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Home My WebLink About0340 MAIN STREET (CENT.) - Health .%340 MAIN STREET, LENTERVILLE A= 208 044.001 IN UPC 12513 NO, 53LOR HASTIH6s, errs 1/7 Tenant Certification Form 340 R00 s �" Required Federal Lead Warning Statement )Y+ L Housing built before 1978 may contain lead-based paint. Lead from paint,paint chips,and dust can pose health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing,lessors must disclose the presence of known lead-based paint and/or lead-based in p p s d paint hazards in the dwelling.Lessees must also receive a federally approved pamphlet on lead poisoning prevention. The Massachusetts Tenant Lead Law Notification and Certification Form is for compliance with state and federal lead notification requirements. Owner's Disclosure (a) Presence of lead-based paint and/or lead-based paint hazards(check (i)or(ii)below): (i) Known lead-based paint and/or lead-based paint hazards are present in the housing(explain). (ii) Y Owner/Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the housing. (b) Records and reports available to the owner/lessor(Check (i)or(ii)below): (i) Owner/Lessor has provided the tenant with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing(circle documents below). Lead Inspection Report; Risk Assessment Report; Letter of Interim Control; Letter of Compliance (ii)--XI—Owner/Lessor has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing. Tenant's Acknowledgment(initial) (c) Tenant has received copies of all documents circled above. (d) Tenant has received no documents listed above. (e) Tenant has received the Massachusetts Tenant Lead Law Notification. Agent's Acknowledgment(initial) (f) Agent has informed the owner/lessor of the owner's/lessor's obligations under federal and state law for lead-based paint disclosure and notification and is aware of his/her responsibility to ensure compliance. Certification of Accuracy The following parties have reviewed the infornation above and certify,to the best of their knowledge,that the information they have provided is true qn4 accurat . P// Y Owner/Lessor Date Owner/Lessor Date Tenant Date Tenant Date Agent Date Agent Date Owner/Managing Agent Information for Tenant(Please Print): Name Street Apt. City/Town Zip Telephone I(owner/managing agent)certify that I provided the Tenant Lead Law Notification/Tenant Certification Fonn and any existing Lead Law documents to the tenant,but the tenant refused to sign this certification. The tenant gave the following reason: The Massachusetts Lead Law prohibits rental discrimination,including refusing to rent to families with children or evicting families with children because of lead paint. Contact the Childhood Lead Poisoning Prevention Program for information on the availability of this form in other languages. Tenant and owner must each keep a completed and signed copy of this form. This form was created by MARGO PISACANO using e-FORMS. a-FORMS is copyright protected and may not be used by any other party. OLIq /vp Commonwealth of Massachusetts Title 5 Official Inspection Form U rTj Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IQ !° 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name Infoirmatlon is required for every Centerville V, MA 02632 8-31-18 r 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. `0`gH11tOF i Important:when fillingout f A. Inspector Information 51* / 33,30 �'� .r•' on the computer, 4��: 'JAMES N use only the tab James D.Sears _ :m key to move your Name of Inspector v tUMARO — cursor-do not * # Capewide Enterprises use the retum Company Name - '. key. 153 Commercial Street °°opF S I NSyr'- Company Address Mashpee MA 02649 CitylTown State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9-4-18 spector'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5lnsp.doc•rev.VM2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1s 62 a6ed xeJ dH 65£Z 9l,oZ b0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspectlon Summary: Complete 1, 2, 3, or 5 and all of 4 and 8. 1) 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 16,304 exist.Any failure criteria not evaluated are Indicated below. Comments: The system is a 1500 Gal Tank H-20 0 Box and 25 chamber's. 2) 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 ❑ NO (Explain below): t5insp.doc•rev.7/26=18 Title 5 Officfel Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 VZ a5ed xe;1 dH Z5£Z 8 XE b0 d8S Commonwealth of Massachusetts k Title 5 official Inspection Form �4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information is Centerville MA 02632 8-31-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.3D3(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Forth:Subsufface Sewage Disposal System-Page 3 of 18 5Z aced xeJ dH ZSU Me b0 d@S Commonwealth of Massachusetts ua, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool oriprivy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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. c. Other: 4) 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 pond ing of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.712 61 2 0 1 9 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Pape 4 of IF gZ @Bed xe� dH £S:£Z 860Z b0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 340 Main Street (Unit 4) _ Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than 1/2 day flow lilNl� ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ® 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. 5) 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 CA. 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 t5insp.doc rev.7126MI8 Title 5 Officia-Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 LZ a5ed xe� dH £5:£Z 860Z t70 daS Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 34C Main Street (U nit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information Is required for every Centerville MA 02632 8-31-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for af!inspections: 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 NIA) ® ❑ 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)] t5insp.doc•rev.7/2 512 0 1 8 Title 5 Official Inspeolon Form*Subsurface Sewage Disposal System•Page 8 of 18 8Z abed xeJ dH t,S:£Z 8l•0Z t,0 da5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 page. CityfTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Description: The system is a 1500 Gal. Tank D Box and 25 chamber's. Number of current residents; NA Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 years usage (gpd)): NA Detail: One water service for all four units Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page r of 18 6Z a6ed xej dH VgU 860Z t70 daS Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name Information is required for every Centerville MA 02632 8-31-18 page. Citylfown state Zip Code Date of Inspection D. System Information (cont.) 2. Commercialllndustrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t6insp.doc•rev.712612018 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 06 a5ed xeJ dH SS:£Z 81.0Z b0 daS Commonwealth of Massachusetts k Title 5 Official Inspection Form � Y1& Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name requinfort redmetion is for every Centerville MA 02632 8-31-18 required page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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 IIA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Tank NA D Box and chambers 2011 permit # 2011 -292. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 20"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. t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposar System•Page 9 of 18 6E abed xed dH SS:EZ 860Z v0 d@S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L�! 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 per. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 10"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 Gal. Precast Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape-Plan 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 inlet cover's at 10'below grade. In and outlet tee, No sign of leakage or over Ioading.,Outlet cover at grade. I5insp.doc rev.MW2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 10 of 16 ZE @Bed xed dH 9S:£Z 9 60Z b0 daS Commonwealth of Massachusetts .UIVI Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth- Not for Voluntary Assessments 340 Main Street (Unit 4) L Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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 tSinsD.doc-rev.7/26�2018 Title 5 Official Inspection Form:Subsurface Sewage Oisposai System•Page 11 of 18 E£ a6ed xed dH 9S:EZ 9 i3OZ t,0 d@S Commonwealth of Massachusetts Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f V 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): D Box is 20"x24" H-20 at 6" Below grade in stone drive way. Box is clean and solid wlfive line's out.No sign of over loading or solid carry over. t5lnsp.doc rev.7,2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 bE a6ed xeJ dH 95EZ 8602 b0 d@S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form .Not for Voluntary Assessments 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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, 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number; ® leaching chambers number: 25 ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Typelname of technology: Oinsp.doc•rev.71281201E Title 8 ORidal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 g£ a5ed xed dH 95:£Z 960Z b0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form f. 1, Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 page. CItyrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cant.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is 25 ADS 26 HC units.Leaching five rows of five units 14.3'x25'. Chamber's are under stone drive way. Ck D Box and camera out to units,little water, No sign of over loading or solid carry over. 12. 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.): t5insp.doc°rev.7/26/2018 Tide 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 9£ abed xed dH 9S:£Z 860E b0 d@S Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments ��r'' 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name information is required for every Centerville MA 02632 8-31-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc rev.7,2612018 Title 5 official inspection Fort:Subsurface Sewage Disposal System-Page 15 of 18 L£ a6ed xed dH LS:£Z 8602 t,0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form f�tb Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owner's Name require dfo Is Centerville MA 02632 8-31-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 3) RIvf r rR0�t jig o t o 1 H 117 � I -a= ;-41 0 3 -3= 15 f Y q 151nsp.doc•rev.712 612 0 18 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 16 of 18 g� a6ed xed dH L5:£Z 96oe b0 da5 Commonwealth of Massachusetts Title 5 Official Inspection Form 16 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc Owner Owners Name Information Is required for every Centerville MA 02632 B-31-18 page. City/Town State Zip Code Date of Inspection D. System Information (conQ 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to P. round water: et P �9 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: 7-27-11 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: T.H. on Design plan 7-27-11. No G.W.at 10'. Bottom of chambers at atound 3'below grade. bottom of chamber's at T above T.H.Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc.rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 6£ a6ed xej dH L5:£Z 96oe 170 d@S " c °y Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 340 Main Street (Unit 4) Property Address Centerville Garden Condo Assocc owner Owner's Name information is Centerville MA 02632 8-31-18 required for every page. City/Town state Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information:Complete all fields in this section. ® B. Certification: Signed & Dated and 1. 2. 3, or 4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist) completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2612018 Title 5 OrMcIal Inspection Form:Subsurface Sewage Disposal System•Page 18 or 18 0t, abed Xej dH LS:EZ 9102 t,0 daS un?