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HomeMy WebLinkAbout0059 NORTH PRECINCT ROAD - Health 59 North Centerville A = 148 I MENEM SEEM ■■ ■■■■ ■■■■■■■■■■■■■■■■■■■■■■■�■■�■■■■■■■■■■■ 1■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ 1■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ 1■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■o■■ 1■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■m■■■■■■■■■ Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Tj 59 North Precinct Rd 't Property Address Nancy LaCouture Owner Owner's Name information is Centerville,/ _ Ma 026.32 2/14/17 required for every _ page. City/Town ; State Zip Code Date of InspectionCID - � Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General-Information filling out forms on the computer, ` use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return ---------------------------------'------------_._.------------------------- key. Name of Inspector DiBuono Sewer and Drain rea Company Name ... -- — .---- - ----- 8 Johns path Company Address ermn S Yarmouth + MA_ 02664 City/Town State Zip Code 508-364_-9587 _ _ _ S113522 _ Telephone Number License Number B. Certification 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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of'.completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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. 'I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 1 of 17 i v vs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd _ Property Address Nancy LaCouture Owner Owner's Name ---------------- ----- - information is required for every Centerville _ Ma 02632 2/14_/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ® -1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: I , System is functioning as intended and contains 1,000 Gallon septic tank as well as a concrete distribution box and a 1,000 GI concrete leach ip t. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound exhibits subst antial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a"complying septic tank as approved by the Board of Health. ' A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts tileficil Inpecti®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 59 North Precinct Rd Property Address - Nancy LaCouture _ Owner Owner's Name information is Centerville Ma_ 02632 2/14/17 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B).. System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed 'pipe(Is) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): t 1 ❑ broken pipe(s) are replaced- ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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): l ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I ,I i C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system.is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 F Commonwealth._of Massachusetts `title 5 Officia.1 Inspection For Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 59 North Precinct Rd Property Address — Nancy LaCouture Owner Owner's Name information is required for every Centerville --- Ma 02632 2/14/17 _ page. City/Town _ State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance.- This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspect;on Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of (Massachusetts Title g Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd Property Address Nancy I-kouture Owner Owner's Name -- --- --— information is required for every Centerville Ma 02632 __ 2/14/17 _ _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping,more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or, tributary to a surface water supply. r ❑ ® 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.] 0 ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist,as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions.in Section D. Yes No I ❑ ❑ 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 isilocated in a nitrogen sensitive area (Interim Wellhead Protection Area=IWPA) or a mapped Zone Il of a public water supply well If you have answered ".yes" to any.question in Section Eahe system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 I i t .. Commonwealth of Massachusetts. Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd Property Address ----------------- ----------- ---- --- Nancy LaCouture Owner Owner's Name ------------------- --------------- — — information is required for every Centerville Ma 02632 2/14/17 page. CityFrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ - ® Were any of the system components pumped out in the previous two weeks? - I ® ❑ -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? N ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? - ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related.to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3— Number of bedrooms (actual): 3 DESIGN flow b 1 330 based on 3 0 CMR 15.203 for example: 1 10 d x#of bedrooms).