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HomeMy WebLinkAbout0470 MAIN STREET (CENT.) - Health 470 Main Street i r Centerville A= 208— 131 S M E A D No. H163OR UPC 10259 smead.com • Made in USA► 3 � ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C+i M °�< 470 MAIN ST( MAIN HOUSE ONLY) Property Address Xr DONAHUE ' Owner Owner's Name 1�6 information is "*t required for CENTERVILLE MA 02632 8-23-17 rg? every page. Cityrrown State Zip Code Date of Inspection y Inspection results must be submitted on this form. Inspection forms may not be altered in any�-? way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority rl 8-23-17 Inspectors ignature 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 sp 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy� 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Cityr 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 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: AT TIME OF INSPECTION THE SEPTIC SYSTEM SERVING THE MAIN HOUSE MET OR EXCEEDED ALL PASSING REQUIREMENTS. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USAGE. DESIGN FLOW AND BEDROOM COUNT ARE FROM OWNER AND ATTACHED PERMIT. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owners Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owners Name information is required for CENTERVILLE MA 02632 8-23-17 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. ❑ ® 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y� 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: A 1500 GALLON SEPTIC TANK D-BOX AND 5 GALLEYS MAKE UP THIS SEPTIC SYSTEM ACCORDING TO PERMIT AND AS-BUILT CARD. Number of current residents: 2 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2016--186 GPD 2015--153GPD. I DID NOT ENTER THE HOUSE SO I DO NOT KNOW IF THERE IS A DISPOSAL OR NOT. THERE WERE 2 INLET PIPES INTO THE SEPTIC TANK AND ACCORDING TO THE HOME OWNER THERE ARE NO OTHER KNOWN PIPES EXITING THE HOUSE. THE HOUSE IS VERY OLD BUT IT DOES NOT APPEAR THAT THERE ARE ANY UNKNOWN PIPES OR DRYWELLS, CESSPOOLS ,OR SEPTICS 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: AUGUST OF 2017 Date Other(describe below): General Information Pumping Records: Source of information: OWNER STATED REGULAR PUMPING LAST TIME WAS MAY 12 2017 BY CAPEWIDE ENTERPRISES. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1500 gallons How was quantity pumped determined? RECEIPT Reason for pumping: MAINTENANCE 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 S of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1993 PER PERMIT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 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: 1500 Sludge depth: VERY LIGHT t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Cityfrown 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 Scum thickness TRACE AMOUNTS OF SCUM Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK WAS PUMPED IN MAY OF 2017. TANK WAS CLEAN WITH METAL COVERS FOR SOME REASON. ( NOT TO GRADE) Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 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.): 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•3113 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 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LOOKED TYPICAL FOR ITS AGE WITH SOME CORROSION. BOX WAS FUNCTIONING PROPERLY AT TIME OF INSPECTION. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): •If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 5 ❑ 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.): ONE GALLEY WAS OPENED AND WAS DRY AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE. THERE WERE DAMP SOILS IN THE BOTTOM. SYSTEM IS FROM 1993 BUT HAS MOSTLY ONLY HAD 2 PEOPLE LIVING THERE FOR QUITE SOME TIME. THIS REPORT CAN NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every 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: GREATER THAN5 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: OBSERVED SITE AND INSTALLED SEPTIC SYSTEM IN GENERAL AREA RECENTLY. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 • f ', Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 470 MAIN ST( MAIN HOUSE ONLY) Property Address DONAHUE Owner Owner's Name information is required for CENTERVILLE MA 02632 8-23-17 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 tits/11/i NN4 ll:Ub bbH/lb49V9 h_J.JAA I JLPRLK rHUt t9'6 BOARD OF HEALTH TOWN OF BARNSTABLE 770 R .nu d alndii►idosl sn*8e Dnpow a 44 t )Oe bi at _ e Ite_ - WA$l anmenml Code at amma ed in has been insullod in ammdenm With the provWons of 11TLRCN dazed . the application for D'ss 0W World Cvnsaucdcn Pgfmit No. THE ISSUANCE OF THIS CI�TFICATE SHALL NOT A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _ PATE fnspecmr . .. • ••...s• .ram •_. - ...._ _ .