•.714 09:38a p•1 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owner's Name information is required for every Centerville MA 02632 6-23-14 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 �} �pputlnulq�� on the computer, he tab V �,tK OF MgSSG�� use only the tab 1. Inspector: �� key to move your o== •'•yG�� cursor-do not ,lames D.Sears = JA M E S use the return Name of Inspector __c� ;C.)key. *: CapewideEnterp ises,LLC _ f•,Cl— p .' �y Company Name _._.. . _ 153 Commercial Street Company Address Mashpee — MA _ 02649- z City/Town State Zip Co e= Q -e1 508477-8877 S1623 Telephone Number License Number . B. Certification W o M 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 6-23-14 spector'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 10,060 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. t5lns•3r13 Title 5 Official InspectV: Llpbs Se wage System•Page 1 of 17 Jun 2714.09:39a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owner's Name information is required for every, Centerville MA 02632 6-23-14 page. Citylrown 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: 6) 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 rep lacement 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): ,sins-3113 Tile 5 Official has pectlon Form Subsurface Sewage Disposal System•Page 2 of 17 Jun 271409:39a p,3 Commonwealth of Massachuseft Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4C, 340 Main Street ,Unit 4 Property Address Gordon Sie-qel Owner Owner's Name require for is Centerville MA 02632 6-23-14 required for every ..,.,,_ page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms 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 thins•3113 Title 5 of dal In spectlon Forrtt Subsurraoe Sewage Disposal System•Page 3 or 17 Jun 4714 09:39a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owner's Name information is Centerville MA 02632 6-23-14 required for every _ _. page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all Inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool © ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in .is.less than 6" below invert or available volume is less than '/2 day flow FAA f/N�' t5ins-3113 Title 5 Oftldal Inspection Form:Subsurface Sewage Disposal system.Page 4 of 17 Jun 2714 09:40a p.5 Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owner's Name information is Centerville MA 02632 6-23-14 required for every page, Cityrrown State Zip code Date of Inspedion 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 Protections 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. 15i,s-3113 Tdla 5 Official Ins pection Form:sibsurface sewage oisposal syvam-Page 5 of 17 Jun 2714 09:40a p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owners Name r information is required for every Centerville MA 02632 6-23-14 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: i Yesi No ❑ ® Pumping',-information was provided by the owner, occupant, or Board of Health ❑ 1 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 NIA) ® ❑ 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 theseptic 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? Els Was ttte 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) 1310 CMR 15.302(5)) D. System Information' Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203,(for example: 110 gpd x#of bedrooms): 440 s t5ins.3113 Title 5 Offidal 6lspeulon Form:Subsurface Sewage Disposal System•Page 6 of 17 Jun 2714 09:40a p.7 Commo wealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owners Name information is required for every Centerville MA 02632 6-23-14 page. Cityrrown state Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.Tank D Box and 25 chambers. r Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El 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)): NA Detail: One water service.for all four units. Sump pump? ❑ Yes ® No Last date of occupancy: Present 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•3113 Title 5 Official hspecfFon Forrm Subsurface Sewage Disposal System•Page 7 of 17 Jun 2714 09:41 a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owner's Name information is Centerville MA 02632 6-23-14 required for every page. CityrTown Slate 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: NA 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 YA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Cl Other(describe): t5hs•3113 Title 5 Otr¢iat ttspedon Form:Subsurface Sewage Dispcsal System•Page 8 of 17 Jun 2714 09:41 a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owners Name information is required for every Centerville MA 02632 6-23-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: Tank NA D Box and chambers 2011 permit #2011 -292 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: ! 20" 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): Depth below grade: 10" F 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 Gal.Precast Sludge depth: 1" t51ns•3113 Title 5 Official hmpeciion Forth:Subsurtaae Sewage Disposal System•Page 9 of 17 Jun 271409:41a p,10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owner's Name information is required for every Centerville MA 02632 6-23-14 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 29 Scum thickness n p Distance from top of scum to`top of outlet tee or baffle v Distance from bottom of scum to bottom of outlet tee or baffle 17" f How were dimensions determined? Asbuilt-Tape-Plan 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 cover's at 10' below grade. In and outlet tee, No sign of leakage or over loading. 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 t5irs-W13 TiUe 5 t)ffi A Inspection Form:Subsurface Sewage Disposaf System-Page 10 of 97 Jun 2714 09:42a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not For Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owners Name information is required for every Centerville MA 02632 6-23-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cons.) 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: El 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: bate Comments(condition of alarm and float switches, etc.). Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No r t5ins•3113 Title 5 Official Inspection Four:Subsurface Sewage DIsposat System•Page 11 of 17 Jun 2714 09:42a p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 340 Main Street ,Unit 4 Property Address Gordon Siegel Owner Owners Name information is required for every Centerville MA 02632 6-23-14 page. Cityr 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 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.): D Box is 20"x24" H-20 at 6" below grade in stone drive way. Box is clean and solid w/five line's out. No sign of over load in g or solid carry over. 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: 15ins.3/13 Title 5 Official Inspection Famx Subsurface Sewage Disposal System•Page 12 of 17 un 2714 09:45a p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 340 Main Street,Unit 4 Property Address Gordon Siegel Owner Owners Name information is Centerville MA 02632 6-23-14 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type.- El leaching pits number: ® leaching chambers number: 25 ❑ leaching galleries number: I ❑ leaching trenches number, length: ❑ leaching fields. number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system 7 Type/name of technology: --- ---------------- - Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is 25 ADS 26 HC units. Leaching five rows of five units 14.3'x25'. Chambers are under stone drive way. Ck D Box and camera out to units, little water. No sign of over loading or solid carry over. 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 SOfriciai Inspection Form:Subsurface Sewage Disposal System-Page i3 cf 17 Jun 2714 09:46a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 340 Main Street ,Unit 4 Property Address Gordon Siegel Owner owner's Name required foe Centerville MA 02632 6-23-14 required for every page. CityrTown Stale Zap Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): y 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-Y13 Title 5 Difidal Inspecilon Form:Subsurface Sewage Disposal System-Page 14 ar 17 0 Jun 2714 09:46a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments i 340 Main Street ,Unit4 Property Address Gordon Siegel Owner Owners Name information is required for every Centerville MA 02632 6-23-14 page. citylrown 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 j -s rr�,N? � 3 0 1 ❑ '3 t t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Jun 2714 09:46a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 340 Main Street ,Unit 4 Property Address Gordon Siegel Owner Owner's Name information is required for every Centerville MA 02632 6-23-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells PO Estimated depth to high ground water. 10 i 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: 7-27-11pate ❑ 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: T.H. on design plan 7-27-11: No G.W. at 10'. Bottom of chambers at around 3'below grade. Bottom of chambers at 7'above T.H.depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15Ins-3113 Title 5 Official Inspection Form:Subudwe Sewage Oisposat System•Page 16 of 17 Jun 271409:47a p.5 Commonwealth of Massachusetts Title 5 Official. Inspection Form - — e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 340 Main Street ,Unit4 Property Address Gordon Siegel Owner Owners Name information is required for every Centerville MA 02632 6-23-14 page. Cityrrown 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 i 15ins 3/13 Tale S Official Inspection Forth:SLbsurfsce Sewage Dlsposel System-Pape 17 of 17 TOWN OF BARNSTABLE LOCATION N -S — SEWAGE# —10 11 - VILLAGE Cx0-V, LJ—&-- ASSESSOR'S MAP&PARCEL-NdF-044 -001 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I 7j.A S LEACHING FACILITY: (type) *71 (size) �A `X t4 J de,1 NO.OF BEDROOMS -aC #QC— Lusi ` `4— N OWNERg,r PERMIT DATE: VCMI-a COMPLIANCE DATE: I 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 I ��y° ��` 'fi �� rQ� I�1' ` . d 2�. ' .. �, t ,. . No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatiou for Mizpoar *rmem Cow6tructiou Perron Application for a Permit to Construct( ) Repair(o-"Upgrade( ) Abandon( ) ❑ Complete System ndividual Components Location Address or Lot No. 3qO/ /l) 19, , / Owner's Name,Address,and e1.No.�$�-� / �65 `.c+/lll��+ C°eri s�erupf/�Gam. � Ca�a isusf" Assessor's Map/Parcel (:90,y— oYV—QQ/(N.0 y®Meti4 Sf- A n Io—rv0 (1P_ Installer's Na e,Address and Tel.No. Designer's Name,Add ress nd Tel.No. nU 0("� UlTi CopS�az�G��ar►,in� Type of Building: Dwelling No.of Bedrooms y Lot Size / sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow(min.r4qu.,red), ��0 gpd Design flow provided `if gpd ''^^,, �L Plan Date � Number of sheets Revision Date uj e UvO, Title '� dt Size of Septic Tank t �l��`7 1,s�jj Type of S.A.S. -aU ��ZC <�(� C( � � MIA Description of Soil 115 yp S Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the constructi aintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the iron tal Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar ealth.., Signed "� - -.04 Date Application Approved by ` - Date 'Application Disapproved by: Date for the following reasons Permit No. c9U 1 t Date Issued P No. 1! Fee / . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[pplicatioft for �Dioogal *pgtem Congtruction Permit Application for a Permit to Construct( ) Repair(r�)`Upgrade( ) Abandon( ) ❑Complete System �lndividual Components j Location Address or Lot No. 3 I O M al'17 19• � , t�/� Owner's Name,Address,and Tel.No.�i$�� rG�� oeC.-i crv�l/� rcle,' ) %/rusf"" Assessor's Map/Parcel �26� OS1S/_ QQ�I,Af o `�Vo ��/urn? �f-, t Apt- 3 6-en4ervi (1p ja£s-0I'7/- y'399 �o8-U7�- In/s�taller's Name,/Address and Tel No. ( _ Designer's Name,Address and Te�L"No. r:w ' ��:]0 f��UlT 1 �C�CI s�(�C.PI b N t .L Y1C- L:,✓�/!'7 @�!'�� y5 vSFf� rskons ijiS (,c2es�- C�rosa;e1 /U. f-�resli Type of Building: c1 Dwelling No.of Bedrooms Lot Size �L 3, `g sq. ft. Garbage Grinder ( ) i Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Y`1 U gpd Design flow provided �� gpd Plan Date /l a fic Number of sheets Revision Date Uj e Title Proms�p� {�C ji l e fc�cQ e Plr:lam JV0 1t a In 9T- CeA01 (>, 1e_ ,rAM _fir .Size of Septic Tank , ;;. c Type of S.A.S. aZ`J_ --ZC) H � �� l�C� ( � �s4emo lei, Description of Soil n5nrr , l�s^� ��,c„ ! r4 S.�4iNy� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction-arid of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envt onmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H�ealt� Signed /r' Date Application Approved by 1 ` Date A ' G" Application Disapproved by: Date for the following reasons Permit No. c O I Date Issued THE COMMONWEALTH OF MASSACHUSETTS ,r . B ''R STABLE, MASSACHUSETTS 4,ertifirate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (4, ) Upgraded ( ) Abandoned( )by 3or4p Q ) J C at Y n r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. p 0 9'7 Z- dated 8 1G Installer ( C_l ,y.� , Designer a, #bedrooms Approved design flow gpd The issuance of this ermit'hall not be construed as a guarantee that the system wDcv fitcoon as designed. Date Inspector k-, Ap gs. _ — <<--,----, --- -----.---- —.