- — ( p 9P t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd Property Address Nancy LaCouture Owner Owner's Name ---- ----- --- information is Centerville __ _ Ma 0_2632 2/14/17 required for every _ _ page. City/Town State Zip Code Date of Inspection D. System Information i Description: System is functioning as intended and contains 1,000 Gallon septic tank as well.as a concrete distribution box and a 1,000 GI concrete leach pit. , I I Number of current residents: ` 2 i 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 t Water meter readings, if available last 2 ears usage d 184 Gpd 9 ( Y 9 (gP ))� Detail: , Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type.of Establishment: t ---- I Design flow (based on 310 CMR 15.203): Cations per day(gpa) Basis of design flow (seats/.persons/sq.ft., etc.): — , Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No . Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts .-- W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e' 59 North Precinct Rd Property Address -- -- ---- -- Nancy LaCouture Owner —------- — --- -- — =----------- Owner's Name ---- information is required for every Centerville — Ma 02632 2/14/17 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 3/18/15 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons — How was quantity pumped determined? --- — Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest Inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe):. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd_ _ Property Address _ --- Nancy LaCouture Owner Owner's Name information is required for every Centerville ___ Ma__ 02632 _ 2/14/17 page. City/Town State Zip Code Date of Inspection D. System Informationi (cont.) Approximate age of all components, date installed (if known) and source of information: 24 Years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer (locate on site plan): ' Depth below grade: 1.5 ' 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.): . System is vented at roof line Septic Tank (locate on site plan)'i Depth below grade: 1 feet Material of construction: { ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 i • If tank is'metal, list age: years Is age confirmed by a Certificate ofiCompliance? (attach a copy of certificate) ❑ Yes.❑ No Dimensions: Sludge depth: I t. t5ins 3113 i' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17. p • Commonwealth of Massachusetts _ W Title `5 Official Inspection Form Subsurface Sewa a Disposal -- g p al System Form Not for Voluntary Assessments 59 North Precinct Rd Property Address Nancy LaCouture Owner Owner's Name information is Centerville Ma 02632 2/14/17 _ required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" 3,� { Scum thickness Distance from top of scum to top of outlet tee or baffle 42 — Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date ._. t5ins•3h3 - - - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts WNW, Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments 59 North Precinct Rd Property Address Nancy LaCouture _ Owner Owner's Name information is. Centerville Ma 02632 2/14/17 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information' (cont.) Comments (on pumping recommendations, inlet and.outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Baffles are in place I t 1 Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ----- Capacity: -- - gallons Design Flow: gallons per day Alarm present:_ ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): j t 4 *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 11 of 17 . t Commonwealth oUlWassachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd Property Address-------- ----------------- Nancy LaCouture Owner information is Owner s Name required for every Centerville Ma 02632 _ 2/14/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): a, t Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes_ ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required); If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd Property Address Nancy LaCouture Owner Owner's Name information is Centerville Ma 02632 2/14/17 required for every ._ — page. City/Town State Zip Code Date of Inspection D. System Information'(cont.) Type: ® leaching pits number.- leaching chambers number: ❑ leaching galleries number: — ❑ leaching trenche's number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments�(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of failure - --- --------.-_-.-- ---- --- ------ - ----- ---=--- -- __.