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HomeMy WebLinkAbout0323 MAIN STREET (CENT.) - Health 3�' 2iIAIN ST.10ENTERVILLE A =208-ftT d�j UPC 12534 0 � N6.2-153LOR HASTINGS. UN PF 3 Oct 31 2016 10:57 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C 32�Main Street Prop My Address Anastasia Rogers Owner Owner's Name ~-+ information is ✓ required for every Centerville MA 1 02632 10-28-16 p page. Cityfrown 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 „�tl�lllllff►►�,��„ filling out forms U/4 119 9/ ������� IN OF A1q on the computer, ``��t�f�,.• S4Ci���i use only the tab 1. Inspector: o? yc key to move your JAMES u''' cursor-do not James D.Sears '0: use the return �.q E—A P-q ;y key. Name of Inspector Capewide Enterprises, LLC '.,_�;•oF �° ' -' Company Name�5 1 N SPEG�o1\ 153 Commercial Street �'''���nunui110%`��� Company Address Mashpee MA 02649 Citylrown State Zip Code 508-477-8877 S 1623 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 10-28-16 pectors 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 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. l5ins.doc-rev.6115 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Oct 31 2016 10:58 Jim The Inspector Man 5085349919 1 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 329A Main Street Property Address Anastasia Rogers Owner Owner's Name information is required for every Centerville MA 02632 10-28-16 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: The system is a 1000 Gal. Tank D Box-Pit and two chambers. 13) 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): ,lns.doc•ray.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 o117 Oct 31 2016 10:59 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts . Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329A Main Street Property Address Anastasia Rogers Owner Owner's Name information is required for every Centerville MA 02632 10-28-16 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. 13) 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 wiil 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 15ins.doc•rev.6116 Title 5 Official trrspWion Form:Subsurface Sewage Disposal System•Page 3 of 17 Oct 31 2016 10:59 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 329A Main Street Property Address Anastasia Rogers Owner Owner's Name information is required for every Centerville MA 02632 10-28-16 page. City/Town State Zip Code Hate 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 El ® Liquid depth in is less than 6" below invert or available volume is less than '/2 day flow zi+C'f/I V t5ins.cioc-rev.6116 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Oct 31 2016 11:00 Jim The Inspector Man 5085349919 page 24 • i Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments w 329A Main Street _ Property Address Anastasia Rogers Owner Owner's Name information is Centerville MA 02632 10-28-16 required for every 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. I ❑ ® 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 watil 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- 10,00Dgpd. ❑ ® 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 I I of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Oct 31 2016 11:00 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 329A Main Street Property Address Anastasia Rogers - Owner Owner's Name information is required for every Centerville MA 02632 10-28-16 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 tsins.doc•rev.an 6 Title 5 ONicial hspection rorm.Subsurface Sewage Disposal System-Page 6 of 17 Oct 31 2016 11:00 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . r 329A Main Street Properly Address Anastasia Rogers - Owner Owner's Name information is Centerville MA 02632 10-28-16. required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box- Pit and two chambers. 0 Number of current residents: 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.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2 015-1,,000Ga's g � y g (9p )�� 2015-1,000 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): i 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. tSins.doc-rev.6116 Title 5 Official hspaction Form:Subsurface Sewage Disposal System-Page 7 of 17 Oct 31 2016 11:01 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329A Main Street Property Address II Anastasia Rogers Owner Owner's Name information is required for every Centerville MA 02632 10-28-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: 2009/2011 12014 i Was system pumped as part of the inspection? i ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping. Type of 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): wns.Goc•rev.8116 Title 5 Officia Inspection Form:Subsurface Sewage Olsposal System•Page 8 of U Oct 31 2016 11:01 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 329A Main Street Property Address Anastasia Rogers Owner Owners Name information is Centerville MA 02632 10-28-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Approximate age of all components, date installed (if known) and source of information: Tank and pit na/ D Box and chambers 2000 permit#2000-269. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22 Depth below grade:p g 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.): Pipeing is 4" PVC SCH - 40. Septic Tank(locate on site plan): 11" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 2 t5lns.doc-rev.6/16 Title 6 Official Iispection Form:Subsurface Sewage Disposal System•Page 9 of 17 Oct 31 2016 11:02 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • . 329A Main Street Property Address Anastasia Rogers Owner Owner's Name information is required for every Centerville MA 02632 10-28-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 28„ Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt Tape 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.): Tank at working level. Tank and covers at 11" below grade. In and outlet Baffle's. No sign of leakage or over loading. Grease Trap (locate on site plan)- i Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins.doc rev.6116 Title 5 Official Inspection Form:Subsurlaca Sewage Disposal System•Page 10 of W Oct 31 2016 11:02 Jim The Inspector Man 5085349919 page 30 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 329A Main Street 190_- — Properly Address Anastasia Rogers Owner Owner's Name information is Centerville MA 02632 10-28-16 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �I 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 tSins.doc•rev.6116 Title 5 OfUcial Inspecllon Form:Subsurface Sewage Disposal Syslem-Page 11 of 17 Oct 31 2016 11:02 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329A Main Street Property Address Anastasia Rogers Owner Owner's Name information is required for every Centerville MA 02632 10-28-16 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 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 Box is 16"xl6"-8" below grade. Box is clean and solid wltwo line's out. No sign of overloading or solid carry over, PumpChamber locate on site plan): ( P ) 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 order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins.doc-rev.6116 Title 6 Official Inspection Form;Subsurface Sewage Disposal System•Page 12 of 17 Oct 31 2016 11:02 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts. Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329A Main Street PrDperty Address Anastasia Rogers Owner Owner's Name information is Centerville MA 02632 10-28-16 required For every page. CitylTown State Zip Code Dale of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 2 ❑ leaching galleries number: I ❑ 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 pondingi damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Precast pit. and two 500 Gal. dry well chamber's•wW stone. Pit and cover at 38" below grade, clean and dry. Two 500 Gal.dry well's w/4'stone. Chambers and covers 28" below grade. Chambers are clean and dry. Wall's like new. 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 i5ins.doc-rev.6f16 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Oct 31 2016 11:02 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329A Main Street Property Address Anastasia Rogers Owner Owner's Name information is required for every Centerville MA 02632 10-28-16 page. CitylTown 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.): 15ins.doo•rev.6/16 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Oct 31 2016 11:03 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329A Main Street Property Address Anastasia Rogers _ Owner Owner's Name information is Centerville MA 02632 10-28-16 required for every page_ City(Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage dispo;ol.system,;�ncluding ties to . at least two permanent reference landmarks or benchmarks. Locate all wills 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 X3 /3-J " �7 3C' r, 38JA L 0 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15,01 17 Oct 31 2016 11:03 Jim The Inspector Man 5085349919 page 35 