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HomeMy WebLinkAbout0239 OLD POST ROAD (CENT.) - Health 239 ®Id Post Road Centerville 209 055001 UPC 10259 No. H163OR .cQHs�� HA8TINGG.MN ll� apf'_bst_ oa LLD �os� QM1��� gk�vd !ay or,,,.�.�.� �3y f�w'"°`j �' or,-pwa ° 'TOWN OF BARNSTABLE LOCATION 091 PGA 1 ,N N:"1S Lai"e SEWAGE#d©C 3-y'3� VILLAGE Ce N Eery r,,11 C ASSESSOR'S MAP&PARCEL olOq INSTALLER'S NAME&PHONE NO. R(A�p,.ram 9 :00r CO. Sub-41-X=0530 SEPTIC TANK CAPACITY o � LEACHING FACILITY:(type)c1 o&AL.CJAAypA6t6(size) lJ %yC 13.5" X!X' NO.OF BEDROOMS Ll OWNER Ap(seLo ArsiKoyi?AS PERMIT DATE: 1 �t�� 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 /�/�/-1,( �_ �� — f,(a Q CX Poi; pk, Al ab�N��s o � 8/2/2021 Health Master Detail Health Master Parcels Search Selections Reports �'IT Applications Logoff crockersh Parcel Septic ' Perc I Well I Fuel Tank Parcel: 209-055-001 Location: 239 OLD POST ROAD(CENT.),Centerville Owner: APA INVESTMENT CORP Septic changes have been saved. Septic 2, 11/8/2013 Septic 1,Cottage-Rt I New Septic... Permit number: 2013-435 Permit type: Repair v Complete system: Q Issue date : 11/8/2013 I Complete date : 11/15/2013 Septic tank size: x1000 Type/Size of SAS: 3-500 gal leach chambers w/4'stone Installer: Our,Christopher B. ,Robert B.Our, Inc. v Card on file: Q - - - Innovative/Alternative Technology type: I/A service type: Select service - Select IA type v Variance date : Abandon complete date : Abandon permit number: Repair deadline date : Repair notification date : Keyword: Comments: # BR (3 + 1) (3 bdrms in buildg# aka 139Phinney's,plus -^` Delete Septic 1 bdrm in buildg#aka 239 Old Post-sm house) New Inspection... Number Inspection Date Inspector Result 0 Select Inspector v Select result v Received Date Comments 8/2/2021 J Save Septic Changes Return to Lookup 2-3 f? l 1'osT 64 A- https://itsgldb.town.barnstable.ma.us:8431/HealthMasterDetail.aspx?ID=14876&mp=209055001# 1/1 �h ru� No.-012 e n THE COMMONWEALTH OF MASS A SEZ eyed in co ter: PUBLIC HEALTH DIVISION`-TOWN OF BARNSTABLE, MASSACHUSETTS Yes Yication for Mis oral 6p Construction er it Q� r ��Y�vJL-r/1>s Application for a Permit to Construct( ) Repair( ) U ra Co Abando ( e S ste ❑Individual Components ocation Address or'DKW. l rK I qJ N �S L A caner s e,Address,an e.No.'611-rj y (Q rt ssessor's Map/Parcel a0q AS ( f t'��,�, C , V t5 c Ilwstaller's Name,Address,and Tel.No. �)� -`'�� Designer's Name,Address,and Tel.No. ��- �� f . �3u(7- C0 , �- `1'� hi— A,rat A� -C l.`ve.S1e-eN 'P- p L4 ta A '-)At'd\r►�i' rT Ade . .0 Mr_i Type of Building: Dwelling No.of Bedrooms Lot Size (� �4j sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided L!4 Q gpd Plan Date (��X lc '� lc Number of sheets Revision Date Title Y Size of Septic Tank 0 (�c Type of S.A.S. �ci�% an i- C p�-Z (�j i �()}J Description of Soil L,D Wy i �/� ►a)� i"n�� (f�g r& j N.( Nature of Repairs or Alterations(Answer when applicable) ( C ,P/JO'S 1 g. 1 0 E 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 End nine I Code and not to place the system in operation until a Certificate of Compliance has-been issued by this Boar f He Sian Ai� ,If era- Date Application Approved by Date Application Disapproved by y } Date for the following reasons Permit No. Date Issued ------------------ No. F Fee ' THE.COMMONWEALTH OF MASSACHUSETTS Entered in com uter: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ` ZIpplication for 0sposaY 6pstem Construction a It C,%r?C lie- %� Y�r.z~�?� Application for a Permit to Construct( ) Repair(_) U grade ,6 Abando ( 6 ❑Compl to S ste 0 Individual Components Location Address or ©t/N 13 1 N N 1 S L A N caner e,Address,and ' o. (��'�_Scl l+ 'Installer's Map/Parcel o� AD (':j/ O U _ l Installer's Name,Address,and Tel.No. SG - {3a.'O$ Designer's Name,Address,and Tel.No. Q . 