-- No. — -- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS lwigogal *pgtem Co gtructton Permit Permission is hereby granted to Construct ( ) Repair (io ) Upgrade ) Abandon Y ( ) System located at 3 o A/67 �� S�6" � - �•� y'(//'� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this p.e Date Q �f Approved by c Town of Barnstable Regulatory Services Thomas.F.Geiler,Director Public Health Division Thomas McKean Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 9 113 Iti Sewage Permit#20l l-a pa Assessor's Map/Parcel 20 g-e -001 C N p Installer&Designer Certification Form Designer: 1✓,,�; n War"s, Inc . Installer: �� `6 �✓1� 1e u�`o� Address: )z W. C rb S s e 1 el 1�#. Address: f 0- �c ©�f T;7� 3-14 kl{ I`1/� a z�y y 1`/I��s erg.s V�1 t Ll s MA On 3J Ur-k '6 W( G r S` r• was issued a permit to install a (date) (installer) e septic system at .0 NM0 i rt S+, GP,4 (W �Q based on a design drawn by (a dres ) Pe`e✓ t:fie _ dated -7127 ! 1 l ]Z�.v °1 I 1 Z 1 1 (designer) 7� I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. ,y,5 �m -C, d ��A 5 y w,n c,.. .rts�d� G� : I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS.or any vertical relocation of any component of the septic s stem) but in accordance with State & Local Regulations. Plan revision or certifie - by designer to follow. Stripout (if required) was cted and the soils we o atisfactory. tN oF'41. PETER T. (Installer's Signature) ' M CIVIL ENTEE ,9 No,35109 Q (Designer's Signature) (Affix Design �- re) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertification fonn.doc TO?I N 0 F 0 A TA 8 L EF SEP 1,11 PI 1: 54 DIVYSM�;' TOWN OF BARNSTABLE LOCATION— d -A- di N �� VILLAGE SEWAGE# !i Cx-v.�-�- �-� ASSESSOR'S MAP&PARCELS. INSTALLER'S NAME&PHONE NO. 1 SEPTIC TANK CAPACITY 1-1 i - 613�� LEACHING FACILITY.(type) -LX NO. OF BEDROOMS _(size) _L OWNER CcftZ�9-0 I LU. : c<<— PERMIT DATE: f L1 COMPLIANCE DATE: Separation Distance Between the: / Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility(If any wells exist on Feet site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within Feet 300 feet of leaching facility) FURNISHED BY Feet h1� i c Town of Barnstable P# 1 311 Department of Regulatory Services - s. �ttNa ►Bt,� 4FPublic Health Division Hate 1 // 200 Main Street,Hyannis MA 02601 'Qh�o ram" Date Scheduled / ` ( t)0.c)D Time Fee Pd. t / Soil.Suitability Assessment for Sewage Disposal Performed By: � `�' `�- Witnessed By: LOCATION& GENERAL INFORMATION Location Address 340 fyla:n S Owner's Name Cm-kr VO(Q //�� / /� / `�2' viS atQJ �Q✓t s✓7tP Address SgW`q Assessor's Map/Parcel: U 3—® 4 1 �Qo l co Engineer's Name /Q¢e r'l c NEW CONSTRUCTION REPAIR X Telephone# SQ G8 r` Land Use Slopes Surface Stones Ail4— Distances from: Open Water Body�2�'ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line Z-0 fif ft .Other SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) zz I � 1 M I ; �! s� - CIO Parent material(geologic) Depth to Bedrockrill N/ Depth to Groundwater. Standing Water in Hole: �) Z�1 Weeping from Pit Face /t \ -7 Estitnated Seasonal High Groundwater DETERAGNATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to soil mottles: In. - - Depth to weeping`from side of obs."hole: _ in, Groundwater Adjusiment ft. Index Well.# Reading Date: IndexWelllevel Adj.factor Adj.Groutidwater Level,,,, PERCOLATION TEST Dates . Time,.. Observation Z Hole# ' 5toe Time at 9" Depth of Perc 362/ 1 Time at 6" Start Pre-soak Time @ y _ lime(9"-6") End Pre-soak t Rate Min/ ch. ( � Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\Sl3PTlMERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole Depth fro Soil Horizon Soil Texture . Soil Color Soil Other m Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders: it v 12"3k �J 54 DEEP OBSERVATION HOLE LOG " Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%: v 3Z -12d� LC srlkrrt �- lU `2e� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil _.. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency, Given DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,.Stones;Boulders. Consistency Flood Insurance Rate Man: - Above 500 year flood boundary No_ Yes Within 500 year boundary No K Yes Within 100 year flood boundary No Yes Depth of Naturally Occurrine_Perviott§Material . Does at least four feet.of naturally occurring pervious material exist in all areas observed throughout;the area proposed for the soil absorption system? L S If not;what is the depth of naturally occurring pervious material?Ct ..._ Certification s I`certify that or (date)I have passed the soil evaluator examination approved'by the Department of Environmental Protection and that the above analysis was performed by me consistent with the'required training,expertise and experience described in 10 C1yIR 15.017. " Signature Date Q:\.SBPn0PERCFORM.DOC t' .2007� No. �v / _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS :Yes 3pplicatiou for �Bigogar �§pgtem Cougtructiou Permit RAication for a Permit to Construct O Repair Upgrade O Abandon O ❑ Complete System ❑Individual Components tion Address or of No. i % Owner's Name,Address,and Tel.No.ssor's Map/Parcelller's Name,Address,and Tel.No. Design-er`'sName,Address nd Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building F No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �`� gpd Design flow provided 4e-*,-� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank ow /S'-/ +-r I0110 0. Type of S.A.S. Description of Soil f f Nature of Repairs or Alterations(Answer when applic lei Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b thi ar o fitth Sig e / Date Application Approve Date 13,461-7 Application Disapproved by: Date for the following reasons Permit No. Date Issued d lol d�`-" " ,', r ,7 i 1 t Fee AQ t/ No. y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH*bIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Mig' onl �pztem Cott.5tructton Permit Application for a Permit to Construct( ) Repair(.,Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. r Owner's Name,Address,and Tel.No. / Assessor's Ma p/Parcel o Installer's Name,Address, Tel.No. Designe,Address nd Tel.No. e;a r 5-3-7 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(min.required)' �/�L� gpd Design flow provided l/ �i� (, gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank If X / S-f-/ �/ l�D d ^Type of S.A.S. Description of Soil "\. Nature of Repairs or Alterations(Answer when applicable)_ �� / / ) Date last inspected: i Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage,dispisal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B°�ar!of Health. . ! Signed,.'5' �,.�. �. Date ''�/� Application Approved l�� `i Y� Date �) /(f Application Disapproved by: Date t for the following reasons Permit No. ""3--5" / Date Issued ----------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFFnY,that the On-site Sewage Disposal System Constructed ( ) -Repaired Upgraded ( ) Abandoned( )by DL Q at `/ �� /�' <2 y., 4 ha+sbebeen,constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.��-�1�`��j � dated Installer Z /2- Designer � _ "7-7r > y #bedrooms Approved design flow- .4190 gpd The issuance g f this permit shall not be construed as a guarantee that the system wilhfunction as desi j Date 3 I 0-7 c Inspector �`� �s Q ———————————=————————————————— ——— ————————— No: O 7�-5� [/ Fee THE COMMONWEALTH OF MASSACHUSETTS EUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1=tgoal 6p!5tem Construction Permit Permission is hereby granted to Construct. ( ) Repair (/`) Upgrade ( ) Abandon ( ) System located at _��/� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with iitle 5 and the following local provisions or special conditions. Provided: Construction,must be:completed within three years of the date of this pe'riti: Date ?C I 13 1c, ) ipprove4-by Town of Barnstable �fHE T "o Regulatory Services Thomas F. Geiler, Director * BARNSTABLE, 9�AM�; ,0� Public Health Division TE039. 1% Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: D Designer: Shay Environmental Services, Inc. Installeri ARCH Construction . Address: P.O. Box 627 East Falmouth Address: PO BOX 914 MA 02536 Hyannis, MA On 8/19/06 ARCH CONSTRUCTION was issued a permit to install a (date) (installer) septic system`af �344`Main Street, Cent., MA based on:,a design drawn by (address) - Shay Environmental Services, Inc. dated 08/01/07 (designer) XX I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF ALq`r`�, CARMEN (Instal er's Signature) E. { .,. � SHAY No. 1181 E�`O S'4NITAR\P- ( esigner's-Signature) C , '(Affix Desig tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form VETO Town of Barnstable of Barnstable P Board of Health AFAmedeaCity t ilA LE,MASS. y Hass. � 200 Main Street,Hyannis MA 02601 O 1639. ♦� O Alfp MA't A' 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi December 12, 2007 Carmen Shay 18.5 Ashumet Road Mashpee, MA 02649 RE: 344 Main Street (Rear Building), Centerville A = 208 - 044 — 001 Dear Mr. Shay: You are granted a variance on behalf of your client, Gordon Seigel, to construct and utilize an innovative/alternative (I/A) nitrogen reduction system at 344 Main Street (Rear Building) in Centerville, MA. The variance granted is as follows: 310 CMR 15.211: The leaching facility will be located 3.4 feet above the ground water table, in lieu of the minimum five (5) feet separation distance required. The variance is granted with the following conditions: (1) No more than four (4) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to four (4) bedrooms maximum. A copy of the recorded deed restriction shall be submitted,to the Health Agent prior to obtaining a disposal.works construction permit. (3) The designing engineer shall revise the plan to show the location of the required monitoring device. (4) The designing engineer shall ensure that the system is designed in accordance to the DEP design standards, along with monitoring and testing as identified by the DEP recommendations. Q:\WPFILES\Shay Seigel IA 344 Main St Cent2007.docQ:\WPFILES\Shay Seigel IA 344 Main St Cent2007.doc Page I (5) The designing engineer shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the revised plans. (6) The wastewater effluent shall be tested quarterly for the first two years of operation for nitrates, TKN, pH, CBOD, TSS, TN, and alkalinity. (7) After the two year period of testing quarterly has ended, the applicant may request permission from the Board of Health to reduce the testing frequency. (8) The applicant shall submit a copy of the signed two-year Operation and Maintenance Agreement (O&M) between the contractor and the homeowner to the Board of Health. The engineer or 0& M contractor shall conduct inspections to the I/A system a minimum of twice yearly. This permission is granted because the proposed plan appears to meet all of the provisions of the State Environmental Code, Title 5 and all of the Town of Barnstable Board of Health Regulations. Sinc ely yours Wayn Miller, M.D. Chairman Q:\WPFILES\Shay Seigel IA 344 Main St Cent2007.docQ:\WPFILES\Shay Seigel IA 344 Main St Cent2007.doc Page 2 TOWN OF BARNSTABLE ' LOCATION 3�� /'/A nJ S�}r SEWAGE Q 6b7",3,f-1 VILLAGE Cc..i Tt 4 v1 lle ASSESSOR'S MAP&PARCEL 07 p`ty_d.l INSTALLERS NAME&PHONE NO.Al2c14 ro ws T S pi- 7 7 J 1362 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) &v.;,s,y.�✓%,/rgAro ize) (Z,. 5 NO.OF BEDROOMS 3 I� i OWNER ,,4 ►✓ o @ b/ j PERMIT DATE: f COMPLIANCE DATE: Separation Distance Between the: /' 1 j Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility C7 4 S Feet Private Water Supply Welland 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 i within 300 feet of leaching facility) Feet FURNISHED BY i i 3 PC- s 3 p OI TOWN OF BARNSTABLE LOCATION 3 ey® / " '/-a.i x✓ S 7`4 SEWAGE # VILLAGE 7 i2 C-2 Ile ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /�Y.c/� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 6 (size) .3a?- X��- NO.OF BEDROOMS BUILDER OR OWNER �r®/L�o�✓ i t 41s?'V era„i COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 J Ile Fc = Q c Qc � , r7, G°,9/A s r 0 OD 3 -- ----.. - _ 4 TOWN OF BARNSTABLE ` LOCATION h/0 /Y7i S 7-4 r±'a_" SEWAGE# I V3.LAGE C �✓?�'r2 r.�r P ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. &�9 e A-e HA 17'- -2 ;Is-�3 dZ SEPTIC TANK CAPACITY LEACHING FACELrrY: (type) d.� 14e-T (size) .3,0?- X/-.1 y NO.OF BEDROOMS BUILDER OR OWNER i r o A 11 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility r O Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A r7, 6 f G2 Rca 6 yXeY G�i/,ems B/.� I 4 t G€I�� OYn ap- NC O F� TI-II s. STYM MCIAL-W,SPEMO - ° , .VIOL � � NT'S SUBSURFACE SAGE jyjS SYSTEAT FOB PART A CEE TIFTCATIO Property Address: 4 i,✓ 6-1-r.v T, tee, r 71-e 1 Owuer's Kame: s'6 O n/ .