundwater inflow(yes or no): . Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Loamy. �o medium .6and., . Ceshpoo i .iT is �a.iivae., Vegetation .iz no2ma PRIVY: No(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.): 17)2.ivy 1.3 not /zzezerzt ram., 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: 44 Main Street CPntprville MA 02632 Owner: Rosemary McEarlene Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the-building. '• 1 C� 10 Page 11 of 11 Y � OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: .44 Main St.rPPt Cen ville MA 02632 Owner: Rospmary McFarlene Date of Inspection: -9 12 2,4 n ti SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: �N 0 Obtained from system design plans on record-If checked,date of design plan reviewed: u e s Observed site(abutting property/observation hole within 150,feet of SAS) CheckedwithlocalBoard.ofHealth-explain: 'Pt �2d no Checked:with local excavators,installers-(attach documentation) e.sAccessed USGS database=explainA1-;6/2:sown.,aaItnz._a&fie, ma.. ups You must describe how you established the high ground water elevation: 11,6ed Cape Cod Comm.iz.ion 1date2 7ag.Pe Coritouzz 4nd l)u&2ie Oatea Supl2.2y Oeii head p4oteet io.n a2eaz mal2.- Sett 1995 Watea scehou2ceh o,,.ice cage cod comm.ih.ion , Leaching Pit Feet Groundwat3%eet Below Bottom Pit . High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical.separation distance between the bottom " of the leaching pit and the adjusted groundwater table is /� feet. �lQ 4 0 a•/.Ilan+.—wrrr-,wr++ `anmltn►I�+/lnnr�+�►Ir � rowN of BARNSTA T.F DQARD QF tl$A1,TI1 __,. a9UI)SURFACK 89WAOR DISPOSAL SYSTEM IROP.RCTION FORM - PART D CERTIFICAT-ION «•TIY 'T•:',t7•'.T1gf•VE7TUf1111I1'1f111f177R �.'�•��IIR� -1 all "9M -VP_; -r. -TYPE OR PRINT CLEARLY- PROPERTY INSPCOTPsD STREET ADDRESS 44 Main Street Centerville . 02.632 ASSESSORS MAP BLOCK AND 'PARCE•L OWNBR's NAME Rosemazy. �!IdEarl•ene ......_ PART` D cH1iVXFX0AT30N , NAME 'OF INSPECTOR RoB.ea� P,a.o"n.i ' o e�rh :P.1 �lacont&ea Son. Inc COMPANY NAME a �.�.�.—. .-----I Box 6 6 COMPANY ADDIMS. �, TolM-or City _ 8ta • LIP COMPANY TEI ZPHONE ( 508'. Y 7.5 - 3338 YAX ('.508'1790 W$ CT3RrI iCATION. STATEMENT I certify .that. I have persohal-17 .i11s•pected .the sewage 'digposa`l. system at this address and that• :tti:e' information reported ,is true,. s.000ra•te•, acid a omplete as of the time ..a,�f inspection.,- The irtePevt i on was a p r•f'o xmed and any recommendations regarding. upgrade, .ma•intenAnee 1, acid. repa•ir .are• eon$is'tent with my trainip,g and expo•rience in the proper futrcti,•on- and maintenance of on- site sewage disposal systems . iChe k one; ' Systen{ PASS*D _ The inspection sihic.h •I have .