0v2 Co .��G- STe.PhFcr+ A•N�A$ T ls-,:. C c'N Type of Building: Dwelling No.of Bedrooms L4 Lot Size LAS 3 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) `f` 0 gpd Design flow provided L 4 Q gpd Plan Date 44 C>9 a.7 1 Number of sheets Revision Date Title f Size of Septic Tank.- G,l Type of S.A.S.( .56o rp CL A 41 L r�ty I— oope Description of Soil ( n A(Mvi- ` Ste'��1� nn, -0,q r'�P A&.ry Nature of Repairs or Alterations(Answer when applicable) C9/� [1 C) 11 Lt Q j�c r+ Lv/ i-� t OF .S rw)I e 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and`nain_tenance of;the afore described on'-sitelsewage dispos system in z ` accordance with the provisions of Title 5 of the En vi •nmen al Code and not to place the system in operation until a Certificate of f Compliance has-been issued by this Board of He gnn + / Date Application Approved by �! ,�( Date t v Application Disapao_ved b_y \, v f1 . f V Date of, ; .�z for the following reasons . Permit No. 4 01 „ Date IssuedIII ell r { - . - - _ - -------------------------------- TR F COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CEFTIFY,that the On-site Sewage Disposal system Constructedi( ) Repaired( Upgraded( ) Abandoned( )by 7Ktl ` at � �� OU) been constructed in acco danc ' TYD 43 with the provisions of Title 5 an the for Disposal System Construction Permit No. late Installer Designer #bedrooms Approved design flow 1 gpd The issuance of this permit shall not be`construed as a guarantee that the system,will'functi, as designed. J Date 1 1/ Inspect r._ cV r _____________ _________________ ___________-__-_--_____-__-___-____-__----------------------------------------------------------------- No. ' ��' ` Fee J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction permit Permission is hereby granted to Const ct( d) e ai( ) Upgrade( ) Abandon( ) System located at �� /� /� i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construc'o mus use completed within three years of the date of this permit. Date Approved byCP / f Town of Barnstable ,oFIME rp� Regulatory Services 4 �p Richard V. Scali, Interim Director BARNSTABLE, Public Health Division 'lF1 Thomas McKean, Director 200 Main Street,Hyanni9,lYiA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer.Certification Form Date: L L116 LI-2 Sewage Permit# DG `4:,S' Assessor's Map\Parcel SCE l Designer: ��e��� I'lAA S Installer: �4U� '� (�U (' Cd, `JV C- Address: ci 2 Z ,oL)-)-6 (Qp Address: Ll r�A-T- R CP OaC�'2dZ,�lc��. M�T On 4 �b 3 !C C)�2,r Q O J C O - was issued a permit to install a (date) )) (installer) septic system at based on a.design drawn by ((ad Tess) �Pi�l1�N IQ1RS dated Q ila';Iti3 (designer) 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. Strip out (if required) was inspected and the soils were found satisfactory. 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. Strip out (if required) was inspected and the soils �Tic`errtif�, e found satisfactory. at th s stem referenced above was constructed in carnpliance with the terms of y the P r l letter f a licable R -W (Installer's Signature) yI . �YL'�f�rYii7�iyw t•� (Designer's Signature) (Affix Designer's Stamp 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. QASepticTesigner Certification Form Rev 8-14-13.doc Town of Barnstable P# Department of Health,Safety,and Environmental Services �t►,E, Public Health Division Date 367 Main Street,Hyannis MA 02601 r . + lARN6TAB[.R • � � b �� �.