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329A Main Street Property Address Anastasia Rogers Owner Owner's Name information is Centerville MA 02632 10-28-16 required for every page, City/Town State Zip Cade We of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar j ❑ Shallow wells N� 15,+ Estimated depth to igh ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health- explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation. Lot and area high Abutting area 15'+ no G W Bottom of leaching at F b6low grade. Before filing this Inspection.Report,please see Report Completeness Checklist on next page. l' t5ins.doc-rev.6/16 Title 5 official inspection Form:Suosurface Sewage Disposal System•Page 16 of 17 Oct 31 2016 11:04 Jim The Inspector Man 5085349919 page 36 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 329A Main Street Property Address Anastasia Rogers Owner Owner's Name information is required for every Centerville MA 02632 10-28-16 page. Cityfrown State Zip Code Date of Ihspection 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 AsBuilt Page 1 of 1 r TOWN OF BARNSTABLE t aCe �lN" AC LOCATION 3 9 A A4 A/* sr_ SEWAGE M 2-6001'� ' VILLAGE G eA/feX V 11 f ASSESSOR'S MAP&LO _da—dy ` INSTALLER'S NAME&PHONE NO. F t , J SEPTIC TANK CAPACITY / 0 O 0• /-'/T 0, /.2 l LEACHING FACILITY: (ty ) ,Cold ChAAt13eR's (size) 6700 6.tL NO.OF BEDROOMS_ BUILDER OR OWNER rPERMTTDATE: COMPLIANCE DATE: l Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility- Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C� F__I o t http://issgl2/intranet/propdata/prebuilt.aspx?mappar=208117&seq=1 11/4/2011 No. nQ Fee $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for Migpoml *p5tem Con.5truction Permit Application for a Permit to Construct( )RepairXX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 2 9 A Main Street Owner's Name,Address and Tel.No. Centerville,Mass. 02632 Richard W. Chils Assessor'sMap/Parcel- f') 6 / l0 329A Main Street Centerville,Mass. Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 02632 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: DwellingXX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other 'I�ype of Building Res No. of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 gallons per day. Calculated daily flow 3 X 1 1 0=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 10 0 0 Type of S.A.S. 1000 gi t Description of SOH2 Loamy sand to medium fine sand. Nature of Repairs or Alterations(Answer when applicable)Adding 1 —distribution and two 500 gallon leaching chambers packed in 4 ' of 1 '—a" stone 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 Certifi- cate of Compliance has been issu by this o of H alth. Signed Date 4/6/0 0 Application Approved by Date.5-- A— W Application Disapproved for the ollowr g reasons Permit No. .1e2d22 - 3-6 P Date Issued 04 No.'ono - L/� '4' - $ 5 0.0 w Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Mioomt *pgtem Congtruction Permit , Application for a Permit to Construct( )Repair]{X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 2 9 A Main Street Owner's Name,Address and Tel.No. Centerville,Mass. 02632 Richard W. Chils Assessor'sMap/Parcel '; 329A Main Street Centerville,Mass. z 6) Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 02632 J.P.Macomber & .Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass.02632 Type of Building: DwellingXX No.:of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) °- Other Type"of Building Res No.of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 gallons per day. Calculated daily flow 3 X 11 0=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 10 0 0 Type of S.A.S. 1000 Di t Description of Soil Loamy sand to medium fine sand. Nature of Repairs or Alterations(Answer when applicable)Adding 1 —distribution and two 5900gallon .leaching chambers packed in 4 ' of 11" stone. 1p 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 Certifi- cate of Compliance has been issued by this oar f..;H.a 4 00lth. 6 Signed ,, � .., Date � � Application Approved by �` Date,r — Application Disapproved for the ollowi g reasons t� _. Permit No. a0e22— 1.