�'i I t� - ^ 7 Y er's Address` Date ofTuspertion: ``////O n L Name of lmspector:(please print)///,4 V•✓Z /4 ,a G 006,4 Company Name: J�Jaffing Adder: o c3 ifs Telephone Number: 6-0Y- '7 5'/3u5" CERTMCATIOTI-4 STATEMENT I certify that I Dave personalty inspected the sewage disposal system at this address and than the information reported below is true,accu=e and complete as of the time of the h spection.The inspection sperformed based on my training and experience is the proper moat maintenance of on site sewage disposal sysMBIs.I am a DEP approved system inspector pursumt to on 3 s 3-10 o'TMe S(310 t5_4800). The system: Passes Conditionally Passes Nerds Further EvaInation by the Local Approving Auffiority Fails D. l The system' a copy of this ins} Lion report to the Approving Authority (Board of Health or DEP)wifliin 3 days co Plating this insp�ior_If the system is a shared system of bas a design flow of MOO QO gpd or Vtsr,the inspector and the system owner shall submit the mart W thr app n-:gtoaal rice of the DER The o?igiraal should be sent to the system over and copies swat m tlg buyer,if aWlicable,and the aPVMVin9 authority. Notes and Comments P+J f 2 — Z"his report only dese bes condigous at the time air you�d�mmder the Qer t ce of e o a�that �r time.This insgeclion does not addres=how the s;:Wm peaorm in the. dgr g�g��5a ne or fer�z`u conditions of use. CO CO c_rt c t`- o tn Pa.Oe 2 of I I PART y'roperty Address:3 `7/0 Cr y7 Owner. G2 d .✓ Si Dam ofInspec-flon: // t- �O ls�on Se-Mary: Cheek 2_ 1'h� Zound any in� on which g - tes t of The� �desribed is 3 10 Ova .I3303 or in 310 CNa I S-304 exist.Any mum feria not evalumed am indic��below- Comments: B. System C€anditionaffy Passes: One or more system compone-as as descnibad in tlBe fir' "onal lassr section need e'D be=laced or repaired_The:system,upon comWerion aaf the. ent."**_ ,as approved by the$oard Of Health,will pam. Answer yes,no or not deterred(Y )in the for-the following statements if"not determined"ple-se e.�alain. . The septic tank is metal and over 20 y cold*or the septic=I-(wu'_tbe -metal ornot)is st mctural7y - unsound,exit-Us substanifid on or t Qr f--H=�:kOMMML SystMWM pass-mmecdan€f - existing tank is replaced with a � ��cf th_ � m Ameta lg it is�?etmally mimd,nca lealdna and if a C&tifacate of Cotes indi cang tlaa't the tawk is less than 2 old i--available- ND e:plain: Observation of backup or obstructed pipes).or due• a brok--en se?sled eves dis�sisraon I3o System pass.isas +*if approval of Board of- th): brznkea t s =la-_d elrst atctio�is N ue- distrfbuti is oz_ . NID e3ml The systerm required pumping more than 4-ids a year due to-b aken or obstructed pipe(s).The system will pass inspecticn if(with appal ofthe Board of Health): broken pipe(s)are replaced obstrtRction k moved ND exala_in: 10age 3 of I I ' LY bJ.Y�d y.A. t r fie'Sal ie 1364 d 5J� 3 1. �3.Cep }� PART A r lrulrope�4ddress•3 Yes 11)),4 Cb 411,T16 tt %lam Owner: o a a n/ i e L- Date of Ispeckion: C i"na tier I -snaffn2.tio a is Req,jred by the Board of Res e Conditions exist Vaich require f er e� i by the Qf ealda i�order s�dm€ ioe if the sysi is tailing to protect public health,safety or -envhonme system wm aless Board of - es accordance--A3.0 OVIR I_s,3 ) 3 that the system is not ftM rnL--a in a Mamne ir—h vein Protect pabuc hem,sz-fe"y andl the e€ceirranmest: — Cesspool or privy is fee of a w�'r — Cesspool or privy is 50 fi=t of a b g vegetated eve or a salt mares. 2. System-till fail Bless the Board of Health,(and Pa eater Supplier,if any)determines that the system is Dinctioning in a mp ner$;fat pgantects tie--p c health;safety EDd ens°mot: _ The system has a septic MA-and soil abs sys (SAS)and the SAS is within 100 feet e,a sedate dater supply or tributary to a supply— The system has a septic tank and SAS . the SAS is vAthin a Zone I of a public water supply: the system has a ptic tank;-d S d-die SAS s withk So feet of a private vrdmr supply well'. _ The system a septic t�and acid the is Iess tier 10 0 feet brat 50 fe`t or More frt►ni a private water ly weV—.Method to determine ce *=Ibis system passes if the well analysis,perform d at a D certified Iaboratmy,for col form bacteria and volatile organic co aims indicates that the well is free polluftion kom that facility and the presence ofaggmaoaia nitro and nitrate ritrogen is equal to or less tI~,att provided m ofer failure criteria are triggered. �v of the analysis must be attached to this form_ 3. Other: Page 4 of I l FOR N � €SEW Ts PART A +;�Ile =� e 0 i G � ,✓ T�'Gtl1' tBB" �� BO Date of�Q ' terms�pb one�t ae o os�d or CIO. SA5 I�I yes No of sere MW f��'��"ea-�p face of the d or ce�aeers due��av�oad�or -h se os ding of eft e sir €t�3 box ab ;e� et €r M overloaded pr o SAS°' Ia�SAS 0-- or c®ssPooi �S=ligsdd Lvel.in ft dis`a- d � paoi �� 6 'belourtm �' sie sta e > d`"''�s�3 ctn' dep oOA� less � exo cjOgg.!d or,,b IICMdAquid a �- �� ire 4c�=4 timel fu�lest of Ped is below hi& imd e��®ram to a s�ie Any or=of the SAS. �oI or ' €of a ate= M-,'Ply or"r, --- - Any w of ocdi Cyr I�''�'is r f➢f — -7' v azr suPFIY- �I a i d3i3 public e11. Any PO-an Of a l or�Ti�iS 54 f=t of a ovate �well_ a rie��der y pot,toa of a=spo®l or gs�y'Iv l� bt-1 j6 feet,fry jP sip a�a � y po of a cess�si or P �e a s b SWPIy III no able tee; E9 aE�ISs. S �v � tpBc epsa �ss for COMOrm amme �es-foed at BDO be Follatfata 6 _ ma indii that the veff is t � arse o�ext an€l i 2b '= are t 'A copy IT 11P Ct s .� Dfftgabov&�_ ` 'a eR_oaf of y1 �Y�s/iyo �h �' faa" €-tomd �e -mod ��{�- desc�ed iaa 3111��353I33,�� Fleajth to dam• zne wbml�b--=c`eSS3rY - F- LwteSf `` Paz To be considered a lam systemtNe Cr gpd' "w each gdf a�11 You must indiszZ« in ' ��s a above) (_[Iia fc�ilo�in- , w l s5" Yes no �rlpZ9 a Ply �fa — _ _ ,he d&� ratc:Z 5 �y 2�8€3 f� a-��- �a -�, car a_yjp ..d _ the sy te-ax-ris cad in a Zone R of--a 3fc scappiy wall is consSdered a significant tlsr�at,or ans m-ed If you have agsw�°red ' Sr e''n€x�s Ssc €ate �o of 'Iar?�off'GO a "��v.. ac.ordarce: 3Id sv si_ c ci .Section, - ed d � i � s � e system 15304- he syst m er sbould cou� e a ;=i p_r tuna$o ace ofsbe e a� 'pane 5 of 11 ITT P JST pa operty A ddr�.e-s /o ZIN4 G F Owner: JL O Al !ems date cries Cheek if the been stone_You miss:L icate"yes"or`Rd-as to each of the fbUowinQ_ Yes�No pumping irrsm ation-%as provided by the owner,occupant,or Board of Healt$ Were any of the system components pumped out in the previous-L,-o creeks? Has thesystem received normal flows in the previous two week penod? Rage large volumes of vrdter been introduced to the S3 MSInre=tlY o3 as pari of this l oon Were as built plans ofthe system obtained and examined?(if they were not available note as NIA) Was the facility or dwelling inspected for signs of smarage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,lasted 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 constn?st?on,dimensioris,depth--of liquid,depth of sludge and depth of scum? Was the facility owner(arid occupanm i f different fist o,;mer)provided wt'�information on.the proper maintenance of subsurface sewage disposal systems Toe size and loeatiou of the SOR AbsoMion System(S on the site has been dete uned based on: 1 Existing information.For example,a plan at th oard of Health_ Determined in the field(z any ofi the fi-ih..rre criten relaied to part C is at slue appmxi on ofd. Mce is unacceptable)j310 CRR 15.302(3)(b)) Page 5 of 11 r :C SYSTYMBUFORMATION Property Address:35/D 1/9i9 Owner.6:0 s2 0.✓ �e �� Date of L spection: FLOW COIND O RESI1DENTL4-L Number of bedrooms(desigp): of bedrwm(ara1): DESIGN flow based on 310 C7AR UM(for le:110 gpdx f-r -dmMS): Number of current residents: _ / Does residence have a garbag grinder(yes or no):-/�V/ Is laundry on a separate sewage system(yes or no):N fif yes separate4uspection required] . Laundry system inspected CySe�or no):_ Seasonal use:(yes or no) Water meter readings,if avail^ le(last 2 years msage(gpd)): / ✓ Sump pump(yes or no): J Last date of occupancy: C® Illi1�PFIS Type of establishment: Design flow(based o I0 CMR 15 apd Basis of design flow( ns/sq%etc.): Grease trap present Industrial waste a tank p em(yes or no):_ Non- discharged to itle 5 system(yes or no):_ Water readings,if available: Last of occupancy/use: OTHER(describe): GENEWA-L TIQ IMEATItONT Pumping Records Source.ofiiiformation: �Nt Was system pumped"as pate of the inspection(yes or-no): If yes,volume pumpecb" S OOQalions—I=gTwas quMauty Keason f pumping 19/N7`.og —v 1 ' OFtYSTEM Septic tank,distribution bosq soil absorption sys-tzmi- _Sing cesspool _Okmflovrcesspoor _NVY_Shared system(res ormo)(if yesS i ;:VU U, 15P .4 dS,Ef any`)' ' _Imtova1ivetAltenradvat=1mology:At ofthe current operation and maintenance contr=(to be obtained-from system owner) _Tight tank- .^A=ch a copy of the DEP oval —Other(describe): Approyinjate age of all components,date installed(if Imowvn)and source of information: Were sewage odors detected-when arriving at the site(,yes or no): 5 P �7 of l l �rr� -i £ aA yapq ° sm d5 */_ lve y'�ec�e� � 4x ��'tt�3ier e> (Cosh 83 � E s✓7�2 v s//@ Owned �d0�✓ ��5� / Bug-DING SEA (locam on sha,phm) Deg`Lq below ire: mamrws of c ctiom mm l✓T� �{� )= DiMnce froln st al°y 11 or sucuon 1 - Commenzs(on cmdMOn Ofj0klts,-','er€tina ei--ideme ofleak'ar...etr): oo� s plan) Dept below made: _ Pl.Aaym-riaiof om: �creM m- l aTg1ass;�olyeda3''er�e athe;{elain) _ �i pa:,?:is metal list age:— 1s age c��by a C�� sf COmts€Sance{yam ems) — �= o_ Dimensions: 100> x S� K S - stuci✓tre deptb.: 6g�� Distance Emm�of SlUd�_o bGWm si omlei LW Or ba :� SC=!hlclmess: DDistmce ftm top of scam to 0P Of 0-atICTted Or bade: Distance fmin bo11-0-a3 ofsam tO bMGM sf ne dM�.Gr berm�e: / A. Ccamments(an pamp cl tlet tee si bade aiao�x�, y/ p ^ as mismd to outtleo imve ,el'dd? g- Vic-)- G_EASE T?- (low co PIM) r Depth below ode: 1� �gia1 of cc-ghc : csr� ne der {erla?nj: Dimets—mum 5-,-tan tbielcaess: Dis`.=i of s .0 a ittwe or bade Dismnm kom 5—mmm of scum uo €f mtL-1-€tee Cr bL°�e: 4Jul L ii'dC ' end--�q.u-j o'Yy:'2 /._ M /J Page 9 of I I pr- i erty A M�'m .3540 A4 7 ea 46;2�'4-� ;�" 171CMEEsr�,�° by ~-=i �Es F�p , iDepth err fie: Fa of 7 aL �esbg=� ,w ?�ensians= CaPachY- Qa$3rmc Desigt Flow gaHonsFda� Adam greyer 4s jmg e Q;r�st pomp on c`a and flo-d s�*iLchreC)Tr):D enL Est be ageneo oc ee€are si�P Depth ox liq€dd ienprJ above mi1et inv. T,-a e=(now if box is kmlei and won 3o au&as Orp�- evz of-Dues 3..akagge itw or am of box,eec.�: � iYy b 1 �✓ j s j kc A-i PUPTUP � n caja cr sites play amps is Timidlig,M-der cyas or no)- : lmt ns m WGA-in.-order(yes or nq) Ccfamelms(BOLL-condfim of Page g of I I 3• 3 ' ' 4i'fi -as��`:FadE��L L•�i1U.= ��Jr3"^�'/k_s��.e�P �'��2��.�'4�51��Cr�_Yu��t'.�J K�✓1 C 7/ 4c ��— DEe of / B uT' "":'F� a�gA � r' U ��..,��'?��`'E.�G=�.':T��•-�.-'.�'�'?�sss'_t€�c3E1'�`-�¢p� .. 1f SAS not located 'type Ieacl g sits,mmnb---_ leaching cb=bma-numb iz c,i�ggau__Hes,n=bcr__ leaching�s_hes,ntnber,I-agffin leac tg fre1cls,mmn'hez; c�etflo�r'c.�s.�cnl,tuber:- . itmovativeta3 enrdme—systems'Ty,eefh�e of hn,613gy. CoYrsnrezxts(aao cofsl,sioby �?Isc-fa � ,leere4 of /ca / soil, co :�icar: CESSPOOLS-4cesspool inust be pamped as pat of n-pectiozi)[-l©--I on site Plan) Nurnber and confz -at=on: Depth—top of laq--aid to et inves L Depth of solids layer: D:pthofscum laye Dimensions of cesspool: Materials of Co an: Indicadan of grmmd . - o=.v dyes or no, _ Comments(note M� of soU,s g:s€Bf rid aull;c'_ s. . a- _ z,!<_. - _- luo Dm ios- CJer 'Z (�G$Zit ? 3f�£t Page 10 of 11 "R fie07 AA ropey CS ''�'?CA✓L /i/ Dates of lums M �l SYST— Provide a sketch off sewage disposal s bmchmmr ss_Loge aTwe'ls w-'d -'0 T yce where-W -fic Tz m sul:�.-y-ent-es ` �L0A,) paac- ), A 2q � � 31 XNSPECTLAIGN FORM--NOT FOR VUL-vi'z Pf ruff SUUM`A- S�--W DAI,> =E EqSPEMON POPS PART C TENT R O nON(con i=ed) /► ,�.✓ r v l/P C�s�er,Crc �w •e'� lM SIB Seca wale: Ch=k canar Sb2Bow wells Esftmmd depth m gonad .tAP feet Ple2se m(Rcm(check)all methods used to deommme the hagh growd vrd=elev2bm Oblamed ftom system desaLmplms cm retard-Ifs daW ofdemSaplaareviewed: Obs-mve I site-(abramg Fapm yl&mwvadm hole wfflfm 150 fea of SAS) amcked with lm:d Dawd off : Checked Y&h lccal excavauss,imanHers-(aMch doMmeatadon) Acoewed IJSGS datalb�3 You most describe haw YOU estaiilished thehigh elevation: 76 c!/ .4 i TOWN OF BARNSTABLE LOCATION i ,� 5—T SEWAGE 4;2007-3S'-,( VILLAGE Cc.✓ 7,C12 vl �° ASSESSOR'S MAP&PARCEL 0 INSTALLERS NAME&PHONE NO.A Rc 14 r vS T S O F 7 J l3 SEPTIC TANK CAPACITY LEACHING FACILITY:(type)3;L 4Q.4y e(gize)3a x (d,73 XJr NO.OF BEDROOMS 3 OWNER 15Daeoo ✓ C l jn� PERMIT DATE:f= � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 6 � � � Feet Private Water Supply Welland 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 �3 � � ® L� s� A) D . 3 / rIL � ' t � I0 TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION Date �1�' �' L7 Owner 6 `O�U on C, L- Tenant A 2:5 jZ �� A9 Address �� Q�?