-- ----- -- ------------- ------- ---- Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration I Depth-top of liquid to inlet invert II Depth of solids layer Depth of scum layer ------ Dimensions of cesspool --------- Materials of construction — Indication of groundwater inflow ❑ Yes t ❑ No. t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd Property Address Nancy LaCouture Owner Owners Name information is required for every Centerville Ma 02632 2/.14/17 page. City/Town State Zip Code Date of.inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i , 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.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Vol untary.Assessments 59 North Precinct Rd Property Address i Nancy LaCouture Owner Owner's Name -- --- ------- --- ---- information is Centerville _ Ma 02632 2/14/17 required for every " page. City/Town I 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 'l I I 1 , t5ins•3113 Title.5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 'i l i Commonwealth of Massachusetts w W Title 5 Official Inspection Fr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd Property Address Nancy LaCouture Owner Owner's Name information is required for every Centerville _ ___ Ma 02632 2/14/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water d , ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: ------ -- __ Date ❑ Observed site (abutting property/observation hole within 150 fe et 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: Usgs maps indicate NGE at 14' Before filing this Inspection,Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 17 s New Page 1 Page•1 of 1 LOCATION SEWAGE . PERMIT NO. Cry✓%�/Z l��AZIC 15%, VILLAGE a . .. ��{��'S,�n�eS •3`S�,.n �.✓�,.,_ �i 3 H�fivr ^'�_.Li"���.e%s�i t /LiiTSY' INS'TALLER'S NAME ADDRESS l; UflDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ; • i I; a I i i • �'RcN'I Q:- NSri i I L a , t I http://www.town.bamstable.ina,Lis/assessing/2009/'HMdisplay.asp?mappar=148132&seq=1 9/15/2009 Commonwealth of Massachusetts W `title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 North Precinct Rd Property Address Nancy LaCouture I Owner Owners Name information is required for every Centerville _Ma 0_2632 2/14/17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A,�B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ` ❑ Sketch of Sewage.Disposal System either drawn on{page 15 or attached in separate file • i � t j I. j I I i I I ' I i i I 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r TOWN OF BARNSTABLE LOCAT10N QQ[ctK7- fW SEWAGE # VILLAGE G' ucY�2����� ASSESSOR'S MAP LOT_ $- 13 INSTALLER'S NAME & PHONE NO. SEPTIC TANK!CAPACITY LEACHING FACILITY:(type) 'D Rz'-c AST- Pv i (size) �x 2 NO. OF BEDROOMS PRIVATE WELL 0&- C WA R' BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No / ��� L I 1 4 f b I I S O i � �I � � N� `� �� S�o�� No... .3.-..16:t - 3o............ THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH Barnstable Conservation Department TOWN OF BARNSTABLE 7_g XpV trttfton for DiriVttiinl Worlto TateMrnrtton F&tt Date Application is hereby made for a Permit to Construct ( ) or Repair (V/),�an Individual Sewage Disposal System at: .... _.�10 .... . _ c�i :�...--•---•-- -•-•----------•---------•-----•--------------• ............. Loc;Minn•:\tll9resy or Igtt No. ............... v ...... -.--. ------j—�--------.-.--------------- -----------------C f------Cc t` ... ......... O er Address Installe Address Type of Building Size Lot....................-----_._Sq. feet .-� Dwelling— No. of Bedrooms.-.--- --------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _------------------------, No. of persons-_---------.--------.--.--- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------------------•-----------------------•--•-••------•-•-....-•-... w Design Flow.............. ................gallons per person per day. Total daily flow...- 3. ........................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......I............ Diameter.....Iq........ Depth below inlet...&&.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- --------------- ................................................. Date......................................... Test Pit No. I................minutes per inch Depth of Test Pit.----------.------.- Depth to ground water........................ (� Test Pit No. 2................minutes per inch Depth of Test Pit..--................ Depth to ground water........................ x . ......................................................................................................................0 Descriptionof Soil_..................................................-------.....-------.............................................................................................. x c, -----------------------••-•...----•---•-••---......-•-•-•--•---•••••-•••----••••-•----••--•••-•--------•-----------•---•••-•---------...••....----•-----•----••••............. ------...... w ...............------------------------------------------••-...------ U Nature of Repairs or Alterations—Answer when applicable.. 5 �9 �-----1_n ao...L ec�G�.�tAT.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beepi issued by the board of health. 