% ArE4y► Date Scheduled Time Fee Pd. Soil Suitability Assessment for See Dispo00M c Performed By: Witnessed By- 7 U: Lam/ LOCATION & GENERAL INFORMATION Location Address � ��a,t, 1!S `,i� Owner's Name A-?A /"L", �VV —tE- j 02-7) L� Address -��7C-C:C: t.flc r✓^- C7 Assessor's Map/Parcel: Zoq/O Ss/ac7 j Engineers Name _ NEW CONSTRUCTION REPAIR t*�^ Telephone ft 5,6 f,' 36 Z /Z.c'S i �tw> ✓t C Uzi Land Use Slopes(%) IS Surface Stones t=11, Distances from: Open Water Body �- ft Possible Wet Area ft Drinking Water Weil fp " Drainage Way ft Property Line l tr.r_. It Other ftS r-n • r^ SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes; M ZA �b rt i � y .. 4 Parent material(geologic) O e'77`) r11;N Depth to Bedrock Depth to Groundwater: Standing Water in Hole: C Weeping from Pit Face Estimated Seasonal High Groundwater " TEI .�r �or> + ri sAsOr�AH tATA , Method Used: ICJ/ Depth Observed standing in obs:hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater.Adjustment ft. Index Well#___.._.._. Reading Date: Index Well level.:._.__ Adi.factor Adj.Groundwater Level— PER+COLATIOl�1 TEST' Hate F Time Observation -- Hole# Time at 9%,, Depth of Perc t Time at 6" _ Start Pre-soak Time Q ` Time End Pre-soak G Rate Min./Inch Site Suitability Assessment: Site Passed L� Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant DEEP OBERVATION HALE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.%Gravel) ZC_- 3 Z 11 L.S `l�a 1j C, S jo✓� ��� .. DEEP OBSERVATION HOLE LOG Hole# , Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency-%Gr vel 36 DEEP OBSERVATION HOLE LQr Bole _ .. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. C rsistenc %Gravel DE£P OBSERVATION HOLE IOG HoXe# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistent °o Gravel) Flood Insurance hate Map: Above 500 year flood boundary No_ Yes ✓ Within 500 year boundary No Yes Within 100 year flood boundary No ✓ Yes Depth of Naturally Occurring Pervious 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? If not,what is the depth of naturally occurring pervious material? Certification / I certify that on ![ !`!( � (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 trainin ise and experience described in 310 CMR 15.017. Signature "- __ Date Town of Barnstable �FTME Tp��o Regulatory Services Barnstable Thomas F. Geiler, Director A+eficacif/ * M AB Public Health Division 9� AS3. � � f ,orE0 aim Thomas McKean, Director 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 00( 13� I"/2A-,rw y1 /_�,-�-July 29, 2013 Angelo Atsiknoudas 4,44 295 Channing Road Belmont, MA 02478 NOTICE OF VIOLATIONS OF 310 CMR: 15.00 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND TOWN OF BARNSTABLE CODE & 353-9- DISCHARGE ONTO GROUND PROHIBITED. On July 29, 2013, Health Inspector Jim Parziale, R.S. in gated;a complaint - agar. sewage ponding at the property owned by you locate at 130 Phinney's Lane, Centerville, MA. The following violations of 310 CMR 15.00, the State Env rne intal-Comae, m><mu Requirements for the Subsurface Disposal of Sanitary Sewage and the Town of Barnstable Code were observed: 310 CMR 15.303(1) (a): Septic system is in hydraulic failure. Sewage was observed overflowing onto the ground. Town of Barnstable Code 4 353-9: Discharge of sewage onto the ground. (1) You are directed to keep the on-site sewage disposal system pumped as many times as necessary (daily if needed)to keep it from overflowing onto the ground. (2)_ You are ordered to obtain a septic design engineer to design the repair plans for the failed septic system at said location and apply for a septic permit with the Health Division within thirty (30) days of your receipt of this letter. (3) The septic system shall be installed in strict accordance with the approved engineered plans within sixty (60) days of your receipt of this letter. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in the issuance of a non-criminal ticket citation of$100. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, CHO, RS Director of Public Health ' a A AAW A vi%aa AV AA 1 a •.V a "A- L/va Ltd//Si LL V1�L1 Al• VI\1Vll1jpjAL 1J V('kj_u) t CAPE COD BUILDING "Your Local Home Inspection Professionals" INSPECTION LEAD INSPECTIONS SMassachusetts State Certified Inspector I-1075 Mid Cape Office IA-� Mr.Robert Beaulieu n 00-828-9 cX 0 2�SS 1-800-828-9387 C 5 0® LETTER OF INITIAL p,1(A- LEAD COMPLIANCE Date Dear., This letter is to certify that I inspected your property located at �1_42r­ -arogffftt no. 1 3 9 , and relevant common areas, in the City or Town of for dangerous levels of lead according to 105 CMR 460.730 of the Regulations for Lead Poisoning Prevention and Control, and determined that there were no violations of the Lead Law, Massachusetts General Laws, Chapter 111, section 197. The inspection was conducted on G� I also certify that I observed no evidence that unauthorized deleading activities may have occurred in this unit or In its associated common areas. y Please be advised that Massachusetts law requires that only certain residential surfaces be free of lead paint. Thus, this letter does not mean that your property contains no lead paint. The premises or dwelling unit and relevant common areas shall remain in compliance only as long as there continues to be no peeling, chipping, or flaking lead paint or other accessible materials and as long as coverings forming an effective barrier over such paint and materials remain in place. The law grants you a 30-day maintenance period to repair deteriorated lead paint or detached coverings over such paint,and to clean up,during which time this Letter remains valid. The initial inspection report indicates which surfaces, if any,contain a dangerous level of lead, as well as those surfaces, if any, that were covered upon initial inspection. Should you have any questions about this letter,call the Department of Public Health at 1-800-532-9571. incerely, NQIS3 A4{ Witliou In•pe to Seal- Member of Massachusefts Association, of lead Testers ,c �d ,�� ������� - Registration No. LOIC rev.doc Revised 7/04 Page 1 of i THIS FORM MAY NOT BE DUPLICATED ONLY AN ORIGINAL IS VALID "Your Local Home Inspection Pr fessiona&, CAPE COO �!lIa ING Cape Cod Building Inspection Services SN Robert Beaulieu P.O. Box 1313 W. Dennis, NIA 02570 508-398-9387 1-800-828-9387 Lead inspection Report Report 4 i I ROM€ INSPE£TEP FOR LEAD Lad poisoning is a disease caused by lead in the brain, Iddn and nervous �f• It can cause permanent damage ZA the eys system. Even low levels of lead can slow a child's development and cause teaming and behavioral problems. FOR'"'ORE aNFORNIATION f Massachusetts State Certified Inspector p I-10:5 Member a(Massachusetts A sociatfoc of Lead Testers obe-Beaulieu &Tom=• _ �`�, Inspector . ® I- 1075 Regisurtion No. � i BUILDING N Lead Inspection / Risk Assessment Report Page Of (� P.O.Box 1313 Method Used: West Dennis.MA 02670 WNa2S Exp.Date ►`3 Mi 3"fl'� (508)398-9387 ❑X-Ray Fluorescence Robert J•Beaulieu Model Serial# Address Ap©RIMENIm a®�®C aaaaC]aC� pl# c®o®©®©000aooaaooa o®a®a Owner Name' S 4 tJ 0 V V%Ak e, Single Family Owner Address: 'Z• l Mufd Family — h, r7 Z #Units — Client Name if different from owner): Condominium Care — Client Address: Day — Key. 1 Deleadir Other AIM AccessrbidHbulhable CAP Capped Comprehensive Ins action !N CAP Capped COV Covered P P (YIN) COV Covered DI P Dipped iNT Intact ENC Encapsulated Comments: L Loose MI Made 1nW Mil Moveable/Impacted .PRE Prepared MET Metal REM Removed ��„ �,�, NA Not Accessible REP Replaced r44 NC No Coating REV Reversed NEG Negative SCR Scraped POS Positive VR Vinyl Replacement VR vinyl Replacement Fioor#j7r C Floor#5—:1 C T - -•--T--+------ -------• ---- ----•---r- +-- : --- - • ._ I ALL' - --- - - - --- E E -- T-- +-- -- - - - - . I --------- -- I . . . . . . . . . . . . 