�oonducted has ,,nat' 'found any information . which indicates than the system- fails . to ' adeduately. protect .public health or the enviropment as defined in• .310 CMR. It' 30.3•, Any failure criteria r,ot evaluated are as stated .in the FAIWIM CHI-URIA :see•tibn of this, for)n. System FAILED* The inspectioh which I have aai ted 'has found that the system fails to Protect the public iiealth and the enVAronmen•t • in acoo•rde;nee with Title 6 , 310 CMR 15 , 303, and as - specifically noted -on .PA'RT' C FAILURE CRITERIA of this inspe 'tion . rm. ' - •t DD2L. Inspector Signature' a s re' copy of this eeeti, f icat•ioh•must -be rovi'ded :to :the •QWN2R•, t{ho8 BUYER here sppli.oab1*) and trh!i DgARD OF K8A Tit. * If the inspection FAILVD., 'th-e .owner' ,oxl"9perator •w.hal, . up�g•rade'•the system. within one year of the da•t•e of the i.napeetiony unless. al owed Qr• resit,red ^t.),ArW{se as urovided iT �jo CMR 1.6 ,306 . i Town of Barnstable P# Department of Regulatory Services = Public Health Division Date .MAS& q 163¢ �s� 200 Main Street,Hyannis MA 02601 ; ��EI1MA'la J . . a '''''l'' ` .� Time l Fee Pd. ~1 Date Scheduled• _ i ---- - foil Suitaiiility Assessment for Sewage is osal. Performed By: Witnessed By: i LOCATION& GENERAL INFORMATION Lion Address'.1- (M ik, M STREe 1_ Owner's Name A05e M Lc12L4tj, 2 1 � Address leand k 2- � 10 EngineersName Assess ors MapP4rcel / D, Me�P�✓ n / l U� N REPAIR # j -2^722. NEW CONSTR Telephone Land Use K Phi I rA_P� �/ Slopes(%) ' Surface Stones - Distances from: Open Water Body>S&o ft Possible WJ Area�Z•�ft Drinking Water Well � t Drainage way4 7 166A. Property Line (O ft Other ft ' SKETCH:(street name,dimensiods'of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) SEE P2vposeQ SelAJA66 PLIOrij • s I - � •�'�Off` i N C= C Parent material(geologic).Py o fdL '�� I Depth to Bedrock o �Dept . I Wee in from Pit Face rer -2 h to Groundwater- Standing Water in Hole:' P g �Estimated Seasonal14igh Groundwater �// 1DtTE �TION FOR SEASONAL HIGH WATER TADLEMethod Used:Depth 04erved standing in obs.hole: in. Depth to sail,'nottics: - Depth toiweeping from side of obs.hole: i in, 'Oroundwater Adjustment Trt 7777-7rIndex Well# Reading Date Index Well level -. Adj•Actor Ao�.dtYlundw PERCOLATION TEST Date 6 Tlme . Observation I Time at 9" Hole# i eJ S t • Depth of Perc Time at 6" Start Pre-soak Time.@ j t 04 I Time(9"-6") --- — End Pre-soak ' Rate MinJInch ..�_ ,� G�µ, �� :> 1; x• . . :( , �/ Additional Testing Needed(YIN) Site Suitability Assessment: Site Passed' " Site Failed: , Original .Public Holth Division Observation Hole Data To Be Completed on Back--------- ***If percolajion test is to be conducted within 100' of wetland,you must first notify the Barnstable C¢0servation Division at least one(1)Wedk prior to beginning- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) Opt Ipa o. 4`S' d AA44:5fkW . , D`' 34 1, -b LDaAt 16YRSgor DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color .Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistencv.% 12 34 ; . tx=504 !o Rs/a H asses 34"- l2d' M¢d1v 2.5 (l4 �/ e DEEP OBSERVATION HOLE LOG Hole t Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cons.i to c veK- a DEEP OBSERVATION HOLE LOG_ Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. nit FAll Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No X Yes�v/ Within 100 year flood boundary No ^ Yes R• Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? V_ If not,what is the depth of naturally occurring pervious material? Certification' I certify that on 7 (date)I have passed the soil evaluator ezairiination app"roved by Department of Environmental Protection and that the.above analysis was performed,by me consistent with the required Wn , rtise and experience described in 3,10 CMR 15.017. Signature Date �O Q:\SEPTIWERCFORM .DOC I ASSESSORS MAP : TEST HOLE LOGS NOTES: �P RKRDS PARCEL : 01 _ i yy 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOR : THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF 2 FLOOD ZONE : NUI I ��'{ . , §F;- ETA-f3L. BOARD OF HEALTH REGULATIONS. Poll � � � � � WITNESS : DoN 0E<f�'l,A-tz-"- 2 tW I . 3..¢f DATE : MF fit, 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, e DR �vo pINE REFERENCE : �R-- �'��"�... �C� . I' Cu PERCOLATION RATE : Z°z MINIINC.4 SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO IY4' t CI; SU �� `%�"IJ�� . • Crl.... Sf�K � INSTALLATION. �t TH- I C�:L-° qj5.,�j TH-2 CAL= l.( �'„� 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION NTERVI c j Ill VI/� ('c P D ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE F RN880} �I -v,3 '. -t ' SAd.tp DETERMINATION. 'Centervill ° a I I< (Dyv-`� rstaric ar 0c (Q` qtC.' { � " q . 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS w. ,NUIi t - p LoAffi LOW'-( SPECIFIED OTHERWISE) LOCATION MAP(�i - 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A l �{ :. fm� -� GARBAGE DISPOSAL. 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON �l 2_5 ABASE OF 6"OF CRUSHED STONE. I�iO I �_ � - wt Ce.c:A-� R�.Mov�� IzC.r'c..,�.-.� o �, > � IN oe're _; I , ?� L JI E Vv MEQ SANS (r- 1� PPOp, LZkH A . tpu_: miw2.°I SEPT I C SYSTEM DES I GN he rJ D FLOW ESTIMATE BENCH MARK i&-) 0 vjlll^p_ `j"l__°l' . L' T? V':.c % '�^ " . of TOP OF CONC BOUND Vet. T3 3 BEDROOMS AT 110 GAL/DAY/BEDROOM - � (GAL/DAY kk,0�'ksp t Cl �v..�.� OP l -L �Jt � 1 I S_ � ? .ELEVATION = 43.00 /`$�� P �'! '`C� - USGS DATUM ASSUMED 41- � yy SEPTIC TANK ��1J.1?- r�I�T� �(qvl p cp Foe 1 .0 33 O GAL/DAY x 2 DAYS GAL _.. TIP F?e C 0NVC 7—t_ . FftPl o USE ) GALLON SEPTIC TANK— 12B FL-- SOIL ABSORPTION SYSTEM I— 44 Eej C1d'6 l:lY L a✓ ( 1—i 4 — {f ✓Y a^ t t�4 i �} d_y i , 20 FLotlLS ^I S I GE AREA 9 'a .0 f CcSSP 44 -1— '�V 20 ft I BOTTOM AREA: 2LI ' 1I >3 3C � SEPTIC SYSTEM SECTION - ` I w I-v f�- - 48: I O � i A � I --------.:.�_ � EXISTING 36 Amx I — \ IytS{ tf I .' 2Ea p'lrDoo .l�q i .? tip- E-Qu' LL NEL L I N I 45 I � . u � ? GAL . I� r�Vur' .� 1 t�lr ' I r r, I C1 a TOP or FNON my SEPTIC TANK0 —46 EL = 48.61+— o 4'�C��U.J�fI-- U N . - � f °ly �/� `-I'/ d 'DOU6te `� n O 1 o I I(� —(241 z_x L D T /10 el , ' Rl �V�H OF Asps c i z I rn �-, I ,r�, A N C �, SITE AND SEWAGE PLAN LOCATION . 44 1`° t, ► -Tiz / 120 FL 46 t` UrIrC. EDGE OF PAVEMENT sgyv TAR,P� (7� PREPARED FOR : 90-27em4--fzy McEALI nab E E S , - MAIN DARKEN M. MEYER, R.S. SCALE . ZQ t a DATE : `� Q P.O. BOX 981 EAST SANDWICH, MA 02537 J w DATE HEALTH AGENT Ph: (508) 362-2922 W Z