� �� *E)z,.X e &t /'PAddress Compliance Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities f 7 t 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements /14. Insects and Rodents �jrs 15. Garbage and Rubbish Storage and Disposal / 16. Sewage Disposal 17. Temporary Housing PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition za��,, Person(s) Interviewed -(Z�- T Inspect If Public Building such as )or Hotel/Motel specify here HOSSS Q WARREN.INC. MRVP # �L Assessors office (1st Floor) !!'' Assessors Map and Parcel # 0 d 8- b l - oo 1 Building Department (4th Flo r) � Zoning INSPECTION FEE .00 RE-INSPECTION FEE $15.00 Request For A Housing Inspection For Certification Under the MA Rental Voucher Program Your Name 60C-�Qt) � . S1 P 1: P _ Affiliation (Circle One) Owner Real Estate Agent Tenant Your Address 20 Cox 3. ?f10 ✓1 Lae: Wj-j MI- p2L4,s- 7 Telephone Number (Day) S 0% Obir6(Night-4 OeL 508 3_7 s'-P, Address of Pro erty Where Inspection is Requested Unit/Apt.# SL1g0 MG s i-cee+, C e,,:,+'rest Ike MA b a 6 3 a Name of Owner Address Q 9x (-$3 ��ov,�ce'�.,,.a / V� d �bJ� Mailing Address (if different) Telephone Number (Day) (Night) Will there be any children under the age of six (6) wh 11 be occupying the rental unit? (circle one) Yes No Was the dwelling constructed prior to 1979%K� No I ------------------------------------------------------------ FOR OFFICE USE ONLY: Certification The dwelling, dwe aq uni , or rooming unit located at was inspected on by Health Inspector for the Town of Barnstable-and was foELnd to be in compliance with the provisions contained within 105 CMR 410.00, State Sanitary Code II: Minimum Standards of Fitness for Human Habitation. However, this certification does not include a determination as to whether this unit contains any lead paint because under 760 CMR 49.02 Massachusetts Rental Voucher Program, a separate lead paint inspection must be conducted. Inspector's Signature/ Date 4�tz MRVP # �y L Assessors office (1st Floor) p� Assessors Map and Parcel # d �- 09q V� r ' t Building Department (4th Flo r)zoning _ �� Gl/�, INSPECTION FEE $001-.00 RE-INSPECTION FEE $15.00 Request For A Housing Inspection For Certification Under the MA Rental Voucher Program Your Name G UC 3 p n Affiliation (Circle One) Owner Real Estate Agent Tenant Your Address- O gO u Telephone Number (Day) S OZ `I B� Ob8 Nig4i-t-i C I L 5U 3 Q 3 7 Address of Pro erty Where Inspection° is Requested 'Unit/Apt.# yam MG;N 5 � GN C �:�-��r�� 1�P MA Cad 63 a Name of Owner O�l oC c�_0 e", L- Address � U x �Z33 �b o.��,vco�o, J �/� C) 7 Mailing Address (if different) - Telephone Number (Day)", (Night) Will there be any children under the age of six (6) wh 11 be occupying the rental unit? (circle one) Yes No h Waslthe�dwelling constructed prior to 1979%K� No Y � ------------------=----------------------------------------- FOR OFFICE USE ONLY: Certification The dwellingdwe ' uni or rooming unit located at .. ng . was inspected on .. by Health Inspector for the Town of Barnstable and was fo nd to be in compliance with the provisions contained within 105 CMR 410.00, State Sanitary Code II: �Mini,ium Standards of Fitness for Human Habitation. However, •`tb.is certification does not include a determination as to whether this unit contains any lead paint because . under 760 CMR 49:'02 Massachusetts Rental Voucher Program, a separate lead paint ' inspection must, be conducted. Inspector's Signature Date /011 - `/ �•T'e' e4.rat,.aeN � .. - ,ya 1 SENT BY:McD,HE 5-28-92 13:27 BOSTON" 201 890 94864 8 ,,' .�., sock 8051 FacE 333 342®,3 •' WIBIT 2-b GRANT OF 9A68M8NT 1, STBvaN 11. BEROLUND of Barnstable, Barnstable County, Hassachusette In consideration of ONE ($1.00) DOLLAR paid. grant to DENIS 4T O'DRISCOLL of 17 Clarence Road, Wayland, )Massachusetts 01770 with QUITCLAIM COVENANTS the perpetual right to lay. maintain, operate, repair and remove water mains, pipes, shut-offa. service boxes and such other equipment andI connections Thereto as may appear to be necessary and advisable by the Otancea in, through, over, undet and upon the following described real estate situste In Barnstable (Centerville), Barnstable County. Massaehueotts bounded and described p. as follows � Commencing at a point on the northwesterly side of Hain Street � e:shown on hereinafter mentioned plan; Thence north 40. 30' 56" west twenty-four and 80/100 (24.a0) feet as shown on said plan; Thence north 57" So'42"west seventy-one and 20/100(71.20)feect Thence notch 66. 3'33"west seventy-eight and 31/100(79,31)feetr d Thence north 49" la'400 east twenty-two and 13/100(22.13)feet) Thence south 66a 3'15"Gut seventy and 26/100(70.26)feet; Thence south 570 30'42"east seventy-five and 44/100(73.44)feats Thence south 40"3W 56"east twenty-sight and 33/100(28.33)fsstl I Thence south $90 110' 2" west twenty and 00/100 (20.00) feet to the Point of beginning, Bela shown as 'Utility Baaetnenc 30' plds" on plan entitled Upton of >l�aaemetrt in Gntetvgie) Barnstable. Kea. for dtevon 8. Bergluad paler 1" 4 s 2W Datet May 15, 1901 Baiter 11 Nye lac- Registered Land purveyors Civil Engineers OstervUI6.Maas."which sold plan Is to be recorded berewlth. i U � s SENT BY:McD,W&E 8-28-92 13:28 BOSTON- 201 800 8466os 8 800K805i FAV 334 1 included in this grant of eesemenr is the right .to enter upon Cho aforesaid premises for the purpose of inspecting, repairing, Improving, replacing, testing end making all necessary connections and taking Mil action necessary or lneidentel to the la9ina, maintaining and inspection of saW water mains, plpas and appurtenances, provided however, that in every such Instance the oremises shall be reacted by the grantee to their pre-existing condition. For title sae deed recorded with Barnstable County Registry of Aeeds in Book 2S10 rage 140. 1991, B88CUTdD me a tooled Instrument this day of �g y(e- , Steven k. ' egi - -0.P.'...— CnMMONWEAj.TH OF MASSACHUaBTTs Barnstable,ss '60" y .1092 Then LUND and acknowledged Personally o fore8oingeinstrurnant ared the to be his free acts and 4e d d STRVRN N. ,before me racy pqb it • „L _�,�... _Q�r.y �'�:, My cominisslon e:pirm/hamfQ 1 14f 19 REEONON JUN 4 92 BOOKAMAGEAL,. �2 N W PM 19t �pY' I CERTIFY THAT THIS PLAN HAS a �:I+tY op>5 BEEN PREPARED IN CONFORMITY WITH THE RULES AND REGULATIONS OF THE LDCUS o a REGISTERS OF DEEDS. 90 C.B, ° FNO. 3G oaS, LOCUS MAP \° N STONE DRIVE ; SCALE 1 25,000 n Gay° �v� i \ 66DJys, ASSESSORS m �PG� Un1 IY DZB\W ��o•` �� MAP 208 PARCEL 44-1 S}�0 V Zp•E4S \ Vo ss 'YI• GRAPHIC SCALE ZONE O y \ 1BOF�E7✓T \ 0 10 20 40 RC & A.P. a 4, g j \>qJ• CONC. r90 cobJ s.W\ SLAB W \ BCRB FND. •t y , 2 2.01'BACK OF E [� 9J C.B. iNO. b 0� DOR N1i BCRB FND RT LOT 1 NJJ v eg' 23,999 S.F. 0.55 Ac. p" you PLAN OF EASEMENT ° °'l IN +� (CENTERVILLE) �T BARNSTABLE , MASS. od FOR t �J C.B. STEVEN E. BERGLUND l� FND. SCALE: 1"=20' DATE: MAY 15,1991 BCR ° BAXTER 6 NYE INC. FIND ,yo'ry REGISTERED LAND SURVEYORS I HEREBY CERTIFY THAT THE PROPERTY FND ,°' CIVIL ENGINEERS LINES SHOWN HEREON ARE THE LINES DIVIDING OSTERVILLE,MASS, EXISTING OWNERSHIPS, AND THE LINES OF THE , STREETS AND WAYS SHOWN ARE THOSE OF ... PUBLIC OR PRIVATE STREETS OR WAYS ALREADY ESTABLISHED AND THAT NO NEW LINES FOR DIVISION OF EXISTING OWNERSHIP OR FOR NEW WAYS ARE SHOWN. DATE: �(Z/ C/JL7C�R.L.S. DEED REFERENCE I BOOK E510 PAGE 140� T #9033 1 se✓c��V•.I.PACEk Nl\0 Be°4y�6 ip 0_ ]PRNSS P9lOEE0EE05 U N ,�I flRiII SSEENES d r � R.tE F,E�rt ER o ya F lip, Lo y uA> LL U P � L 6l L ,? o� a�y� d N .� re'• m N 2.so W y 26`\gip Ate•$`e9 6a J b mV 41 <'� aS IP V ro05 d ul U 19 dao O1-r,irn I nos �'M /•Nd ° d Z a 1+ .m do � u TOWN OF BARNSTABLE LOCATION S+ SEWAGE # VILLAGE ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 50� LEACHING FACILrTY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 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) � �Q(� Feet Furnished by '314 q © J 44 A g AC 34 �7 TOWN OF BARNSTAELE LOCATION 3 � m�� S4- n ' SEWAGE'i�f `iLLAGE ` ��'{.N y�1 L 0 ASSESSOR'S MAP dt`CO'1� INSTALLER'S NAME&PHONE NO. I SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Ci' (size) NO.OF BEDROOMS BUILDER OR OWNER \ ( PERMITDATE: COMPLIANCE DATE: 11113A91P 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 P&AI 40 a A� f) ge t TOWN OF BARNSTABLE L-OCATION ?�D Q�n :S� SEWAGE # l VILLAGE f?�Pf�'i �� ASSESSOR'S MAP 6z LOT /7 a INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY I<<��Jh LEACHING FACILITY:(type) �� "� y S (size) — 2/XC/ NO. OF BEDROOMS 7" PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes NO ly i yo' � TOWN OF BARNSTABLE i LOCATION 3 Vo ltir9iv s T SEWAGE# 2S-13c V LLAGE e-44." ,t ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. Af"r,57 SEPTIC TANK CAPACITY /L/5-Z, C,yL LEACHING FACILITY: (type) c—I G:�,zr-ys (size) x 5'/t i� GvueYs NO.OF BEDROOMS 5� OR OWNER aX. PERMITDATE: 'J"7s COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Aee 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 leachin facili ) Feet Furnished by n I I i I TOWN OF BARNSTABLE LOCATION '3 yy him/.4-1 6;; SEWAGE # 7S' VILLAGE ASSESSOR'S MAP &LOT v�ak/�5'��/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 15�5- G,94 i LEACHING FACILITY: (type) l"/Xz-/q (size) 5 x 6'© NO.OF BEDROOMS y -W.qLBER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 3.C r Feet Private Water Supply Well and Leaching Facility (If any wells exist j on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac g facility) Feet Furnished by 5a �Clga,vT a� /loUsr- ell rUGW3 4o i iqlln Dry Fr G 0 pa� � l3�aGk----------------------- Dour C BOA b ;�-- P pool— J t P, 339 578 788 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent Street&Num r P 3 ce,State,&ZIP Code Postage $ Certified Fee 2-0 Special Delivery Fee 1 Restricted Delivery Fee LO Return Receipt Showing to Whom&Date Delivered n Return Receipt Showing to Whom, Q Date,&Addressee's Address 1 0 TOTAL Postage&Fees $ M Postmark or Date 9 EO Z Cn a Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). n 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the CJ return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. CO ' 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. `o LL 6. Save this receipt and present it if you make an inquiry. a t Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 208 044- - Account No: 126722 Parent : Location: 340 MAIN ST Neighborhood: 44BB Fire Dist : CO Devel Lot : Lot Size : 1 . 03 Acres Current Own: BERGLUND, STEVEN E State Class : 130 43 LEWIS BAY RD No. Bldgs : 3 Area: 3222 Year Added: HYANNIS MA 2601 Deed Date : Reference : 2510/140 January 1st : BERGLUND, STEVEN E Deed MMDD: 0000 Deed Ref : 2510/140 Comments : Values : Land: 45300 Buildings : Extra Features : Road System: 340 Index: 950 (MAIN STREET (CENT. ) ) Frntg: 150 Index: ( ) Frntg: Control Info: Last Auto Upd: 090493 Status : D Last TACS Update : 083089 Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : Taken: Account Status : Hold Status : THIS PARCEL IS IN-ACTIVE Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [208] [044] [001] [ ] [ ] FORM30 HOBBS&WARREN,INC.— let—, THE COMMONWEALTH OF MASSACHUSETTS a �U BOARD F HE wALTH lJ = - N or /_ CiTYftWN DEPARTMEN L ,, / c,�,M r ADDRESS ° � r � A, !'�7l /✓� T �ELEPH �ONE / Address�� % �IV fin. � Y� �ccupant C_ t\l m Floor,551./CJ, Apartment o. f7 No.of Occupants No.of Habitable Rooms I No./Sleeping Rooms No.dwelling or rooming units Storiesry�, Name and address,ofowner- yE�� °�1 ��l��C.L� Remarks Reg. Vlo. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: /CKES F01 7 J Dual Egress:and Obst'n:: ❑ B ❑ F ❑ M Doors,Windows: l I C.._ Roof Gutters, Drains: ► Walls: Foundation: Chimney: BASEMENT Gen.Sanitation:_ Dampness: 1 / / N Stairs: W _ , p _ Lighting: �.. STRUCTURE INT. Hall,Stairwa : A L � � -(V)1TT,� Obst'n.: 1 i la 1A if V � Hall, Floor,Wall,Ceiling cj irl f Hall Lighting: w r Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui .Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom— Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted # l 1 / ) �Iv Locks on.Doors:ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE i° ! ► OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR ;THE AUTHORIZED INSPECTOR.(See Over) f "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY INSPECTOR�/P" f r''t///� 11l it I tl l � r�i At 'TITLE f f J A.M. DATE ✓ 1 � TIME P:M. rl A.M. THE NEXT SCHEDULED REINSPECTION P.M. f w .b. 410 750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when-found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is _ _ _ issued to-comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or _ longer. (B) Failure to provide heat as required by 105 C_^iR 410.201 or improper - venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. ' (D). Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A); 410.253(A), 410.253(B) and the lighting in common area required by 105 CMR 410.254. -- - . (E) -Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage system in operable condition_as required by 105 CMR 410.150(A)(1) and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, Which prevents egress in case of an emergency 105 CMR 410.450 and .410.451. (11) Failure to comply with the security requirements of 105 CMR 411D.480(D). 7 (I). Failure to comply with any provisions of 105 CMR 410.600 through 410.602 -..-which-results in.any accumulation of garbage, rubbish, filth or other causes :.of sickness which may provide a food source or harborage for rodents, insects -<or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The'presence of lead-based paint on a dwelling or dwelling unit in .violation of the Massachusetts Department of Public Health Regualtions for - Lead Poisoning Prevention and Control-105 CMR 460.000. s(K)) Roof,.7fouridation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or ilpaiti nt to health -or dafety. ' L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted -plumbing, heating, gas-fitting and - ' electrical,wiring standards or failure to maintain such facilities as 4- are required by 105 CMR 410.351 and 416.352 so as to expose the occupant or anyone else to -fire, burns, shock, accident or other danger or impairment _ "toshealth or safety. (M) Any of the following'conditions which remain uncorrected for a period of five or more days following- the notice to or knowledge of the owner of said condition or conditions: (l) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack 'of a. stove and oven , or any defect that renders either operable. - (2) 'failure to provide a washbasin and.a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. Q)= any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted. plumbing heating,, gae-fitting, or electrical wiring -standards that do,not create an immediate hazard. (4)- 'failure to maintain a safe handrail or .protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B).. (5) failure to eliminate rodents, cockroaches, insect infestations and other pests,as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially Is"# the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board, of health.. SENDER: o ■Complete items 1 and/or 2 for additional services. I also wish to receive the y ■Complete items 3,4a,and 4b. following services(for an H ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. 4; ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address W permit. d ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N t ■The Return Receipt will show to whom the article was delivered and the date delivered. Consult postmaster for fee. o I 0 3.Article Addressed to: 4a.A ' le Number d I a 3 S-2 E s 4b.Service Type c°� ❑ Registered j j Certified Im I co ❑ Express Mail ❑ Insured c W I �a ❑ Return Receipt for Merchandise ❑ COD 7.Date Of Deliv p 5.Received By: (Print Name) y 8.Addressee's Address(Only if requested I W C `rr i and fee is paid) g 6.Sign at re (Ad resse rAger o\ = N PS Form 3811, Decemb ss4 ` Domestic Return Receipt 1 r UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Print your name, address, and ZIP Code in this box• I j Public Health Division i 'own of Barnstable P.O.Box 534 Hyannis,Massachusetts 02601 M I rl Q)CJTOWN OF B STABLE„�� 1.0CkTION v 1 ✓ SE` AGE # Irii.s AGEC rwyl ASSESSOR'S MAP &`CO —y��`'� INSTALLER'S NAME&PHONE NO. v SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMPTDATE: COMPLIANCE DATE: 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 P&Aj At ` .. �y 1 Commonwealth of Massachusetts Executive Office of Enviromnental Affairs Dept. of Environmental Protection One winter Street Boston Ma. 02108 John Grad ' D.C.P. Title V Septic Inspector P.O. Box 2119 T eaticket, MA 02536 WILLIAM F.WELD (HM 9 13 Governor /�� ARGEO PAUL CELLUCCI / Lt.Governor �SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR �VCOPART ACERTIFICATION 3 1999 Property Address: 340 MAIN ST.CENTERVILLE MAP 208 PAR 44 LOT 1 Address of Owner:Date of Inspection: 10/6198 (If different) WTAXEName of Inspector: JOHN GRACI DENNIS WAITEKUNAS;BOX 350 I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number. 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This Inspection is based on criteria defined In Title V Conditio all Passes code 310 CMR 16.303.My findings are of how the system is performing at the time of the Inspection.My inspection does — Needs ur er Evaluation By the Local Approving Authority not Imply any warranty or guarantee oftheiongevltyofthe Fells septic system and any of Its components useful life. Inspector's Signature: �T/ Date: low98 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127/97) - One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 340 MAIN ST.CENTERVILLE MAP 208 PAR"LOT 1 Owner: DENNIS WAITEKUNAS;BOX 350 SANDWICH MA. Date of Inspection:1016198 _ Sew.acte backup or.breakout or hioh.static water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to on ovoilocaded or cloggei.l cesspool. SAS is in hydraulic failure. (revised MUST) Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 340 MAIN ST.CENTERVILLE MAP 208 PAR"LOT t Owner: DENNIS WAITEKUNAS;BOX 350 SANDWICH MA. Date of Inspection:10I8199 D] SYSTEM FAILS(continued) Yes No 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 340 MAIN ST.CENTERVILLE MAP 208 PAR 44 LOT 1 Owner: DENNIS WAITEKUNAS;BOX 350 SANDWICH MA. Date of Inspection:1016199 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _X_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x — As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revlsed 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 340 MAIN ST.CENTERVILLE MAP 208 PAR"LOT 1 Owner: DENNIS INAITEKUNAS;BOX 350 SANDWICH MA. Date of Inspection:1016198 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g•p•d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd). nfa Sump Pump(yes or no): No Last date of occupancy: nIa COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow.0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nla Last date of occupancy: nla OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: SYTEM WAS PUMPED ON 924199 BY GELTZ System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: rya TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date installed(if known)and source information: SYSTEM WAS INSTALLED IN 1976 PERMIT 76.136 WITH REPAIR IN 1990 PERMIT090.179 Sewage odors detected when arriving at the site: (yes or no) No (reyleed 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 340 MAIN ST.CENTERVILLE MAP 208 PAR44 LOT 1 Owner: DENNIS WAITEKUNAS;BOX 350 SANDWICH MA. Date of Inspection:1016198 SEPTIC TANK: x (locate on site plan) Depth below grade: 9" Material of construction:x concreate_metal_FRP Polyethylene—other(explain) If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L10'6"H5-T"w6-8-- Sludge depth:0 Distance from top of sludge to bottom of outlet tee or baffle: o Scum thickness:U Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:0 How dimensions were determined: MEASURED Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERYTWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: rva Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nla Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:nfa Distance from bottom of scum to bottom of outlet tee or baffle: rds Date of last pumping;,la Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) We BUILDING SEWER: (Locate on site plan) Depth below grade: w, Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction IIne:TOWN Diameter. Ala Q'Imments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04117)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 340 MAIN ST.CENTERVILLE MAP 208 PAR44 LOT 7 Owner: DENNIS WAITEKUNAS;BOX 350 SANDWICH MA. Date of Inspection:1016199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: nia Capacity: nla gallons Design flow: ryagallons/day Alarm level:_nia Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nia Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ve: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 340 MAIN ST.CENTERVILLE MAP 208 PAR 44 LOT t Owner: DENNIS WAITEKUNAS;BOX 350 SANDWICH MA. Date of Inspection:1016198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: rda leaching chambers,number:Na leaching galleries,number: 6-GALLERIES leaching trenches, number,length: Na leaching fields,number, dimensions:Na overflow cesspool,number:nIa Alternate system: rua Name of Technology._nra Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) THE LEACH FIELD IS FUNCTIONG PROPERLY.SHOWS NO SIGNS OF FAILURE CESSPOOLS: (locate on site plan) Number and configuration: nIa Depth-top of liquid to inlet invert: ria Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY: (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na (revised 00127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 340 MAIN ST.CENTERVILLE MAP 208 PAR 44 LOT 1 DENNIS WAITEKUNAS;BOX 350 SANDWICH MA. 1016198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) AQ 37' FyA I..l r, (revlced 04R7197) Page 9 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 340 MAIN ST.CENTERVILLE MAP 208 PAR 44 LOT 1 DENNIS WAITEKUNAS;BOX 350 SANDWICH MA. 1016198 Depth of groundwater 10 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS I (revisedW2737) rage 10 of 10 0 TOWNJOF BARNSTAB,�� `q -,- � 5� LOCATION aAS SEWAGE # yII 1 AGE ASSESSOR'S MAP& INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) t U (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: 1� 1,3 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) r�f \ Feet Furnished by �� l Q�-L WIF) 4b SD CERTIFIED SEPTIC SYSTEM REPORT F NOV LOCATION 340 MAIN ST . CENTERVILLE, MA 02632 MAP 208 PARCEL 044001 LOT 1 PREPARED FOR SELLER DR . STEVEN BERGLUND 39 SHEPARD "S WAY BARNSTABLE, MA 02630 BUYER NONE AT THIS TIME PREPARED BY HILLIARD HILLER, JR. P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 Commonwealth of Massachusetts Pit Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld C,owmor Trudy Core Seentary,EOFJ► David corn B�S�trurha SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 3W ST G'ex-r1'ee.-1eec Address of Owner: OR JTev{,v ��GLv•vo Date of Inspection: /,Zy/y -'s /"Ap (If different) 21 Name of Inspector: A11Zelf .SX ,Bn,P,v3I�9$G,� �►/9 �?C3r'• Company Name, Address and Telephone Number: G,E�t/TXi�ri/GG�C -q-A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance.of on-site sewage disposal systems. The system: L,-fasses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails ' Inspector's Signature: � Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or,repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If'not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 Is FAX(617)S56-1049 e _ Telephone(617)292-5500 " Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30o G A-le. fr'ifi�s/r��•� s"�T Owner: OrP. ST1' 4WAC L Date of Inspection: B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The wstem has a septic tank and soil absorption system and is within 100 feet to a surface water supply ca oibutary to a surface water supply. The wstem has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system ha., a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35/o hifiv Si Gl�,litL/l�i�t..et �•/1: Owner: 44-49-14 Date of Inspection: 1"PA ' X, D] SYSTEM FAILS (continued): 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. !revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property.Address: ,3�✓O tiiAi� 5� CL.v�/LCr//GL/t' �i�° Owner: Dk'. SiXv1fl oe4r C v t'i0 Date of Inspection: ,�pfj�0 API.-� i Check if the following have been done: '_'Pumping information was requested of the owner, occupant, and Board of Health. //None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or a5 part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. i,"'The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow JZThe site was inspected for signs of breakout. ZAII system components, excluding the Soil Absorption System, have been located on the site. 1/1he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. VThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. Zhe facility o.%ncr (and occupants, if different f c7r ov,,ner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: S% G ,l/l✓L,!l//GL/� /� Owner. �R SJ,evly .dG'2GGr/,vy Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: y Number of current residents: oZ Garbage grinder(yes or no):, V Laundry connected to system (yes or no):_Jf,5' Seasonal use (yes or no):-&V— Water meter readings, if available: 3,7V 6VYL 141;15;3 42*9 Z. mod% S�urf'�t/ �Ofli?i.�rr ,vls if 7' 3 Yo e 3 YO" Last date of occupancy: n�ds��lLy COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped gallons Reason for pumping. TYPE OF SYSTEM _ 4.