4-4-4-4- I I I I I I • • • • ; • I . I ._.�.___�__�.._f__ ._�-._z_..�_-.�_._T___i_.____• • ._ ...... _ _ -------- A(Street Side) A(Street Side) Pb(lead)equal to or greater than 1.0 mgtCM2 with x-ray fluorescence Dangerous. INSP. DATE lead Hazards? Q 3 U 9 d (YorN) „ Inspector..(print) tgnature Lic.# R.A. DATE Urgent Lead Hazards? (YorN) Risk Assessor(print) Signature Lic.# LIRA RepCov,Privinsp,1.0,7131/02 t3VILUINGj Cape Cod's Original Inspection Service-c— `". 1 1lIISPE�'t10H �1 Serving All of Cape Cod Since 1975 "Your Local Home Inspection Professionals" Lead Paint Inspections Mass. Lic.-'#1-1075 DISCLAIMER CONCERN.INtG LEAD PAINT REPORT The Information contained In this report concerning the presense or. absence of lead paint does-not constitute a comprehensive lead paint inspection.at least one test Is performed- on each surface. The results.of'which-ax:e:reportod,�s e, represenative of the whole 'surface. If a child under-slx years- of age resides-.or vylii reside In this dwelling, the owner may face.'criminal and clyll Ilabilitle§•unless ALI, lead point vlolations have been corrected. - This 'lead report cannot_assure that the property•otwner has met-his or her obligations under=the law. 1t Is unlawful.for rental property owner*to-use.the pre'serice'of lead as the basis for dlscrlminatlon agalnWtemnts .or potenttar tenants.with young children-. It I's also unlawful to.dlstrlmInate'.against'tenants .or.potentlaf tenants If they are pregnant. Serlous-lead polsoning.hazards are created when materials containing lead paint are disturbed, unless proper. safety guidell-nes .are- followed-. THEREFO RE;-MASSACHUSEVrS LAW REQUIRES THAT: ANY DELEADIN'C WORK' DONE- ON THE:-PREMISES' TO ATTAIN COMPLIANCE WLTH THE LEAD *LAW MUST BE DONE BY.-�A. LICENSED DELEADING CONTRACTOR; A.LETTER OF COMPLIANCE WILL BE WITHHELD 'UNLESS DELEADING WORK'HAS BEEN PERFORMED BY A CERTIFIED OR LICENSED DELEADER ACTING IN ACCORDANCE WITH-ALL-APPLICABEL LAWS AND REGULATIONS. A LIST OF LICENSED DELEADERS MAY. BE OBTAINED BY CALLING THE DEPARTMENT OF LABOR AND .INDUSTRIES AT .(617-797--851'9)- ANY RENOVATIONS OR REHABILITATION OF PREMISES CONTANNG 1NG.DANGEROUS LEVELES OF LEAD PAINT MUST. BE DONE WITHIN COMPLIANCE*OF THE PROCEDURES SET.'FORTH :IN THE REGULATIONS ISS'UED.'BY THE DEPARTMENT..OF LABOR AND .INDUSTRIES(-4S11CMR 22.11) 1NICLUD KG* SEALING 0FI? THE WORK AREAS FROM,-ADJACENT AREAS AND USING A' HIG14 EFFICIENCY PARTICAL ACCUMULATOR VACUUM (H.E.P.A.) AND 'TRISODIUM' PHOSPHATE SOLUT.IONTOR THE FINAL CLEANUP. ANY DELEADING WORK'DONE ON THE. BASIS OF THIS REPORT MAY QUALIFY THE-OWNER OR OCCUPANT FORA STATE TAX CREDIT.'OF UP TO-$1.Ona.D0. FOR A-PERS.QN.TO. BE ELIGIBLE .FOR THE TAX CREDIT HE OR SHE MUST HAVE PERSONALLY PAID FOR THE DELEADING.- THE DELEADING MVS.T HAVE BEEN DONE BY A LICENSED DELEADING CONTRACTOR j1N ACCORDANCE.WI.TH. REGUL'AT.rONS,: ALL V.I0LAT.I0NS OF LEAD. LOW !'MUST HAVE BEEN ABATED,: AND A LICENSED .INSPECTOR MUST REINSPECT. THE--PROPERTY. AND. CERTIFY. ON* *FORM CLP DEPART MEN OF REVENUE THAT. ALL MATERIALS ON THE PREMISES THAT CONTAINED DANGER OUS. LEVELS OF LEAD 1t`1 V.IOtAT.ION OF THE LEAD LAW 'HAVE BEEN ABATED. Caution NOTE:A COPY OF THIS REPORT MUST BE ON SIGHT AT TIME OF RE-BVSPECTION AFTER DELEADING PROCESS STRIP ALL WINDOW WELLS OR COVER WITH FLASHING SEE NOTE FOR FURTHER REQUIREMENTS DO NOT PRIME OR REPAINT UNTIL THE INSPECTOR HAS SEEN THE BUILDING NOTE:MASS.GL CHAPTER III SS.190-199 Requires that: I a"*�&AY4 �.VL�t V• page_ of f�. Initial Inspection done on: Tr by �.1�ice!