1..--.� L Signer �d -. ` - Application Approved By ...--...-.. C , J- \........... . ......... ..................................�............ ..........``'iDate Application Disapproved for the following reasons.; .................; .. ... .. ... .. . ......................... ........... ..................... ........................................... ..... . ...--..... ...... ...................--......--...................................... . -- ---- ........... ........................................ PermitNo. ...............J.�----6--.).......................- d+ Issued ........................................................Dare....... Daze „_,i'r'^`..1-i' .ti.,--....�.3.•'''i+4.""�ti.!•r�-..-.... ..:�---a.�.....-vR.+.-•^'.�•....�... ,.�'�......r..-.�...�,.I'r.. - --v” :... .... - v . w ,.. .. r �,� �.. •`mod, / �/�% +�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Anjifiratinn for Di ipw3u1 Works Tnnitrnrtinn Wrm t Application is hereby made for a Permit to Construct ( ) or Repair (V/11'an Individual Sewage Disposal System at: .................. ..9.....T(C> ..__ .�F.G I .......... •tion-Addres- ...................... Loca ................... or Lot t No. `. _. ��/ �oU �.Q O er Address .q .____ .......... Installe Address UType of Building Size Lot............................Sq. feet .. Dwelling—No. of Bedrooms------ 3--------------------------------Expansion Attic ( ) Garbage Grinder ( ) a` Other—T e of Buildiu 4 YP g -•-•-•------------------•--- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------_-------- W Design Flow------------- --?.................gallons per person per day. Total daily flow.._ >3. ........................gallons. WSeptic Tank—Liquid capacity............gallons Length__-.______.._._ Width................ Diameter................ Depth................ x Disposal Trench--No. .................... Width-------------------- Total Length.................... Total leaching area.. .................. ft. 3 Seepage Pit No------j............. Diameter----JP_----- Depth below inlet_.(Qf.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.................. ....................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water........................ (Tq Test Pit No. 2................minutes per inch Depth of Test Pit---------:7--------- Depth to ground water........................ a' •-•••••••.._.......-•----------•-••••-••--••----•-•---•--•••---••••............... .--........ .------------------------ ..._.................... 0 Description of Soil-•----....-•----•-••-•-----•--••-•.................................•-----------•--------.----•--- W V ............••••-••••-•-•••••••-•---•--•--•••----•--------••----••-----•...--••••.......••••-•-••-•-...•-•-.....••-------•--••--••------•---•-------....-••--•..............................:.... W U Nature of Repairs or Alterations—Answer when applicable._.--—'t-4:5T k9,t�---_1.0 D. ..... act-G{�-i/�tT-•-...•... ................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. gne Si fl�........................ --! �� --............. ..... ..........Le ..._J... Application Approved By ............. .-.. _�a, ..-t,t,K ai................................. .................. ............ ........ . ....... Application Disapproved for the following reasons: ............. ................. .. ........................................... .......................................... .. ... . .........................................1............ .. ........._............. ...--...._. .. ... ....__....._... .. _........--......................--.............. ........................................ Date PermitNo. ............7 .......J� ....................... Issued .................................................................... Dace >�������.� �.�.v.�-_...�s--�.��...m...=:_..:...,.�.....�.-,.�a.m-�:st.�.a_, �.w.��-...t.:.�s..��..,.�.,�.�:_...�._....���.�.-a._.,..-=.z�...�..�-�+�.�.-u-_�.a...V.•-.�.�.�...� .ems-.�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�erttf rate of Coinlalianre THIS IS TO CERTIFY, That the Individual Sewage Disposal Systems constructed ( ) or Repaired by ............................................. ...!4--Ph...l_.�AN- ....5-i° �.C...__..... ..... 1�,[auet at . - .......................... - ...... .............. ................-:._............... ......-. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .......r�..�...�.- �.. . dated ........................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........._........�.f...-.. ,n..73._.._._......-.... ................ ` Inspector ...._..- -- � --- ..--- ...............---- ..................... ......... �— - —.a­­—r as—--w.—r—.s»..c—.+..,..:—.mac—..n.———e..Ta—---.—ri—+..g�[ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH y TOWN OF BARNSTABLE No... G FEE....: ? ... Dispav l Works Tonotrudi.on rrmit Permission is herebyranted G !