__ ..... CP7/�� ;V } OF BARNSTABLE - 7 © d ssaacs T3 0 LOCATION - VILLAt E��wT�'/ts+/�1�' ASSBSWIt'S kAP G LOT01 INSTALLER'S NAME Si PHONE NO, - SEPTIC TANK CAPACITY LEACEMNO FACILITY-.(type) cr-j'Age YS �. rr-- no.Op BSpRMUS PRIVATE WSLT.OR PUBLIC WATSR,._--- BUfIWi3R OR 01i►IE1gR_ bAT$#ZRJUTiii V •��� COI�LiAiECC81,SSUED�_�, VAIRIANC$GRANTED: --• ._. _.Yam. �.. � .. ._. � _ r5 �.•' � Pao t, iS�Tia�r (0 No.... ....... FEB.... ............ THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH 6l m=bbCarr n TOWN OF BARNSTABLE to Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ,r Ile ......................................... ------------------................. ---------------------------................o-r'--Lot----N-•o.--•---------------------------------------- Lorcti -:\ddn•sa .. ........=.....T...................wf.. ?--------------•. owner Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms.........___________------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures _---------------------- -----•-------•--------------....----•-•--- ................ W Design Flow............................................gallons per person per day. Total daily flow--------------_.............................gallons. WSeptic Tank—Liquid capacity------------gallons Length---.__--__--_-- Width.........:...... Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................--- Total leaching a rea....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.............._----- Depth to ground water........................ G%, Test Pit No. 2................minutes per inch Depth of Test Pit--- ................ Depth to ground water........................ 0 Description of Soil........................................................................................................................................................................ -----•......................••-------------.....-------•------------•---._...---...----...------------------- -- V Nature of Repairs or Alterations—Answer�yhen applicable._._.% ..._1..�..... ___ ..___.. 5v �_ �` _ --.�....5................................................. .O_'�e.... k�_.c ..... .- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl 11 ia has=issuedthe �- ApplicationApproved By . ...... ...... . ..... .. .. .......... .. ... .. ............... :............................... ................ .................. Dace Application Disapproved for the following reasons: ............ . ....................... ................................................................. ............... .......... ........................................................... .................................................................................. ... .. Dare Permit No. ?... ........ .. Issued ....... ... . - Da e ,— ___——— — — — — — — — — a0a a No .... FEE Fps........,...�............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ApPration for Diripwial Worth Tomitrnrtiori rrrmtt t � Application is hereby made for a Permit to Co nstruct ( ) or 1tcLxtir (,, an Individual! Sewage Disposal System at: Lo,:,i -Address / or Lot No. / O y�9 /1 v C ... b.. -----•----•-•---•---••-------••-------•---••----•.......................... ......... .............°......---•--•---.......--•--------•-••---.......---------•--.....---•-•--- Owner Address � s- Installer Address Type of Building Size Lot............................Sq. feet ,-� Dwelling—No. of Bedrooms--------- -----------------------------------Expansion Attic ( ) Garbage Grinder ( ) 114 Other—Type of Building --------------------- ------ No. of persons---e'-- ------------------- Showers ( ). — Cafeteria ( ) dOther fixtures --------------------- -------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length------------- -- Width................ Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------- ----- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........ ................................................................. Date..------------.....-----------.......... W Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 •---•-•--••--•.........-•---••--------••-......----•-••-----••-...---••••........................................ ...............•----...................._. 0 Description of Soil...............................................-------•------------------------------------- .................................. .....------•-----....---..•... V .............................................. ------••••-••-•••-•-•------•--•-----••--------------•-----•-•••-------•-•••-•-•--------....---------•-•--••----•-•--•---•------------•.............-•---•. W ..--•------•--......