� Septic tank/1irAF&W6GA-bex/50il absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: !r/STiS+y iv /r�s- P�.GfiT I:r-7S-17 Sewage odors detected when arriving at the site: (yes or no) tzevised 8/15/95) 5 0 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 3yv "/,4/ Si P.vT�C /GG C cif Owner: VA' 5Tf.11M',v ".CG L v vo Date of Inspection: "-/iB s SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: .4,::!E6ncrete _metal _FRP—other(explain) Dimensions: S12 X O G* C47,0 Sludge depth: /.:1" „ Distance from top of sludge to bottom of outlet tee or baffle: I8 Scum thickness: O Distance from top of scum to top of outlet tee or baffle: — Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Tfil-/: 6 Lf fs Lc�f.`ry Gcrao GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of 5rum t- hottorn of owlel tee or bathe Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 r c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 yo hi9iie/ 57 G f it/T,"e ozC6 C Owner: O/� sdfv l��GLvwD Date of Inspection: TIGHT OR HOLDING TANK:_— . (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design floe: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if, level and d;str,buticr. ; equal, evidence of so!id! cam,over, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_` (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 i ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 y0 -/-,vT4.,f eL'[ oer/f Owner: Of. A6,e/16 Lv�iv Date of Inspection: -1%- Q ia/•11r'119T� SOIL ABSORPTION SYSTEM (SAS): . ' (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) if not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number,length: leaching fields, number, dimensions: / f40 /T XB, overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) 151cl'.Psy Ty 31G11- F/CAD 7&Z—,,U 6-64S CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) Corments: (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.) (Yevised 8/15/95) B L , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 3 yo 1"1,,41 53 Owner. ;D/Q . SjYdff/ dVilGe44,r Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' FRo,Ur I � s i /7, 8, DEPTH TO GROUNDWATER Depth to groundwater: 4�2 S feet method of determination or approximation: T/' Sr?f.' _ ' s°,c� dolt /4 iy.� i 5 s>=',•s i'�vT/ir�cJ S7�<yt y 8. QC'/�G4u'ND" DTD (revised 8/15/95) i 9 Ti7c"' GSA%^ "r ® I°:'t.. S 7.4 — 5; IQ. TOWN OF BA NSTAB DONC'ATION y0 1 < zIJEWAGE # VILLAGE (I)Pn er d l tk ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. /�f / Al(f 0 77,'-Q furs SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (. CL l -C S (sue) NO. OF BEDROOMS 7' PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER A) DATE PERMIT ISSUED: DATE COZIPLIANCE ISSUED: VARIANCE GRANTED: Yes No s. �a �s . yo� I-- Fims..a.r............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allp iratinn for Biipnsal Works Tonstrurtiun Jkrufit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: I ....lei.aj) 3ire4..eoaite_AI e............................... -----------------------------------------------•-•----.....-•-•--•---•----•------................. Location-Address ; orAddlTs. t No. EQG►,k�� S�ev¢h - ..3_ ............................ ...... fiOwner ] `------------------------------------------------- {� Installer Addre Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) U '4 Other—T e of Building .............. No. of persons_......._......_...._......_ Showers — Cafeteria Pa Other 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 ( ) a Percolation Test Results Performed by--------------------------- ---------------------------------------------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------------------------•--------------------------------------------------............................................................ 0 Description of Soil-----------------------------------------------------------------------------------------------------------------------•------------------------------.._....---------- x W -----•••---------------- ----------------------•----------------•-------------•--••-----------------•-------•-- ---------------- - 7 ------------- UNature of Repairs or Alterations—Answer when applicable.�5 ___ (1�. �__`�l�u__-6*'�.�1�[� ._ _�5__.�1 ......... ---------------------------------------------------------------------------------------------------------------------------------------------- Agree-n nt: 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 Complian has been issued by the board of health. Signed --------------------------------------------------- ---`� /GO -- - ------------------ Date Application Approved By ----------- 3..-Dve /oD Application Disapproved for the following reasons- ----------------...................................................................................................................... ........................................... ........................ .......... -- -- . ...-------- -- ----------------- Da 1 q Permit No: ....... � _---_----------. Issued -- -------------------------------------------------------te-------- Date t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE AppliratioitA for Disposal Works Tonstrnr#ion jrrmff Application is hereby made for a Permit to Construct ( ) or Repair ()4�) an Individual Sewage Disposal System at: Location-Address Z. ? Lo No. CL Owner ]? A r-rG1?4tocu! ------------------------------------•--------------•-----•--•--------' _3S0_-- � r ...................... Installer Addre Type of Building Size Lot-----------------------------Sq. feet U a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...................... .- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ , 9 --------------------------------------------------••----•--•------------...........-----------............----•------•-----••--------------•--•---•-.......•. ODescription of Soil........................................................................................................................................................................ x �v w --- --------------------------------•................ .----------- - U Nature of Repairs or Alterations-Answer when applicable..� 1�c4._.5!- . �,._'�.�5 _ t1�?r _.leat ._� e,.._.__.. -26.-tp !.c!!-.47-.--•---------------•-----------•------------•--.....---------........---...........-•-•---------------------- Agreem nt: 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 board of health. I' Signed ------ -------- ------------------------- ` � G 9Q.................. r 1e , ApplicationApproved By ---------- ..... {f- -------------------------------------------------------------------- Application Disapproved for the ollowi g reasons- .............................-------............ --------------.-..------------- --- -----......----fe----------------- - ----------------._..............................................................................................'---......-.....--.......--....--......--...........------ ................Dare ----------------- Permit No. -------- .6------llvq-------------------------- Issued - Date THE COMMONWEALTH OF MASSACHUSETTS J3E� BOARD OF HEALTH TOWN OF BARNSTABLE Certifira e of Comlalia nee THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed-( ) or Repaired by--------------- -- -------J-'..�.-`y.a ..� -----------.--------------------------nsta-ll--- I � l � Ier .....................................................................1------------------------------------------- . at ---------------------- --- - ►. ----.................. has been installed in accordance with t e provisions of TITLE 5� The St Environmental Cod"e as described in the application for Disposal Works Construction Permit No. ...................................1�_,.. �---)- dated --/-�--------------------- ----- - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED_AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. % ' ............................................. Inspector� . DATE-------..:4.--.:./..�� ....THE COMMONWEALTH OF MASSACHUSETTS (r lr1 BOARD OF HEALTH TOWN OF BARNSTABLE Noa h..... `.... FEE o..-.... Disposal Worko Tonstrudion unfit Permission is hereby granted........,A-- .......�.oi •----••-•------------•-••----...--••---------------•-----•-••---•---..................... to Construct ( ) or Repair (- ) an Individual Sewage Disposal System at No. ? t ` - ' !1• _& �� --•------------------------•-•-•-•-------------•---------- �_._....._ -- v �-----•-a--,-------------� - - -•-----•-•--•-----•-- street as shown on the application for Disposal Works Construction Permit N6 717,___ Dated.......................................... � -- ;'_e .._.....-•--••••••••••••••-•--•-...•--•..............._...--- � DATE................�,f._v..l.,Z�..--�--�...................................... ...................... 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E EN No IIIIISSIMMER ' �I■■■r■■■r■.g■ 1�■I■■.■■■■.■■■■ ■■ ■■■ ■■■■■■■■■■■e il■■�■■■■■■■■■■■ ■■ ■ ■ mom III ■ON1 � ®!A ■ ■ ■ ■■■1■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ®■■I■■■■■■■■.■■■■■.■■■■■■■.■■■■.■■■■■■■■E a � TO 7;OF BARRN�ST J LOCATION S�v Aneir/ .s 7- 2 SEWAGE # 7S-/3C • Lam? / 1,'II.LLAGE G Vr"? // ASSESSOR'S MAP & LOT a�S/oyy�l INSTALLER'S NAME&PHONE NO. 0a L-,0'GZ y SEPTIC TANK CAPACITY V5Z-1 C9e LEACHING FACILITY: (type) (size) 8"A WIt/Z,-e- C,,VuWis NO.OF BEDROOMS BtMZ2kOROWNER rl�'. sT�v�v f� �Lvvp PERMIT DATE: 6-- 3-7s' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 leachin f �ii,li��,�'') Feet Furnished by i � y s TOWN OF ARNSTABL .30( LOCATION /ir/ 6"— )SEWAGE # 7. VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACU ITY: (type) (size) S'x 5'a NO. OF BEDROOMS V -BURDER OR OWNER PERMIT DATE: C-3-7> COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 3.C r 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 leac ng facility) Feet Furnished by �R 2�, a� � ' � � .. �� Y• � 3, ��- "y a�' B �`RovT ��= Hvvsr- tac LOCATIOP 5EW&C4E PERMIT 1J0VILLAGE re IWSTNLLERS 1l&t-. F- 6, ADDRESS IEWIL E . ,5 1J E e, ADDRESS 1 DATE PERNA T ISSUED D &TE COMPLI &KICE ISSUED : V/— L� 7 �qo �y> 1 LOCATION 5EW6,C,E PERMIT UO. VILLAGE - . - - - - il�lSTQLLERS� 1J�I�II � ADDRESS 43U1LDER 5 iJ &V AE ADDRESS DN.-TE PERWT ISSUED D �.TE COMPLI &I ACE ISSUED . "� -7 .n C- . i . $ b +� �� F 1 � __ � � -� _ � P No....... 0----.. Fms.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH �� -v�..... ..........OF.......................................... ........--._...-------................--" Applirtation lar Dbtip i al Works Tows urfion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --------------------------------------•-------•-------------------------------------.._..--•---•-- ...................................................--•------------------------------------------ Q_...—ocation• dress or Lot No. .................... ---........••-----••-•------.........-•'- 11wn.r Address a ......................................... ...........••'--•"'•-----•--•---...........------•--------••-----....................--•-••...--- staller Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms-------------------------------------_------Expansion Attic ( ) Garbage Grinder ( ) pa.., Other—Type of Building ________________•_._________ No. of persons............................ Showers ( ) — Cafeteria ( ) 0.' Other fixtures ------------------------------------------------------ W Design Flow........................................... -Mons per person per day. Total daily flow--------------------------------------------gallons. WSeptic "1'ankLiquid capacity_��allons Length---------------- Width---------- ---- Diameter----------...... Depth--------------- x Disposal Trench—No-----------__________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No--------------_----- Diameter.................... Depth below inle ._�2 ___----_.. . Total leaching area._______..._.-_-sq. ft. z Other Distribution box ( ) Dosing t nk Y ( ) — f �C� Percolation Test Results Performed b � ---------------------------------- Date Test Pit No. 1----------------minutes per inch Depth of T st Pit-.._...-.___--_____. Depth to ground water.---___--___-._-__._._.- LL, Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to gr nn w er__.__-___ ______ __- •-----. ---•-------------• - - ...-•-•-•-•-----' ............. d� yam- - --------------_---------- Description of So'1O ------•-----•--•••-•---•----•-----•------•--•--•-•----•-----•----- _' -- ----�..... ................................v --------------------------- ------------------- --------------------------------------------------------------- ------------------------------------------ - - - ----- -------- V Nat r of Repairs or Al erations Answer when pplica le._.f_5- '------- - ----- --t"'------- Agreement: -b............. .....-.-.-.-.-.-.-.-.-.-.-.-. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board f health. Signed ... �--------.........I.``- •---_---------------- --?