��......--- g �' ......••-•-.... to Construct ( ) or Repair ( Qj an Individual S wage Disposal System Street as shown on the application for Disposal Works Construction Permit No.� 3_"..`_ Dated.......................................... Board of Health DATE......................... 7' P -- ----------- FORM 38508 HOBBS Q WARREN.INC..PUBLISHERS c �., THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA I fig" 3Z Application -fur Dhipoizd lgorkii Tomitrnrtion Vrrmit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at, L Sq Nosh l _01�'Il6 d Lo at'on•Ad s or Lot No. 1�C a �2 1 L�ti----- ------ Y,............................................................. r \ / ddress nstal er Address Q Type of Buildin Size Lot.. O.v....Sq. feet ' Dwelling o. of Bedrooms-------Z............. __---.---_"__.Expansion Attic ( ) Garbage Grinder `4 Other—Type of Building p S ( ) ( ) YP g No. of persons ---------------- Showers._.... Cafeteria ......._. Q g Oths Mures --•------•------g(--- '----- -- --------------- ------------------•---------------•-- W Design Flow ......gallons per person per day. Total daily flow-__.Z4 d..........................gallons. W Dis Septic `Tre Li tNo ca�acity.- V-d6allons Length................ Width................ Diameter---------------- Depth._.____"_-_----- q 1 g" x p i _ _._.. Total Length-------------------- Total leaching area--------------------sq. ft. Seepage tPit o bo x . Diameter.......... Dosi.. tank Depthbelow inlet__ _______. _- Total leaching area..................sq. ft. Other ~" Percolation Test Results Performed by.__. ,__ �?,� Date.........................._"--_.__...-- Test Pit No. I................minutes per inch Dep of T t Pit.................... Depth to ground water_..__ _._".-.._...- 4-1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.._".-.-"_-"-"------.__. --- - --------------- J O �l Description of S�il ` e ----------------•-- --- �` "� fV � � ----------------------- i --------_"--------------- ---------------------------- ----------------------------------------------------------�-----------&v-iv- ------ I4 U Nature of Repairs or Alterations—Answer when pplicable.".---"--"""-------------"--__"-_".-.__-_._ __ ___.___- -------- -- -------•------------------------------------------------------ --' --.It - Gs Agreement: � �- The undersigned agrees to install the afored'escribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ue by e boa d ff h th Signed....... --- --- '---•- ... •-------•----"---._...-•---- Date Application Approved By----­----------- � -•-•-.-- !� - ',, -"74------ Application Disapproved for the following reasons________________________ •------------•-•----------------•---......_........................ Date---------•--.. ...--------•-----•------•-•-----•-•-•------------------------------------••---•-•---•--...•--•-••--•••--•.......------------.......---•------•------------------------------------...........------------ • Date .. Permit No......................................................... Issued...... �� �'r^ o 2 ... ................................... Date �� v No1/9 F>;;s.... .r�............... THE COMMONWEALTH OF MASSACHUSETTS BOARD JQF HEA1 T- - Appliration -fur Bhivoottl Workii Tottotrurtiutt Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: r) '-""4JnCAd�r-ess� .......................... or Lot No. Ile) Ixow ,r 7 C G/i �L f�G/r I f Ldress .................................................. •----_...__............._.......__._._....... ....-•••-•-••---------......•-••••-•......-•-........--•---------...................._........--- Installer Address /5 q Type of Building Size Lot............................5 feet Dwelling-No. of Bedrooms--.----�:--•-__. -.-----__-Expansion Attic ( ) Garbage Grinder .�1�_''__________________ No. of ersons--__`�________--__-_--- Showers — Cafeteria Other—Type of Building p ( ) ( ) 0.i Othu fixtures ---------------- --------- - W Design Flow...j.. ................................gallons per person per day. Total daily flow----- .........................gallons. WSeptic Tank—Liquid capacity---Vwgallons Length--________-•---- Width................ Diameter_......_..--.-- Depth........-....... x Disposal Trench—No ____________________ Width-------------------- Total Length----------_......... Total leaching area .--___.-...__--_sq. ft. Seepage Pit No.--/ ... --v--_- Diameter.................... Depth below inlet_ _______,.�..... Total leaching area------- ----------sq. ft. z Other Distribution box ( ) Dosing p ( ) G ��yJ , �0. > `/ _ a Percolation Test Results Performed by------.in'-.__j = _ Date----------------_._--_--.--___---.--- Test Pit No. 1----------------minutes per inch DeptK of Te/'Pit.................... Depth to ground water_--------------------- (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.--.---_---_------..-. ---------------------- ...... ; ----••-•-•--......; =......1 ......... G Description of Soil---- -----D`..l-.: _ ,,.if:. , i �l G f C� - ......... - - ---------------- x -• - • . ...........