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Home My WebLink About0251 MAIN STREET (CENT.) - Health 251 Main Street (Cent.) Centerville, A = 208 102 No. 4210 1/3 ORA � F2 1o�ro b i Commonwealth of Massachusetts a0S-- /D4E- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Main st r Property Address Amanda Perna Murray Owner Owner's Name information is Centerville !/ Ma 02632 5/28/16 required for every _ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, / use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain c Company Name 8 Johns path Company Address S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 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 b e Local Approving Authority 5/30/16 I pector'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 �o V S Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Main st Property Address ' Amanda Perna Murray Owner Owner's Name information is required every Centerville Ma 02632 5/28/16 l.�i' page. r.,,y City/Town State Zip Code Date of Inspection ` B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found an information which indicates that an of h f Y y the allure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1,500 Gallon septic tank as well as a 1,000 gallon pump chamber. System has an 11ft x 31ft leaching trench. System is functioning properly and in good shape. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. CitylTown 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•3/13 Title 5 Official Inspection Form;.Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °,M a 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 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 asses if the II water y p e ate 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 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.] ❑ ® 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins•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 M 251 Main st Property Address 'Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a 1,500 Gallon septic tank as well as a 1,000 gallon pump chamber. System has an 11ft x 31ft leaching trench. System is functioning properly and in good shape. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 213 Gpd 9 ( Y 9 (gp ))� Detail Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. City/Town 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: none provided 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 14 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3feet 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: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M a 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 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 24 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. I 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-303 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. 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 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. City/Town 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 Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No' Alarms in working order: ® Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is in working order " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 251 Main st M Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 11x31 ❑ 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.): Dug down on top of leaching. Stone was dry and clean. 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-3/13 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 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 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.): No ponding no break out 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Main st �M Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. CityFrown 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. Cityrrown 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: 5+ ftfeet 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: 10/29/02 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: Test hole on plan 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 6/9/2016 Assessing As-Built Cards TOWN OF BARNSTABLE C� LOCATIOI.' �a 2s/ A MAIA4 sr. . �SEWAGE a a?Lf7W VTLL:"3ECFNnegy/ ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��07J�L /�1.IJ�9L v�✓/�/'f%ti9i LEACHING FACILITY:(type) (size)l8.a�3 ,X NO.OFBEDROOMS BUILDER OR OWNER ly PERMITDATE: 101)1/li _COMPLIANCE DATE: Slwlu;L Separation Distance Between the: / Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facibr; (If any wells exist /L on site or within 200 feet of leaching facility) / Feel Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) e Ile) Feet Furnished by 01/3Sd/t! �/_._ -Sl�ot►�f S jAISPk�C poN o 57!9�, http://www.townofbarnstabl e.us/Assessi ng/H M di spl ay.asp?m appar=208102&seq=1 1/2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 251 Main st Property Address Amanda Perna Murray Owner Owner's Name information is required for every Centerville Ma 02632 5/28/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins,-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 251 Main Street 0 e�l�� a(7� � C) a Property Address �^ HSBC \ L Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name Q 43 Triangle Circle Company Address l Sandwich MA 02563 City/Town State Zip Codes 508 364-0894 1328 �- Telephone Number License Number t = 'E B. Certification I certify that I have personally inspected the sewage disposal system at this address and ttgl�theme information reported below is true, accurate and complete as of the time of the ins ection. The inspection was performed based on my training and experience in the proper function and m intenance 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 Q'-p— z, 64, January 17, 2008 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. t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Inspector'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. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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. t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 ❑ ® 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. t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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.] ❑ ® 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. t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? SAS also inspected ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 340 gpd g ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: undetermined 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: Last date of occupancy/use: Date Other(describe): t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 j every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner's agent 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, distdbution 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) ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): Pump chamber Approximate age of all components, date installed (if known) and source of information: Age. 5+years. Certificate of Compliance issued 518102(Board of Health permit#2001-686) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: n.d.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.): Sewers were not accessible for inspection. Pipes entering septic tank were PVC. Septic Tank (locate on site plan): Depth below grade: 3 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: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness trace Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every 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.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): I t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments note if box is level and distribution to outlets equal, an evidence of solids carryover, an ( q � Y rY Y evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in workingorder: Yes No ❑ ❑ t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber was opened and appeared to be in sound condition. Pump, switches, and alarms floats appeared normal but could not be tested due to the fact that electricity had been shut off to dwelling. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® Ieaching galleries number: 1 ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils. t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Main Street Property Address HSBC Owner Owner's Name information is Centerville MA 02632 January 17, 2008 required for every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. MAIN STREET LOCATIONS A B Z 1 27.5 f E 27 f E 2 31 FE 31 fE LEACHING GALLERY w 3 40.5 f E 40 f E ® 3 A PUMP CHAMBER EXISTING 3F] 2° ° r DWELLING # 251 SEPTIC TANK B NOT TO SCALE t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Main Street Property Address HSBC Owner Owner's Name information is required for Centerville MA 02632 January 17, 2008 every page. CityfTown State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 7 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: 10129102 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: Approved design plan on file with the Board of Health shows bottom of system to be 5 feet above the high groundwater elevation. t5-2853.