(o q Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS certificate of Compliance . THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaied4X )Upgraded( ) Abandoned( )by J.P.Macomber & Son Inc. at 329A Main Street Centerville,Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.,ROW— dated -I Installer J.P.Macomber & Son Inc. Designer J--P.Macomber Sgit iTnc-,\ n The issuance of this per h 1 nt�t be construed as a guarantee that the�systernlwill ftzncti6n ash'elsig-�n`efdgl Date Inspector r "'11 X11-� � f No. 26nrf ----Fee $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS � a i6o0ar *pgtem Construction Permit Permission is herebyranted to Construct )Repair Upgrade( g ( ) P � � Pg ( )Abandon System located at 329A Main Street Centerville,Mass. d' 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 permit. Date: Approved by , c• IT .;i 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) LioseAh P.MacomhPr ,-rr , hereby certify that the application for disposal works construction permit signed by me dated 4/6/0 0 concerning the property located at 329A Main Street Centerville,Mass, meets all of the Mowing criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will Et be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable) • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation '/ +the MAX. High G.W. Adjustment. 2F 3 DIFFERENCE BETWEEN A and B / SIGNED J)t, �l DATh;4/6/00 [Sk teh oposed plan of system on back]. q:health fo cen f .. `I a. � �>--. 11 I O �( h r ? , 66 'down of Parnstable Subdivision Plz. h � J` Planning Board ,. . . .' " .Rick and=�4 •Childs ;Lnwood �Rickex*,.,,Qhgirtnan•.' Centerville... Sass.. WhAis, 14ass•.. Gentleman s �« "The ward -of flea.lth `agpraVes this subdivisianka presented ! rovidecl t iat Tvwn 'hater i� made available to each individual -lot. to ns of:`se a wa e° di s �o`s l s`.stems "ust be su'br�.ttted to and approved 'by the Roalth Depart`nent before c©rstrii6tion can'be s'tarted.on each individual lot... '� `a a Y.}' .L >?.i. t ''4 1'" Y , r, - �fr ;,. ,_•' t {., _ s ! { ,, '. f � - t .� of I �•. •� .y��/ • r./{J�/_%/ .� e,• ay Eoard Of•Beal h ! � " ' +„ 1.r f a • • "!.. y. r •« Y y' v • • .` " . - .... . .•,. • a .. V-- 4Le, HOWARD W SEARS, Clerk ` of Ibc "own 0E-Bornstobfe Moss. hereby rerlify thotPOILL CENTS ILLS. e.no7icc of oppr-�40 oJP//? p/ors by 'tl7e . � , r,,► o Balwsto,61e P/c7r'ni�?q 60' ar-cl hits bean received a7PC/recur _,)eolof1'hi;p off CC and no opoeol. wos -'ccerwcc/C141r.,r'�the rwen ty e%iy5 r;dx t after- - ` Sl!C i I''l3C6! t 00/7 r'eCOrdin o�dOic�NofiCe P 9 KEY. MAP 13 1966 SCALL OF MiLws Dotc JUL o ,L ` Towrw C4.eAajj0c -� vs.C3eo•Su�vQY NY.a►>vNg , t4 � .�y /C�er/i•Fy rhot 1`his p/an lwcr.9 moa�C J� accca one with the Bcar-nsfobte .A/on4w* E card ir�sTruclions and tlxaf the pet monen� a poinfs `s�iown on this p/ors or�r ir�exis�`onCC '� o. ors the cyrou 7c( i0o2a.I966 G. - . Surveyor" 0�8 O' _The 20 1�_ Wd_y_,Sfo be us�'dinc mo n r �? wl/b 1`he .8ruce_A. Besse, cf ux. rce l Q ad /ofs/_ 2-ors 3 0 Q1' S. ra Ai r �,� •�p� Za%5 f I Rai/6ew C-^n efux. . -yi _ ohc �c Lone, Cen tervil� � "8ri %f its /Q 400 ° 24 400 r rea �. _ _AV O-�, h A.Rulh n S'E er-So 7 Q �j• � .38Ash larval S� M� S, Lpf 3 6 . Taun ton, Mass. " vX_ APPROVAL I RMUIREt) UNDEIR THE SUIDIVUION CONTROL LAW. TOWN Of 'BARNSTABLE PLAN!1ING BOARD - DATEJUN 2 01966 "� uBDIvISION PLAN j LAND IN CEN-rF ZV1LLE MASS. 3 13ELC>Nd(Ne TO R t CHARD W. C N i LID SCALE 1.iN= d0F APR, 2519 INELSON `k'� { RICHARD tc ••� c? �• eEARsc H 1. A.w Nac_so" SEARSI~ -PIC+.iARD LAW SUP.VaYORS CmwrF_Rv1 LLE.,MASS. 5`!0 F. 1 • - +x'�tt ..act . �WY „I L I I _ ' ffLL ' / • Clerk a fhC a° a 1F4t.L p r� Moss. hereby c�erti�Y thot Town O�Bornstoble, o v llbc nofce of oppr-over/ oi`11?1s p/on by .t*e •�j ,�'i�,� �. �.,' �� Bor .�lFob/c P/ori,�-�inq Boar hos been receivea(: �,�cu5; o�. c�r�c• recorc�cal ofrhis oirf ce and no o�ooecy� wos �, 1, ,�` r , 1,ccc i Yed dur'/' 1 he -1w&n f dos r7ax t ofifer•- ssf r - ng Y Y such �sce:p t-c-n d r-ecor C)1f7 o)'60 * Notice EV 4►P Dort. o E F M SCALE ��$ � To w�iv Cc.Etc � . U•S.GrEA.Su�irtEY. NY ►rNNg ✓G�rfi f'y yhcof this p%rr was moo�c occorct br>c� wiA47 • the f3arnsfoib/e, h/onr�ir� S� E c.7rd /i� r'ucf'ons coed tfx.�t hePermonenf * . ' po/nfs s/?oW/17 on Yhie P/Orl or$ ,rpeX/sfonce s ' F on the f Q o r crtwrdt4 N 7: Apr, 6,/966 Sur vCyorCIS c o D F --� -,- p =f1 L.P. ^. co 4- 7- Zo-cS P� !0 Aoffhew C. Fi*n efux a o. I• o , . �.v. z 6rioh c%f�c Lone, cen icl-V ,(? A o , iQ 400 24 400 post Ce`'re v ��c �Sp;� : •• �� A Ruth Syrn0n //� 'Eer-S 7 38•Ash font;/ S� Miss, on �f 3Q6 ' Taur tor;, Mass. APPROVAL I IieQUIREC? UNIrfN THE .50DIVII-AQN,CONTRC t-LAW.` .� TOWS# OF BARNSTAELE; to PLAT+ tijNG BOARD SUB01VISION PLAN J, DA LAND IN CENTEFZ�ILL.E . MASS. �, 3 BELONG(SiG To R I CHAPUD W. CHI I Of i:'4P w cyG � SCALE 1 IN= d0f: APRIL 25•4960. ptc SON n+ . :� RC HARD w . �^-� ,`' u �` ry -' &L-s ON ESEARSE 'K fc+4ARo LAW, SURVEYOl�.S ca 6%AfiSc = ) N c3 •,� F,n. 1277fi� t CENTERVI L.L.E.,MASS. ,5 Su t( ,