� . ' U ------------- �1 -any' `l -- �W, ------------------------------------------------------------------------------------------------- �':t` r1'�'� _ `------------- U Nature of Repairs or Alterations—Answer when applicable._-.---.....................................l. _.._........_.-.,__..__._........ 3X__ Agreement: G 6:tl �G 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 bee 'ss d.b the o�a',r�fof h�alth. ' 1G�(/� Signed -----•--•--•--------- ---------------------------- Date Application Approved B / _ _� f� ! ✓ !!•�_' PP PP Y / Date Application Disapproved for the following reasons: ----_._-- ---------------------------------------------------------------- ---------•--------------------------------------------------------------------------•---------------•---•.......-------------------•----------.......---------------------------------.......--------••-- Date PermitNo......................................................... Issued............................. ------------------••---• Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 06 HEALTH.,,, ..........................................OF............ ..G�- ................ ............... rl Tertif irate of f1,untplitturr �- THIS IS TO CERTIFY, That lie individual Sewage Disposal System constructed ( ) or Repaired ( ) by-. i� r—� = .1 ..... --------- ------- at... .....- ----1�-^ -/ ------- ----------_ ....'......"'.[-f-=ram-- St---er --------(.�-::G(ri-----------------^-..-----..._-•-----.................................. has been installed in accordance with the provisions of Article XI of Theme-State Sanitary Cpde as describ_ed�' the application for Disposal Works Construction Permit No.- ------- __r+_-"_. ------- dated...... `__ _'_ .0 _..._.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................. --••-•---------------••-•--••-•••••••-•-•---- Inspector-----------------------------...................................................... l THE COMMONWEALTH OF MASSACHUSETTS BOARD 0.177 HEALTH .........; ............ '....../....OF.........f ... �- c'x:=.................................... FEE -- No. ' �-- _...._.31 ._ Di-spofial luarkq � fot qyv iou Vrrmt Permission is hereby gr � �� /� -- --- ------- " ----- ............................................... to Construct or Repair (X �n I idual Sewage sp` sal ystem �/ }� at No. - =!---- /= l�< G�_ ! %/`�.l✓' C +� �_------- - t .... /s eet 1 _ as shown on the application for Disposal Works Construction Per it No.. l/%.._..:>D?tted__U..... .�.....f --•••- .�4..........`-+j .l .+ ---.mac --------- Board of Health DATE-------------------------------------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ' LOCATION SEWAGE PERMIT NO. _ L- V 2 efv- / 3" VILLAGE INSTALLER'S NAME & ADDRESS B U I*L D E R QR OWNER ZV �62e DATE PERMIT ISSUED fg1-7 DATE COMPLIANCE ISSUED �_�C � � 1 O lT4 54 •. 33� � c 2 y - , p > :t• - i d e r � . ,«t Y T'yt -• ♦ e, . - I x r •' - { -., * 1 ,2 i , .. r. " t "+ •. , _ :r . + ,* V N �,..- j��.. f vtF �".!; S , \X�>I1�lflCV�IU'wr-xl/rt'cr�/s:..�Jifl�av�: 'NJk/.LJux LL 2 PEAS TONE �� LOAM •6 FILL �12"MA%r^_ n Sib - r- T- MSDIUA e� f 11 / i ! D O 'J rD l 1• { Z• �'! EA loan .. .O , R 4 !I ] D I S T.' l C r° ° ° � .: . ySl w •L4MIN 5'M . 1000 I e D,. o 1000— GAL. 0 GAL. �.. , a PRECAST OR ° SEPTIC 6: 10 e° 81,OCK TANK ° ! 'e. n °° o SEEPAGE PIT ck6 o p d 1 _ D 20' MINIMUM ,-{p ° DO o pl7 TO M60rurt FOUNDATION Fj Oe 1WASHED STONE SahCI= SCALE:- 1 4' ELEVATION SKETCH r` IoI ---+i PERC. RATIE y kegs}�ari?� ►'x`+ SCALE : 1" 4' TEST -BY :Maul} 79ny°t. � . PECTOR �r+_a'A s WATEQ BACKHOE OPERATOR TEST MADE ON h I zore _ I R' I IVOR - Al e TG-ICPHON� fG` 1000G �� Q rp ,. + 9j'` 110 1000 t�0 t t lei �• � i tAJ 44vvr,C. 9� I YV CTtA A/ S I T a/y` eatr✓C'Ce7 GAi2 t o' b` © L-67 1.4 s $y -70 p 7 . Z. �`T�STHc> E 1�xt� ATER Y1/A-t- l IOO:OQ'Wp tr Sant1 i S`t`� .o _0 I HEREBY, CERTIFY TtfAT 'THE ST.RtUCTURES %DOWN HER o1J WAS LOC4T � AREA - 1S,o00 . APPROVED BY BOARD OF HEALTH - DY`AW'-AG*rj)A - r-IELD 501VIEY O� y1tUTH - t0d' DATE I9— ��c� '1974, AND CONFORMS 10 THE F-b0 SETBACK R_0G ZoNtNG sY-LAW of 'THE roWp� OF S- c�.ae..is7pesC t MASSACMusrr' S. ,�► , �_�;�sOF --�1 EDWIN ,1' EDW14 A. �^ A. ` C YOUNG v YOUNG �f 9096 o o ,� No. 13134 LoT 14 Lo-r 1 qv� �.�. ELEVATIONSCHEDULE 87, r7 °J ' CELI.�rz FLoo R PROPOSED SITE PLAN I. INV. . AT FOUNDATION .67 91 . 1? SEWAGE SYSTEM DESIGN 1 s: 2. 1 NV. INTO SEPTIC TANK -9LLZ • G7' IN 3. INV. OUT OF SEPTIC TANK = ,0U Q,SO B�+!?�1VST/ Ri L4� MASS 4 4. INV. INTO DLSTRIBUTION BOX _ ,SO 0-00 SCALE I"- �' APR Z Z 197 C- 30 .� r*Er—.sett ,4.,.6 -.5 INV ' OUT OF DISTRIBUTION BOX _ ?5t_Bi 8 •83 6 INV INTO SEEPAGE PIT _ 90•00 89, SU CAPE COD SURVEY CONSULTANTS ROUTE 132 7 BOTTOM OF PIT = 1.00 �rs� HYANNIS,MASS. A DIVISION BOSTON SURVEY CONSULTANTS, INC. I 8 BOTTOM OF STONE LAYER s r lei