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable 1HE Tp� y�P ti� Regulatory Services lARNSTABM ; Thomas F. Geiler,Director v$ i6 `fig prEo3�A Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. i HOMEINEX CORPORATION 102 PartridgerHill RoadOCharlton,MA 01507 Toll Free 1 800 640-0045(MA Only) ��M�� • Telephone(508)2484500 New England Toll Free 1900 258-5349 Fax(508)248-5163 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: i'1 t1 Owner's Name: v►N Owner's Address: Date of Inspection: 17 T ® Name of Inspector:(please print) Raymond L. Camosse k Company Name: Homeinex Corporation Mailing Address: 102 Partridge Hill Road `' Charlton.lVIA,01507 Telephone Number: 508 248-4500" e CERTIFICATION STATEMENT `z I certify that I have personally inspected the sewage disposal system at this address and that the ' to tion 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: '' Date: �` I 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 the 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2—A Oil Owner: 1, �• Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D. A. System Passes: 15� I have not found any information which indicates that any of the failure criteria described in 310 CMR 3-3 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 required. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: C. Further Evaluation Is Required by the Board of Health: Conditions exist which requite 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 page nalm Board of Health determines In simordance with 310 CMR 15.303(1)(b)that the system is not functioning In a manner which will protect public healtlr,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 ar a salt marsh n 2. System will fail unless the Board of Health(bad Public Water Supplier,it any)determines that the system is functioning In a manner that protects the public healthy safety and environment: _ The system has a septic tank and soil absorption system(SAS)and die 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 r►f a private water supply well. _,,,_ The system has a septic tank and SAS and the SAS is less than 100 hxt 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.fur coliform bacteria and volatile organic compounds indicates-that the well is free frorn 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: I • Page 4 of I] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 111 , - Owner: Date of Inspection• p� D. System Failure Criteria applicable to all system: You EM indicate"yes"or"no"to each of the following for Wnspections: Yes No l� Backup of sewage into facility or system cotNponent due to overloaded or clogged SAS or cesspool _ -m� Discharge or ponding of effluent to the sdtfkft of the ground or surf 'e waters due to an overloaded or /� clogged SAS or cesspool Static liquid level in the distribution box atWl a outlet invert due to all overloaded or clogged SAS or rcesspool 'Liquid depth in cesspool is less than 6"bslo%.%invert or available volume is less than�i day flow _ Required pumping more than 4 times in the IM year NO___T due to clogged or obstructed pi Ws).times um s .N p P pe( ) Number l� Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool of 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.[This system passes U elk well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from polluElou,from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leas than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.]�(Yes/No)The system Laj&I have determined that one or more of the above failure criteria described in 310 CMR 15.30.3,therefore the system fails.The system owner should co t e go d of Health to determine what will be necessary to correct the failure. L Large Systems:. To be considered a large system the system most serve a facility with a design flow of 10,000 gpd to 15,000 6Pd• 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 fat 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 9 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. Page S of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 SOL C. Owner: 1��—I v a,` "w✓ Date of Inspection: 3 `� Check if the following have been done.You must indiSLW;'yes"or"no"as to ewh of the following: Yes No Pumping information was provided by the owner,occupant.or Board of Health _ Were any of the system components pumped out in the previous two weeks? 