� !Ste+ Lic.# Risk Assessment done on: by Lic.# Reoccupancy Reinspection, if needed,done on: by Lic# Final Risk Assessment Reinspection done on: by Lic.# Recertification Risk Assessment Reinspection done on: by Lic.# Final Risk Assessment Recertification Reinspection done on: by Lic. # Deleading Contractor License#: Deleading methods: Scraping Demolition Power sanding Caustics Heat gun Replacement Covering Liquid encapsulation Other Work was done in the following rooms: Work was done on the following types of components: Start Date:—/ / Finish Date:_/_/_ Cost: S Lead-safe renovator: Lic#: Moderate risk owner/agent: Auth.#: Deleading Methods: Replacement Making intact (interior) Making intact(exterior) Covering Liquid encapsulation Work was done in the following rooms: Work was done on the following types of components: Start Date: / / Finish Date: / / Cost:S (Doesn't Include Owner's Labor) Low-risk owner/agent: Authorization#: Deleading methods: Covering Liquid encapsulation Capping baseboards Replacement(ONLY doors,cabinet doors,shutters,shelves not affixed,drawers,windows on hinges) Work was done in the following rooms: Work was done on the following types of components: Start Date: / / Finish Date: / / Cost: S (Doesa t Include Owner's Labor) Private Letter of Interim Control and Recertification rev 8-02 Page 3 of 3 EXPLANATION OF LEAD INSPECTiONISURFACE ASSESSMENT REPORT FORM COLUMNS StDEu r r = _ Refers to A,B.C,or D side of dwelling unit Refer to diagram on cover sheet. Refers to architectural element(s) being tested. If two locationsisurfaces are listed in this column,subsequent llStiEZFACE«.'-v,: ::<:< columns will be subdivided to provide specific information corresponding to each surface. 3'.4%"-. D=` >tahA.' Y The actual lead result. A numerical reading indicates that the surface was tested with an XRF analyzer and a reading(or average reading)greater than 12 mgkxnl indicates a dangerous level of lead. A'poe or'neg,notation {4 indicates that the surface was tested with sodium suede,and a'pos'notation indicates a dangerous level of lead. Each location tested must have an individual result recorded in the'Lead'column. Qom` �:<v.CvCiv-+{y{(•{y:{:y�:-:>i The L (loose)column indicates the condition of the painted surface(s)tested. A check mark(J)or'yes'notation €< F<<h=>vs:<;<< >w.: in this column means one or both of the surface(s)tested is not intact. If this column is left blank or has a'no' notation,it meant that the surface(s)in question is intact Some leaded surfaces are in violation regardless of their condition;others are in violation only if the paint is not intact OVStRABTYh=ry The'owr abr(owner abatement)column denotes whether or not a surface in violation can be corrected by a trained homeowner/agent who is not a deleader. Ayes'in this column means that the trained owner/agent may elect to ` < delead this surface b performing one of the specified low risk deleadin .activities. A' 'in {.:. Y 9 P� gno this column means that only a licensed deleader is permitted to delead this surface. XLR SRF;PktP;< The'dlr srf prep'(deleader surface preparation)column denotes whether or not a deleader is required to prepare a urf advance�s ace in of it being e ng deleaded by a trained homeowner,agent performing certain low-risk deleading activities. A' es'in this y column means that a licensed deleader must be used to peror udace preparation if the +�:>'{•j?::j•.t?y,r.,.:..;ii.:wi:�';TtiQ:::•i:i::-: h -S�- < h -ry'{`=t=>' .. r` low-risk activity selected is encapsulation or v•:: ::::;rr : , :A ty p covering a friction(mpact surface with loose lead paint. SU JSUES < : The 'surfacelsubsurface' condition column denotes the condition of the paint layers with respect to potential eligibility for encapsulation. Surfaces/subsurfaces rated a 7 are ineligible for encapsulation. -:SUBST COND.. .:. r The*substrate condition column denotes the condition of the base substrate(i.e.wood,plaster,metal or masonry) _- with respect to potential eligibility for encapsulation. Substrates rated a'2'are ineligible for encapsulation,unless ` the substrate is repaired. <:INITIAL'TAPE The results of the initial tape test(s)required for encapsulation are recorded in this column. Surfaces receiving a 7 on the initial tape test are ineligible for encapsulation. =X-CUT:TEST:: :< The results of the optional x-cut tape test(s)performed by the inspector are recorded in this column. Surfaces receiving a'2'on the x-cut tape test are ineligible for encapsulation. ''COMMENTS.i; ; The'comments'column is for other observations that may be relevant to the deleading of a particular surface }•SU(T.1~ORF1Vt,AP;;,: The'suitable for encapsulation'column indicates whether a surface is potentially suitable for encapsulation based on the results of the inspector's evaluation and an in P� to twit performed. A' es'indicates that the surface can Y Pe 9 Pe Y be further evaluated b X-cut to testingan 'd patch testing; a no indicates that the surface is ineligible for 9 ' < <° ::.: ;.ry._ encapsulation. `:DELEAD:DATE :;=' < The'delead date column indicates the date that the surface was determined to be in lull compliance with the Lead ?} `: Law. ELFAD.METHOD* The'delead method'column indicates the method by which each surface was deleaded to full compliance with the Lead Law. Refer to the'key'on the cover page for method codes. CAPE COO BUILDING s INSPE010N 14C+ S P.O. ?Jx 1313 West -_:o:: (508)3484-187 :aNwsat�otSFoaxsu_s� u Robert 1 9eCweu �:C,�RTC,v:� Page�o� v ns for(pint) Uc R Signature Gate lisle Assessa:(print) Uc or Signature Date .tidress of?ro;PZy CASE NLMER # �� Apt* City loom i1D_ LOCAL IOw I L_^ADI TYP_OF I:URGI IC I IC ID=i AO DEL_AD SID_) LOCATION1 IL_AO TYP_OF URG IC IC D=_,=AO D`LEQ SUi«-A." HA ;r�O ? DAi� t TH OAi� MiH SURFACE ( HAZ ARE) IHAcj DATE- M-�i I DAit McTH Up Wags AAA L wA Y I Window Sill MJI AIM L NIA Y t o Low Wags AML wA� Y win Apron AIM L NIA Y o t3aseboa.-= AIM L NIA Y wm cas+ng AIM L wa Y e Chair Pa AM MA ' 0 Y Header Stop MII AIM L NIA Y Rad9aror 1-!" AM l NIA Y Int SIc;s is. Mn AM. L NIA Y Floor I AIM L NIA Y Wir Ire..Sash MA AIM L wA Y Ce,T,nq AIM L NIA YTJ =sreria Sal / MA L WA Y Door 1K AIM L NIA Y Par,Bead 1Mtl L MA Y "w Cas"g IVA I Aar.L wA Y Bhrd slap Mn t wA Y r riAt:a•-2 MA.L NIA Y I Wir:r.Sash MA L N!A I I IY I T1res► I — AtA L wA I Y If wrnd--m SM I IMn A/M L wA I Y I I caor I�t.+ i :.V L wAI Y I I I Win A;:zn I OW I AIM L -JiA I Y !2 Oaa Cas I.S`�A,_ I tol; N;A I Y I I I f I ^I Y N;A Y I heacerS::p JIM AM L MAI Y I +hres:ws I --1 AV L N.'.; Y I I I ( Ir:Sc;s IM/I ijim L NIAI Y I Ooor , A-V L N;A( Y I I ( Wir.IntSash t It1J1 AIM L NA; Y I D= A.V.:as-:y i % : w:. Y I t ( _z a Sin (P I!M L wAI Y ( I Dox jamb I :.':: N A( Y I I I I ?a-Bead IMn L wA I Y I I hres`-1d I I A�'•L MA Y 1 I 1 Barw S. I it-In L N!A 1 Y I 000,--as-y ( I I.?: N A I Y I I :k`Sot SaSn I6V1 L N ,I Y I i YI _gar I�.e I ARt L NrA Y I I I I :Cas:.i i t A1.1 L N+AI Y I I I Tres-,:: I '"i IV Y 1 f I Y I f I Cirse:tea.