-•-----•---------•----------•-------------------------------------------- ----------------------- - .................................................------- U Nature of Repairs or Alterations—Answer hen applicable_---- --------7%___.. ........................ -•--• ---••-•-----•.............. ......_....---.....--•-----................ Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance-has been issued by-the boardIo-he lth: Signe ...... ... .---``Z- ................................... l `!� Dare ApplicationApproved By :, �/�� �%� ..... Y fi.......V: ..L.....> .................................... .................D�te.................. Application Disapproved for-the following reafonr: -- --- ----------- ---..................--------------------------------------..-.................. /....... ... ............................................................................. ..............'-.......................................................................................-.... Dare Permit No. 1( _ ................./_ ..... Issued ........ .�... 6 ..... ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (fertifiratE of Toutplianre THIS IS T 0-, C RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired b �G i InscJlrr ^ at .......G . .�..�� ............................................................. / "' ... -�i.... ... �2/T ................. .F'........................................................... has been installed in accordance with the provisions of TITLE �of,. he qSate� vironmental Code as described in the application for Disposal Works Construction Permit No. ........_.....................�.......-.. �.. '..-. dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ..............��.'. .Y..� ..�............. ................ Inspector ...... ----- --- --------- ........ ...... ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE � '�� .t_. FEE....�.�........... No. .... Raposttl orko Toriotrution "rrntit Permission is hereby granted /---•-----C•-�•---------•------------•------••-••----•...............•-••......•...... to Construct ( ) or Repair (--)an Individual Sewa�,e Disposal System I� �\ Street " ...- as shown on the application for Disposal Works Constru tton Permit No.I.�'�_...__l-p/u-Dated..�._.���_.__...ld._.'... Board of� ealth s DATE------------- P ? - I� FORM 36508 HOBBS✓!WARREN.INC..PUBLISHERS cm TOWN OF BARNSTABLE LOCATION 24',_? // �� SEWAGE # . ell 6 VILLAGE CZ: .- 7,E Zl (//le� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE SEPTIC TANK CAPACITY S� LEACHING FACILITY:(type) // Y� (size) NO. OF BEDROOMS `S PRIVATE WELL OR PUBLIC WATERy/ 'BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 23 VARIANCE GRANTED: Yes No l � � �� 3£ � s� �� � AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction#1169857 Page 1 of 4 A Massachusetts Department of Environmental Protection 1100323190 '' - BWP AQ 04 (ANF-001) Asbestos Project# r w ! Asbestos Notification Form ❑ Project Revision ❑ Project Cancellation f T,. A. Asbestos Abatement Description 1. Facility Location: WELCH 470 MAIN STREET a.Name of Facility b.Street Address BARNSTABLE v MA 02632 000-000-0000 c.City/Town d.State e.Zip Code f.Telephone X IX g.Facility Contact Person Name h.Facility Contact Person Title Instructions 1.All Workslte Location: 1BATHROOM sections of this form must i.Building Name,Wing,Floor,Room,etc. be completed in order to comply with MassDEP 2. Is the facility occupied? �a.Yes l b.No notification requirements of 310 CMR 7.15 and 3. Is this a fee exempt notification(city,town, district, municipal housing authority,state facility, or owner- Department of Labor occupied residential property of four units or less)?M a.Yes FE-11 b.No Standards(DLS) notification requirements 4. Blanket Permit Project Approval, if applicable: of 453 CMR 6.12 Approval ID# 5. Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: MassDEP Use Only Approval ID# 1 6.Asbestos Contractor: Date Received INEW ENGLAND SURFACE MAINTENANCE LLP 1850 WASHINGTON ST a.Name b.Address WEYMOUTH MA 702189 781-337-2117 c.Cityrrown d.State e.Zip Code f.Telephone C000196 h.Contract Type: yp ©1.Written ❑2.Verbal g.DLS License# 7. IJOHN P.VALLIQUETTE S060773 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8. IRICHARD K.BOWEN MO610 44 a.Name of Project Monitor b.DLS Certification# 9. IFLI ENVIRONMENTAL INC 000144 a.Name of Asbestos Analytical Lab b.DLS Certification# 10.01/30/2020 01/30/2020 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 8-4 N/A c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11.What type of project is this? a.Demolition FEZ]b.Renovation �c.Repair F111 d.Other-Please Specify: 12.Abatement procedures(check all that apply): I-1 Glove Bag Qb.Encapsulation Ec.Enclosure d.Disposal Only e.Cleanup f.Full Containment �g.Other-Please Specify: https:Hedep.dep.mass.gov/eDEP/WebFonns/AsbestosBWPANFOO1.aspx 1/29/2020 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction#1169857 Page 2 of 4 13. Job is being conducted: FRIa.IndoorsFE�] b.Outdoors 14 a. Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed, or encapsulated: 25 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct,Tank c.Transite Pipe Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation 25 0 e.Transite Shingles 0 0 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f.Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. Jr.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j.Insulating Cement 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15. Describe the decontamination system(s)to be used: AS REQUIRED 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) AS REQUIRED v 17. For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: NEAL MCMORROW INSPECTOR a.Name of MassDEP Official b.Title of MassDEP Official 01/29/2020 ISAW 20-074 c.Date of Authorization(MM/DD/YYYY) d.Waiver# ON-LINE ON-LINE e.Name of DLS Official f.Title of DLS Official 01/29/2020 28111-2020 g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A-F apply to this a.Yes; b.No project? B. Facility Description 1. Current or prior use of facility: IRESIDENCE 2. Is the facility owner-occupied residential with 4 units or less? a.Yes b.No 3. IWELCH 470 MAIN STREET a.Facility Owner Name b.Address CENTERVILLE MA 02632 000-000-0000 c.City/Town d.State e.Zip Code f.Telephone 4. IX I ix a.Name of Facility Owner's On-Site Manager b.Address MA 00000 000-000-0000 c.City/Town d.State e.Zip Code f.Telephone 5. IX X a.Name of General Contractor b.Address https:Hedep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANFOOI.aspx 1/29/2020 AQ 04 -Asbestos Removal Notification Form ANF-001- Transaction 41169857 Page 3 of 4 MA-70000 000-000-0000 c.Cityrrown d.State e.Zip Code f.Telephone g.Contractor's Worker's Compensation Insurer X 01/01/2021 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 11400 12 a.Square Feet b.#of Floors Note:Temporary storage of Asbestos containing C. Asbestos Transportation & Disposal waste material is only allowed at the place of 1.Transporter of asbestos-containing waste material from site of generation: business of a DLS a.Directly to Landfill or b.To Temporary Storage Location/Transfer Station licensed Asbestos FE] contractor or a transfer station that is permitted NEW ENGLAND SURFACE MAINTENANCE,LLP 850 WASHINGTON STREET by MassDEP and c.Name of Transporter d.Address operated in compliance WEYMOUTH MA 02189 781-337-2117 with Solid waste e.City/Town f.State g.Zip Code h.Telephone Regulations 310 CMR 2 If a temporary storage location/transfer station is used, list name of transporter of asbestos containing 19.000 waste material from temporary storage location/transfer station to final disposal site: RED TECHNOLOGIES 110 NORTHWOOD DRIVE a.Name of Transporter b.Address BLOOMFIELD CT 06002 860-218-2428 c.City/Town d.State e.Zip Code f.Telephone 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: RED TECHNOLOGIES 1203 PICKERING STREET a.Temporary Storage Location Name b.Address PORTLAND CT 06480 860-342-1022 c.Cityrrown d.State e.Zip Code f.Telephone 4. Name and location of final disposal site(asbestos landfill): MINERVA ENTERPRISES I MINERVA a.Final Disposal Site Name b.Final Disposal Site Owner Name 9000 MINERVA ROAD c.Address Note:Contractor must IWAYNESBURG OH 44688 330-866-3435 sign this form for DLS d.City/Town e.State f.Zip Code g.Telephone notification purposes D. Certification "I certify that I have personally examined IKEN FURTNEY I KEN FURTNEY the foregoing and am familiar with the I.Name 2.Authorized Signature information contained in this document PARTNER 01/29/2020 and all attachments and that,based on my inquiry of those individuals 3.Position/Title 4.Date(MM/DD/YYYY) immediately responsible for obtaining 781-337-2117 INESM,LLP the information,I believe that the 5.Telephone 6.Representing information is true,accurate,and 1850 WASHINGTON STREET YMOUTH complete.I am aware that there are 7.Address 8.City/Town significant penalties for submitting false information,including possible fines and MA 02189 imprisonment.The undersigned hereby 9.State 10.Zip Code states that I have read the https://edep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANFOOI.aspx 1/29/2020 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction#1169857 Page 4 of 4 Commonwealth of Massachusetts regulations governing asbestos abatement(453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection),and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." https://edep.dep.mass.gov/eDEP/WebForms/AsbestosB WPANFOO 1.aspx 1/29/2020