44 X Has the system received normal flows in the previous two week period? _ Have large volumes of water been introduced to the system recently Orr as part of this inspection? _ Were as built plans of the system obtained and biermined?(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 7 _ 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 tm 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 Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Pact C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)) Page 6 of)t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:—a�� Owner: E I �.-i Date of Inspection: `� d FLOW CONDITIONS RESII)ENTIAL Number of bedrooms(design): Number of bedrooms(actual):DESIGN flow based on 310 CM 15.203(for exampld: i to god x#of bedroom:): 3 Number of current residents:�. Does residence have a garbage grinder(yes or no)._ Is laundry on a separate sewage system(yes or no):' [if yes separate inspection required] Laundry system inspected(yes o(no): Seasonal use:(yes or no)._ Water meter readings,if avai le(last 2 years usage(god)): Sump pump(yes or no):._ Last date of occupancy: /,g ujs- wcl,J COMMERCIAL NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 66d Basis of design flow(seats/persorWsgketc.): 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 Sourc Pumping information:Records -P�l -� � v j,7 �J a12 i � d t"a' Was system pumped as part of the inspection(yes or no): F--1 If yes,volume pumped: al�lon��#Iow w 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 ani maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval . Other(describe): -Ze 4v, `'f/4y k fU22e Approximate age of all comp9se70date installed(ff known)and source of infortation: were sewage odors detected when arriving at the site(yes or no): Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q�5-1 �10;" Owner. —I L 1 Date of)Inspection: BUMDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _4o pVC_,other(explain): Distance from private water supply well or suction line: — ---- Comments(on condition of joints. venting,evidence of leakage,etc.); SEPTIC TANYok,(locate on site plan) I Depth below grade: o� Material of construction: concrete meta)_1'lb ftass_polyethylene ,_other(explain) If tank is metal list age:,_, Is age confirmed by a Cttd cgte of Compliance(yea or no): (attach a copy of certificate) Dimensions: ) l D Sludge depth:`_ f Distance from top of sludge to bottoms of outlet tee or 64e:ILL Scum thickness: ;a , Distance from cop of scum to top of outlet tee or baffle:�F e Distance from bottom of scum to bottom of outlet orbaffle: /(® How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle c onditi as related to outlet invert,evidence of leakage,etc.). ors structural integrity,l{grad levels ®U GREASE TRAP:,_(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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: l v ow Date of Inspection: n 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: _ Comments(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: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: '� (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition Qfpumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNIARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM UaORMATION(continua() Property Address: I n h 5L74 Owner: `� — Date of haspection: ��—)�► a�'�1 SOIL ABSORPTION SYSTEM(SAS):( (to.eate on site plan,euavation not required) If SAS not located explain why: ------------ Type leaching pits,number: leaching chambers,number: leaching galleries,number:_ r / ._.,C leaching trenches,number,length: / r leaching fields,number,dimensions: overflow cesspool, number: innovative/alternative system Type/name of tethrltilogy Comments(cote condition of soil,signs of hydraulic tailW�e,le etc.): vel of ponding,damp soil,condition of vegetation. CESSPOOLS: (cesspool must be pu"as part of inspeetion)(locate on sits 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: (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.): Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continue ) 3? sly Property Aaamw: 2 �< Owner. I Li U Daw of Inspection: WWI SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including