/ Date ApplicationApproved BY----------------------.................................. ---•-------••--•-•••••-"'--'------- ---'--------•---... -------------- Date iApplication Disapproved for the following reasons--------------------------------------------------------------- ---------------------------------------- ---•••••••-•--......••• •'•'...-•'•-•'---'----'------•-•••'---- ------------ -------------- ate . PermitNo..................................-...................... Issued----- -----`- ............................... Date No.•••••-/3•-0••••-- Fzcs....D_e. - ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFHEALTH . OF.... �............................ ................... ........................... Applirtt#inn for Bi_qpugtt1 Works Tonstrur#ion Vrruii# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. `-�..---------{-'---<='y' - -- -�---------------------W / / j wner Address ------------`................ ......-- .. ----------------------------------------- --------------- •--------............----•----.......----•----------•----------------------------- staller Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------------------•------------------------------ 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 ( - d h_ //C 1� . aPercolation Test Results Performed by--- - --------------- Date•----__-__------_--__-__----___--_-----. Test Pit No. 1_____________•__minutes per inch Depth u T s� t Pit....._..................... Depth to ground water..--__--.-_.-----_---- ' fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix •-••--••••-•----------------------------•--•-•--•••--•••--•-----••••-•-••--•-------•--••-•-----•..........••-- .............................................. 0 Description of Soil..................................................................................................._---------------------- --------------- --------------•.._..-------- _. U ------------------------��---a---------------- -----------------------------------------------------------------------------------------------_.-.------------- W ---------- -------------- --------------.....................--- ---------------------------------------------------------------------------------------------------------- U Natpre of Repairs or Al erations _�Answer when pplicable.. ."- Z. ' _.-__ '- .. ._. -_................. -- -- -------- -- ------------- v - - -'-- Agreement: J The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign s------ '- ..a'!.--�•---�. -1--------•---•------•-•------ G -t J -- Date ApplicationApproved By...........................•------•-•--•--•----•-------------•----...-------•-•••............•... Date Application Disapproved for the following reasons:................................................................................................................ ..-•••••--•••-•---•-••••••-••---••--••••-•-------•------------•-••...•----•---•--•-••--•-••••-••-•••-••--••••-•-•-••-------•----•--•-----•-•----••----•--•-•--------------•-••......................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................I.............OF........ ..................................................................... IvErr#ifiratr of TOmplittnrr THISJS TQ CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (-- L- t by-----••--------•-•.............•-•-•-•-•-•s•• ------•----------------•-----------------------------------------------------------------------------------------------•-----.-._-------.-•---- , Insta er �at-----------_f/_0._._......•- 'J......-•-- ----•-\--•-- '= has been installed in accordance with the provisions of le XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit N � .. ........... dated...._&_..-? - ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l ry� ........................................OF.. .. :.......................................................................... c J No.... 3 ........ FEE...`-................... �rrk,�,�ntt�#r�tr#i�at �rrmi# Permission is hereby granted________r r.d________--_ __._..... to Construct ( ) or Repair (t- ) an I dividual•-Sewage Disposal System at No. ,� (_f J wI Ec,4-.� 1 �I C ¢-, .� • •-••••••-•••••---•-••-••----••......-•--•-. •---......._.--------- ---------.. ------=--------------------------------------------------------------•-- "y Street _ �. ~ as shown on the application for Disposal Works Construction mit U____ __ ____________ Dated___.1..l3. ............_.__........ / Board o Hea th DATE,E�'--••3.......... J-------------------------------------------•-- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS e�v /- J_ 9 1 �I i 1 yr•`f __ _ _ S 49'18'56" W stockade fence LEGEND o N ----- _ X 95,73 -----------1-6-3-.512-A-9,5---------\ 0 98 -- EXISTING CONTOUR N a 0 x 100.98 EXISTING SPOT GRADE " --�_--_ 93,96 \ EXISTING CONTOUR o ono. 95.44 W EXISTING WATER SERVICE e. i � - x � 8v BRICK Benchmark No.; 1 LAMP FLAGGED SPIKE SET/ G EXISTING GAS SERVICE r N ' -95--` _ � e - EL.=94.83 (Assumed datum) � --0.1-1:W.- OVERHEAD WIRES � a - --------- O LT% \� �� Q TEST PIT ° 5` LOCUS DECK ^ O i.-�94 8a/' �ARKING $TONE �' BENCHMARKPT E 8�T � LOCUCP NOT S SCALE cS, ' �REA _��! ------- \0v 1 `o �`' GENERAL NOTES: I r EX/STING 96,81 i BUILDING(#344) `x I \\ (LOl 1) j 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL T.O.F.=100.74±1 x 98,9,1 API 08-04 -001 CND 1 BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 97V2 N\ �� 95,16 \ 23,999 S. t �`� OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE o,� LOCAL RULES AND REGULATIONS. 20' WIDE gti c, UTILITY Qv ,Q 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR , TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE o I ` G'� � 98.2 ;y•� ��\ EASEMENT-�\ e DESIGN ENGINEER. �!;I39,70 lip WALK + �� \�� 95,81 j Q0�Q9 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING L 99 73 � 96,0�/ STONE 95,74 I FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN • p 99� 1 96-g3 DRIVEWAY \ z ENGINEER BEFORE CONSTRUCTION CONTINUES. b ® O.H: 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. Im' P UFh RE-CONNECT i P ' 100,06 99 0 \ / p 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF (A THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF ' + �\ \` °o0 9 ,769 ' � p } HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.. C° I 99.69 ❑ � �� of / ' p I 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. OF Mgss 99.3 i-----i 9E, � � ' 96 I 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. Q� 9� 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS o� PETER T. �G✓ i i I 1EXISTING I �� c7�, 95.41 \ \� AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE I I BUILDING 340 I t' DIRECTED BY THE APPROVING AUTHORITIES. Jg McENTEE Ln 1 (# ) a o G) 1 x 100.011 I "� O. 6 EXISITNG WATER SVC. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY CIVIL i 4-1 BEDROOM CONDOMINIUMS LP 99.77 I 1 `9 � TO HOUSE NO. 350 THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING No. 35109 6 p I I T.0.F.=100.94t/ �- 0 N cn I I �\ C 96, 9 9 6.9 9 CONSTRUCTION. op R£GISZE�� `�� I j V,�\E 14.2 CHARCOAL 1 1. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS .p c0 I , IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND FSS10 i1 II 99,7 + i x�98.0 I -I j, '\ ANT REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). (z11/ r I I ORCH TP-1 \ •�dT� ,� 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE ) EXISTING S.A.S. BDG.#344 99.82 � ��\'� 99.75 I �� 1--4p 10 INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. p , TDD.00 99,85 x TAKEN FROM RECORD AS-BUILT �� L�4MP x , & \ I 1. 101 0 \ 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND DATED 8113107 ' O OT r -u»r IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. x 99,6 1 TP-2 x I I I �Iml I PROPOSED SLEEVED EXISTING SEPTIC TANK , ' I 9�, L9 i WATER SERVICE OWNERS OF RECORD -- -- I 20804410A - WELLS, TOWNSEND P (1500 GALLON-TO REMAIN) j r_________ --� / I I � 1,0' PLAN REVISION-9/12/11 20804410B - NAMES, KATIE ELIZABETH TOP OF TANK, EL.=99.19 ! �, 100,03 i I I I i `9� 1. ADD UTILITY EASEMENT-BK 8051/PG 335 20804410C - MEDLIN, KAREN M INV.(OUT)=97.86t I 1 p ll Q I • I J 2. SHOW WATER SVC. TO HOUSE #350 WITH 2O804410D - BRANDT, AUDREY EXISTING S.A.S. (BDG.#340) I 9 4 RELOCATION AROUND PROPOSED S.A.S. 20804410E - RUBINO, THOMAS A TAKEN FROM RECORD AS-BOIL-7' 1A)'11 7 v L----------------101, b9,27 �c�iL5 2080441OF - SOLIWODA, PAMELA H DATED 11 1/08, TO BE PUMPED I I o' IPROPOSED 2080441OG - STRANGER, MARTHA E / 00.40 o � WATER SVFILLED W/SAND & ABANDONED LAMj,= 44.26 � 8KE + 9CB 8 39 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 31 , 99,6 85.29 z 100,22 + 100.18 , N 49.39'50" paved sidewalk UP N 50.50'00" 340 MAIN STREET, CENTERVILLE, MA o Prepared for: Centerville Gardens Condominiums, 340 Main Street, Centerville, MA 02632 99,58 edge of pavement/berm 98.65 97.93 100,11M1oa Engineering by: SCALE DRAWN JOB. NO. 100.52 Benchmark No. 2 Engineering Works, Inc. 1"=20' P.T.M. 194-11 MAIN S TREE T TOP OF CONC. BOUND Cross field datum) 12 West Cfield Road, Forestdale, MA 02644 DATE CHECKED SHEET No. (508) 477-5313 7/27/11 P.T.M. 1 Of 2 FINISH GRADE SHALL NOT BE < EL.94.8 j FOR A DISTANCE OF 15' AROUND THE SEPTIC TANK PERIMETER OF THE S.A.S. PROPOSED D-BOX PROPOSED S.A.S. CHARCOAL INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT FRAME INSTALL INSPECTION PORT OVER END UNIT VENT T.O.F. OUTLET AND SET TO 6' OF FINISH GRADE & COVER (H-20) SET TO GRADE CONNECT F.G: 96.33 (MIN.) ,j ALL LINES EXISTING F.G. EL.=99.8f F.G. EL: 98.0f /MAINTAIN TO 97.83 (MAX.) TO VENT 2% GRADE (MIN.) OVER S.A.S. INSPECTION BIAXIAL GEOGRID-BX TYPE L = 46' L = 11'(MAX.) EXTEND 1 FT. BEYOND S.A.S. PORT S=1% (MIN.) S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC 12" iEXISTING 6" 10 I S" BUILDING(#340) 14" 1 o.7s° ro EXISITNG 48" LIQUID INVERT 4-1 BEDROOM CONDOMINIUMS S' LEVEL T 0.F.=100.94f/ GAS BAFFLE INV.=94.67 PROPOSED INV.=94.50 5 ROWS OF s UNITS AT 5.0'/ NIT = 25.0' 2' INV.=97.86t D-BOX INV.=94.40 EXISITNG (H-20) SOIL ABSORPTION SYSTEM (PROFILE) 20.0' EXISTING SEPTIC TANK BIAXIAL GEOGRID / BX TYPE PORCH PRODUCED BY TENSAR CORP. ATLANTA GEORGIA ; (n p 1 NOTES: RESTORED DRIVEWAY SURFACE �2, 1 CONTRACTOR SHALL VERIFY ALL EXISTING PIPE COMPACTED, CLEAN GRAVEL BACKFILL BACKFILL WITH CLEAN 1'f DOUBLE INVERTS, PRIOR TO INSTALLATION. 18" MINIMUM COVER SHED STONE TO TOP OF CHAMBERS , 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE OVER UNITS BREAKOUT=TOP � ON A MECHANICALLY COMPACTED SIX INCH CRUSHED TOP ELEV.=94.83TEFFECTIVE STONE BASE, AS SPECIFIED IN 310 CMR 15.212 (2). INV. ELEV.=94.40 12" 3) INSTALL INLET & OUTLET TEES AS REQUIRED. BOTTOM ELEV.=93.50 Oo 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEEAS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. PLACE APPROVED 4' MIN. SEPARATION FILTER FABRIC TO HIGH GROUNDWATER H=14.2' OVER STONE p 98.56 EXISTING SUITABLE SAS LAYOUT SPIKE2 HIGH GROUNDWATER, EL=89.43 z UNITS MUST BE STAMPED H-20 MATERIAL SEPTIC SYSTEM PROFILE SEPARATIIONSBETWEEN USE 5 OF 5- DEACHcROW & NO STO36HC UNITSINE TH NO 63.25" TYPICAL SECTION 16" SOIL LOG 34.5" DESIGN CRITERIA DATE: JULY 27, 2011 (REF P#13,364) ly BUILDING #340 SOIL EVALUATOR: PETER McENTEE (SE#1542) TOP VIEW NUMBER OF BEDROOMS: 4 BEDROOMS (4-1 bedroom condos) WITNESS: DONALD DESMARAIS-HEALTH AGENT SOIL TEXTURAL CLASS: CLASS I Elev. TP- Depth Elev. TP-2 Depth END CAP END CAP -so" DESIGN PERCOLATION RATE: 4 MIN/IN 98.43 O/A 0" 98.60 O/A O„ FRONT VIEW SIDE VIEW END CAP DAILY FLOW: 440 G.P.D. SANDY LOAM SANDY LOAM REAR/TOP VIEW 10YR 4/2 10YR 4/2 97.43 B 12' 97.60 B $ NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW DESIGN FLOW: 440 G.P.D. TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY GARBAGE GRINDER: NO SANDY LOAM SANDY LOAM DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. LEACHING AREA REQUIRED: 440 = 594.E S.F. 1OYR 5/8 1OYR 5/8 rr 4640 TRUEMAN BLVD ( ) 95.43 36" 95.93 28" ®HILLIARD, OHIO 43026 Are 36HC DETAIL a .74 C PERC O ADVANCED DRAINAGE SYSTEMS,INC. UNITS MUST BE STAMPED H-20 EXISTING SEPTIC TANK: 1500 GALLON CAPACITY 36"/48' I PROPOSED SEPTIC SYSTEM UPGRADE PLAN PROPOSED D-BOX:: 1 INLET, 5 OUTLET (MINIMUM), RATED H-20 2.5YS6/4D ` 2.5Y 6/4D USE 5 ROWS OF 5-ADS Arc 36HC UNITS WITH NO 5-10%GRAVEL 5-10%GRAVEL 340 MAIN STREET, CENTERVILLE, MA SEPARATION BETWEEN EACH ROW & NO STONE 89,43 MOTTLING 108" gg,43 MOTTLING 110„ Prepared for: Centerville Gardens Condominiums, 340 Main Street, Centerville, MA 02632 7.5YR 5/8- 7.5YR 5/8 4 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF UNIT) ss.10 STG. G.W. 112" 89.10 STG. G.W. r 114" Engineering by: SCALE DRAWN JOB. NO. 60 88.43 120" 88. 120" Engineering Works, Inc. NTS P.T.M. 194-11 (Arc36HC Units) 25 UNITS x 5.0 LF x 4.80 SF/LF = 600.0 SF 9 g DESIGN FLOW PROVIDED: 0.74 600.0 S.F. = 444.0 G.P.D. PERC RATE 4 MIN/IN. ("C" HORIZON) 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. ( ) ESTIMATED HIGH GROUNDWATER, EL.=89.43 (MOTTLING) (508) 477-5313 7/27/11 P.T.M. 2 Of 2