des to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. L-0/d4/-r 10J Cc T� l Zr Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addreaa: V3('1 Owner: -I- < Q Date of Gupection: l 31 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)ell methods used to determine the hlkh ground water elevation: Obtained from system design plans on record-If chocked,date of design plan reviewed: Observed site(abutting property/observation hole witli(n 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach ocumentadon) Accessed USGS database-explain: You most describe how you established the high ground water elevation: �3� �� ` � ��-a��_ _�� -._ :S�POSTA6E- , HOMEINEX CORPORATION ; ,�, i -� Specialists ' .,�, $6�� L Inspection Sp v P i� 102 Partridge Hill Road Chariton, MA 01507 v cn 2 1 0 If A4 Member _ : '-= i _ -- 1! ) iEt1t iS ik'stlE� llSt1 7 ; tiiil tl ! !t ii i?j 1 ___ f / l i � l a I r _ __ . . _ � �- � �.�`�. � -. .� 3 { 7 ,, i ..� ,, V �� '� :� �.y. TOWN OF BARNSTABLE r c Ltk�A°�=i�� r A, MA .97 . SEWAGE ,VP�L`i ,E � -,-FR VIZLE ASSESSOR'S MAP & LOT S /O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size.) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: I U COMPLIANCE DATE:' Separation Distance,Between the: 1-�Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _ :Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet site or within 200 feet of leaching facility) Edge of Wetland and Leaching Faciliry (If'any wetlar. s exist within 300 feet of leaching t"aciliry) Feet Fur:ushed by bps r f�/�r✓�1 /YI�'TvW'/(� � rS+l�dir • r �NSf�e"TION q 1l Town of Barnstable P# SE,P 18 Ego Department of Health,Safety,and Environmental Services CC"Cb —i = Public Health Division "Date o. 367 Main Street,Hyannis MA 02601 GHLF� '�►� Date Scheduled SF`<Z100 1� Time.``U�d� Fee Pd. 10t�+fl^ T� Soil Suitability Assessment for SSew age Disposal Performed By: / �� M** Witnessed By: �e 4.w 1GJ 4T(Y1] I,tJGATION & GENERAL INFORM i. ON .. Location Address Owner' ame ! 'R'r Gow�^/1� Addres '�-J / J Assessor's Map/Parcel: C,� 1/�/� Engineer's Name , �/ . 20 /0'0 p 7,/I�4� NEW CONSTRUCTION (,' REPAIR l� Telephone# M I Land Use 7 � �� yrp Slopes(%)_!3Y0 Surface Stones 'Y t , , Distances from: Open Water Body uift Possible Wet Area-411 o ft Drinking Water Well R 1 Drainage Way*7 tt Property Line 410 R Other I R SKETCH: (Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) 6RIPW� CO�ftt&) Parent material(geologic) Depth to Bedrock dQ Depth to Groundwater: Standing Water in Hole: 17 Weeping from Pit Face Kkq Estimated Seasonal High Groundwater -7-7It MDt-lzACg:�> CR=10MR—�) n T R tNA`I ION FOR SEASONAL, GM VAT ttT' . Method Used. r Depth Observed standing.in obs.hole: in. 79epth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment R. Index Well# __.._..__ Reading Date:__.____ Index Well level. _ r` Adj.factor- Adj.Groundwater Level PERCOLATION TEST gat ' ..:: _ ririie Observation Hole# Time at 9" :Depth of Perc ((� 1 ` Time at 6" Start Pre-soak Time @ ' c I Time(9"-6") End Pre-soak . 5 M Nate Min./Inch � . r Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant t DEEP OBSERVATION �IOI,E LOG Hole t Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface on.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistencv.%Gravel) 1 .�o •:,.�,.,. • .. . ;.. )` �'•e,,..f • ,..., . . �'`n"t ,'� - ' , a`> _ tom` ". . DEEP OBSERVATION HOLE LOG H le# .. . Depth from Soil,Honzon Soil Texture Soil Color Soil Other Surface(in.) " ' (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. t �q' Consistency,%Gravel _ ... DEEP E}BSER�?ATION HOLE. .0 Dale ... . Depth from Soil Hori?�°n Soil Texture Soil Color Soil Other Surface(m.) fl (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.%Gravel o • ` b ' is �'` . t " S DEEP OBSERVATION HOLET0G Hole Depth from I Soil Horizon .Soil Texture Soil Color Soil Ot h er Surface(in.) friJSDA) I (Munsell) Mottling (Structure,Stones,Boulderes. Consigency,% ravel . Flood Insurance Rate Map: Above 5,00 year flood boundary Nu Within 500 year boundary No Y s� With _in 100 year flood boundary No Yes Depth of Naturally Occurring_Pervious Material z, 2 Does at least four feet of naturally occurring perviou merial exist in all areas observed throughout the area proposed for the soil absorption system? C If not,what is the depth of naturally occurring pervious.material? �_ Certification I certify that on lig, xpertis (date)I have passed the soil evaluator examination approved by the Department of Envqmenal Protection and that the above analysis was performed by me consistent with the required trainin and experi n e escribed in 310 CMR 15.017. Signature J Date No. jag,-- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for 30i,5pool opeum construction 3permit Application for a Permit to Construct( , )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. D_j J !xJ Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's N me,Add s ,and Tel Designer's Name,Address and Tel.No. 0 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1�.o 4 gallons per day. Calculated daily flow 10 gallons. Plan Date G Number of sheets Revision Date Title F / Size of Septic Tank_ I/ 5 DO Type of S.A.S. e C er S Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1� � /4 C n S IV 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 provisio e 5 pEnvironment de and of pl system in operati n un ' a Certif- cate of Compliance has be tied by s of th Sign — ate Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ;JF � _ :.... _• _ _ . .. tea. _ _ ee Entered in com ufer: f° ,.. THE COMMONWEALTH OF MASSACHUSETTS p , Yes ,PUS' BLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS W, Zipprfcatfon for Mfgpooat *proem Conmructfoo Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual-Components Location Address or Lot No. j +a/ Ownei's Name,Address and /Tel.No. Assessor'sMap/Parceli Installer's N me Add s ,and Tel N� Designer's Name,Address and Tel.No. ~ - L -j:>A ve A Sa st> (� nOType*dfBuilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �� 0 gallons. Plan Date Z 9 Number of sheets Revision Date Title / Size of Septic Tank 5 00 Type of S.A.S. x e AC S Description of Soil, 1 Nature of Repairs or Alterations(Answer when applicable) L d /P/9C we A01 d 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 Tit�e 5 oth Environment -Lodeand of pl� tbf system in operation u ' a Certif- cate of Compliance has been' ued by s of th f ..-02 j�0• Sign P Date Application Approved by Date i --- Application Disapproved for the following reasons �r 4 Permit No. t '�` Date Issued p i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CFRZI t th On-sit Sewa Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by 0 7 1 H o at r>J rl M4 A.1 e N e r e has constructed in accordance with theRprov4si s f/ ill and or D' osal System Construction Permit No dated Installer TT ( Otis r y o Designer , Vic" A S g ti.! The issuance of thi permit shall not be construed as a guarantee that the systnwfynction.as e�igne . Date lU InspectoMl. e Q No.ZQ '.- oD .�- Fee i v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS Mfigoot 6potem Conztructfon Permit Permission is hereby granted to Construct( )Rep r(��Upgrade )Abandon( ) System located at c ,'2 y� Wd , 11��'.r 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 o et d wit 'n three years of the date of t e Date: Approved by TOWN OF BARNSTABLE r L �1 �" Ma S�, SEWAGE # LOCATION -14 VILLAGE� AS/S►ESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY (type) � '� (size) NO. OF BEDROOMS 19 BUILDER OR OWNER f C C a�. 0 COMPLIANCE DATE: PERMIT DATE: Separation Distance Between the: 1 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist I=eet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlapds exist ' �" Feet within 300 feet of leaching facility) Furnished bye/� �° rMSPOC.177ON 0 i 31. �3l Ln, 7'0'F F a Cc • I A• TE rU Postage $ 0 Certified Fee y�iZ�!! � / Postmark O Return Receipt Fee ' y p (Endorsement Required) �s SEP 2 41009 O Restricted Delivery Fee r O (Endorsement Required) "' vs'Ps p Total Postage&Fees m � Sent To AMa £DNA Sfreet,Apt:No.;---- 4 or PO Box No. 5 3 C, --------------------------------------------------------------------------------------- o;ry teteAP� Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece • A record of delivery kept by the Postal Service for two years Important Reminders: • Certified Mail may ONLY be combined with First-Class Maile or Priority Maile. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt maybe requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery. ■ If a postmark on the Certif led Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present It when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000.9047 i SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION . ■ Complete items 1,2,and 3.Also complete A. Si ature item 4 if Restricted Delivery is desired. y Agent\ In Print your name and address on the reverse ❑ X e`6 so that we can return the card to you. B. Received by(Printed Name) i 4 C. Date,??Peli ry ■ Attach this card to the back of the mailpiece, or on the front if space permits. c.: D. Is delivery address different from to Yes t 1. Article Addressed to: If YES,enter delivery address No ❑No s � re S% 3. Service Type L O w 41-M ❑Certified Mail ❑Express Mail C hta - 1 ❑Registered ❑Return Receipt for Merchandise 601 Z6j ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (transfer from service labeo i 7007 30200001 3429 8547 PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 G7 i • Sender: Please print your name, address, ard ZIP+4 this "ax • CO I -zs I I ,r" 'x Townof.Barnstable ' 'IO Health Division W I I 200 Main Street O rn j Hyannis,MA 02601 00 q(tw t--AC— �1�fi7tf�}�}j�lii!Itffiiiti!11113�IISfi�il Yli27}i111f}71 t!}f.!}f 17� TOWN OF BARNSTABLE BAR-W P307 Ordinance or Rdgulation �iRNING NOTICE Name of Offender/Manager 1 140 4 4,,\1 4 Address of Offender MV/MB Reg.# Village/State/Zip //1 12 1 To('V�V' Business Name • am/p11 on 20!2-f Business Address Signature of Enforcing Officer Village/State/Zip i1A i 3 Location of Offense A-6, I �-t Enforcing Dept/Division Offense 4.-1 t 0164 -s Facts f.r- 1 0 i A'It) -1z- -w -,>If J?f t.-i4wto 94 HL-V4 This will serve onlyl as a*warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE f vb by 4„c,IJA4 LOCATION SEWAGE # 1` VILLAGE Ce;K�\/IUL6 ASSESSOR'S MAP & LOT 20� INSTALLER'S NAME 6z PHONE NO.�X�STu.1tti w SEPTIC TANK CAPACITY LEACHING FACILITYA ype) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERRy�3L,ic BuifteDGER-OR:0WNER V042M Czi x tu-4 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �-- �. � . . } , o � � � �� - : �', F � �� z �, � � ��S, �- �µZ� i . � � �o ' �� G,�� .-G _ ASSESSORS MAP: - �D� EST HOLE �O"GS NOTES : w PARCEL: � 1Q .. ;OIL EVALUATOR ; AV1 VI TNESS : rr I . VERTICAL DATUM: FLOOD ZONE: I^ [�T.. . ►��P�Lr�� _ I� �, 2 , MUNICIPAL WATER I AVAILABLE . I )ATE: ( ,�� / REFERENCE �111I "�j -- d 3 . SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT SYSTEM UNLESS N ERRCOLATION RATE: 2 mI t OTHERWISE NOTED . va' y ' C�+ Imo/ 4 . ALL PRECAST 1r ✓ - G, ' R CAST UNITS TO CONFORM WITH AASHTO : TH- I TN-2 5 . PIPE PITCH - I /4" PER FOOT UNLESS OTHERWISE NOTED . °` PI ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE WITH MA. ENVIRONMENTAL o CODE (TITLE V) ,AND LOCAL REGULATIONS . LOCATION MAP �6" = l,o;w�► 7 • CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES P N TRU O f u E PRIOR OR TO CO S CT ION . N . _. 31 Gol�-•PW1109 70 ve dl-I _ I, )L,q 1t�1t-l OF I H l'; ,�1,c �- ot,;�— � �p e�Cj _'��r "T�, I W f�� I.lu�.., ►�1 : �l��I�L. . ; I � �,��. U II t�jl I oa `� „ r, �I At 11�1 OCT it I SEPT I SYSTEM DESIGN , ' FLOW ESTIMATE I ). , (. r ;n 1v Oir , BELROOMS AT III GAL./DAY/BEDROOM GAL/DAY SEPTIC TANK V4� .' :y,:.. ;ink. ^:,±.:..",;s,y, "rora,r ""., "•Hxs;, • /' .. -. 97•+ , / GAL/DAY x 2 DAYSROO - ... .�... .. _. . ..�•�� fr�bS�T � ao GAL 99.9. \6 0' �• USE r 6` q � / .,.� GALLON SEPTIC TANK 2 . / G� A st ST9NE '„k jl ♦ Auk DRIVE I .. 0 I L ABSOfPT I ON SYSTEM z r. 1 0.7 � /` ' /.,. e��.�� ..,�,,.. r:,,,,�.w„ ,"12 /^I Ra/FNr• , 9a 9�a• `� .- , , ,t _. 1 ' t.'/ Pl,V�r. Bey, TaN.Nza TER ,T�j7�30 _ � . .,� •F•✓:M ^., ±'Nmyr+prartt+v+"M' ..n,,,,3ssxraw,+,.,,;,,n:r; ' DE`,.AREA: 10,90 a L, : py r covE'R BOTTOM AREA: � -� 1 10% �� , A,y,► • , 1 ,M1 / ter• •� !!ff ` . - �� ' co _ - �: , 9S.9 C QVT,lbSEPTC: SYSTEM SECT _ �. .r T All.l'� S .T1 •i?o14�IP •?< l l � 9l.S sNEP '"'�naa•r a --'W" `" •,r"pr +' S 40 U { — QROU D' u!'t t e A o i R ' � �.. may, „rr -.1!.n'� '•. .,,• ' " D .. ._ ,«• -. ....._,.. .__ ..., .� � aI :' •, . ...- �Q1r!6t r .., � - .__.._ _ , .... •.m .... -- .._ .,.., ,,..,.._-,... _- __, mow., .. . .-.._... k `S N, 97.0+ 77 0 0/0l MAX, E,.... r ROUND 1 ^( � t rf i r _ :i qr� Ib , ell 008 -. .. , + r ett;! 4. ( My �~ LEV , t' : lfll * ,. �� •, MAP 8 tT: I -- M 1i ,.. _ D-BOX f �� I CEL 102 - �_ GAL . , ELEV �>~ � � I1 / ,,...---•- p� ----r----.- C. EV ¢ 77� 6-Al� -ni I , : .•. �d�„-,rp.^:•• tea, F✓If;.:.,. :. � - -:, ; cr r c �_.p•\� �s'�C i I - "1 r��Y S I TE : AND SEWAGE PLAN LOCATION : ��''if �"f+ 1 5 i LAO ..�puM ? PREPARED FOR • , "(I 1:.. , .. .. _fit ..._ Q =1+ Dv- _Q_ ! UC SCALE: 1 -30 � r a . ► _.1IIl(1 --- 1. YM '.... _ � SC 'ALE : o i5 ao 60 k>9. .::._.., _... .. DAV I D B . MASON . R :S . .__ __u. .., DBC ENVIRONMENTAL DE5 I GNS D� JE : + DATE HEALTH AGENT EAST SANDWICH. MA ( 508)833-2177