—a Alu Ni:, w'n=:.Sill I ( Ml :.lV L NIA) Y I I I Cjcse:wafts I� I ATd l NIA Y f WinA;,rn 1 AA'L w:.) Y C:Basehcar I AIM L N/A Y I win cur, ( 1 !rM t wA Y ZIOset Pole AIM L NIA Y Header S::; Mn Alu l w:. Y Clcset Shea AIM L wA Y Int Steps I I Mn AM.L N'AI Y 1 I C.Suapr-m 1 W L WA Y Win!n;Sash MA AIM L NIA Y Cicset=loot AIM L NIA Y E x Si tM L WA Y Closet Ceamg ! AIM L NIA Y gar,; A= ead Mn L MIA Y Fffea�x AIM L NIAHy Bred Step � MA L MIA Y Mantle AIM L NIA m=s:Sass+ ( MII L NIAJ IMR AIM L wA Y I OMLIEW,S I S TRUCTURAL 0i_. S 1 1 w AIM L WA Y f IMII AIM L wA 7T I IMn AIM L wA Y I I I I II-In AIM L WA Y I I '_ACLU E uraCes IISMS M IMSe DCXe-c tan D:rnaue In;att only Dy a licenser oeteaaer. IDE L•Y_A T CON M:;SJRE.LOOSE PAINT IC IC S1D_ LOCATION ME.;S'JRE,LOOSE PAINT IC IC (M;JP�TSAN 288 SO.IN.) DATE M`t HX (MORE THAN 288 S- IK) DATE tiCTHOD ?T Page lnspe_tor(pint) Lic: Signature Gate Address Assessor(print) Lit/, �t�py�Siig�n(aature /j Date Address of Prop�y CASE NUSER 1 Api w city ROOM - . siDl LOCA7,104f I LJ{D iY- OF (uRGI IC I Ic lo_::ao o�L:Ao stoo Loc:. low t�.ol rra_of ua� tc Ic o=l:A� SUF-ACE MAZARo HY DATE WTIM oAic M_""iht SURFAc� tiAUnD HAc. oA�c I NLiH ji)EI DATe METH Up Wafts AAA L WA Y Window St0 MA AIM L WA Y A a Low Wafts AIM L WA Y Win Apron � AIM L WA Y ``.. C o Basexar s AIM L WA Y Wm Casing rf1/( AW L WA Y oCtwir Pan �" AIM L WA Y Meader Stop AM AN L WA Y Radator (� W.L WA Y In:Stops Mtl AIM L WA Y Floor AdId L WA Y Yin Im Sash vt� Mil AIM L WA Y Cedog W AIM L WA Y Egeno:Sal �T{ AAA - L WA Y Odor I AIM L WA Y Par,5ead Mn L NA Y ^ocr Cuc=g ' AIW L WA Y shnd Stop ju MA L WA Y -5mr:a-a MAL WAI Y { Wu:Er.Sash IMA L MIA I Y I T'►res I-- A.'A L NIA-1 Y Window Sin IMn AIM L Km Y I I I Door IDA I kV L N.-AI Y I I I WinAp:-on AU L WA Y L'ox:ts-_ I i9A I A.`!.; K:I Y I I win:2s:ng I AX L N. Y ( ( I I IA I A'�= N;;I Y header S:a I ?I AM L WA Y { I A,t.'L N:,k Y I I ( In:Sty I :JAI L NA Y I Door AV. Y Win. I I ( I I Win.Irti Sash Mil '?a L NrA Y DacI_u_:, t iAlu L WA Y it I x.e:a:Sill I IIM L NIA I Y I i Coo-la I I "''L A:.I Y I I I Par Bead IIM L WA I Y �:ues a I ku- WA I Y { ( I 5bn--Stop I I'm L Y I I I Door A i I �,=!.nmI Y I { 1wir__::Sasn I Imn L N. Y I I I Ow:,as:; I I ^v L �A I Y I I Closet�xr I ' i l `,� Y I i Aiu ,�. I IJ�p�' L N'41 I i TtireS:w� I A9d WA Y tI I =se:Ja-.a (V - AJ1I L NA Y Window S� (�"l I M? W L WAI Y 1 I Close:Waft I I AX l WA Y Win A;= AM L NIA I Y P 3asexar A/M L NA Y I i Win C" I A,t/L WA Y Closet Po=e4VI AIM L WA Y Meade'S=? u1 MA AV L WA Y Closet Shed � AIM L WA Y lint Sc; I Mn AN..L WAI Y C:Supports AIM L WA Y Win Ito Sash Mil AU L WA Y Closet Floor AIM L WA Y k l W L NIA Y Closet Ce&T f� AIM L WA�, Wil L WA Y Fireplace AIM L WA Y� MR L N/A Y Mamie AIM L WA Yow .W I rM L WAI Y IMn AIM L WA Y OMA+EN,s I„�e UC i URAL}EC:S. I Mn AIM L WA Y JfM AM L WA Y IMn ABM L WA Y i I M/I AN L WAI Y I I I �A�;LUU_J Jar-ACz-:Suratss us=in tnese oczf:c-can oe raoe tn;a=only oy a timnse-celeaaer. Sro` LO 7tJN M=�SUr:.L0.^.S_PAINT IC IC SID'aJ LCCA T ION M=- SUR=_:LOOS=PAINT Ic IC (MCA-E 288 SG.IN.) DATE kcamoC (MC-R THAN 288 SC.IN.) DAr KETH01 J RTi._i�_[J ..1-in �� 3 Page�011 tnspe--or(pant) uc"r, Signatsue Date Risk Assesso*(print) lic s Si mrwre Date Wdress of Property t� CASE NUMBER _ Apt= City i0om SIDE) LOCATION ILEADI TYPE OF URGI IG IC DEELEAD DELEAD SID= LOCAT IOW TYPE_OF URG IC IC DE EAD DzLEQ SUFFACE HAZARD HAt. DATt METH , DAi-z W--.H I SUFtFAC= 1LEXD1 HAZARD IHAZ?I DATE= ME I DAit MtTH M Up Walls AAA L WA Y Window Sig YA MA AIM L WA Y A o Low waft AN L WA Y ( Wm 1f Apmn AIM L MA Y c o Basebca:--s AN L WA Y I win Casing of A/M L NIA Y A o Chair Paa A!M L WA Y I Header Stop MA AIM L WA Y IRadaw AM.L WA Y Int Stops MA AN. L wA Y Ftoor ( AJA!L MA Y Win Int Sash MA AN l WA Y GesTmp lull AIM L WA Y Exterix SA MA L WA Y Door I#A AIM L WA Y aar,Bead MA L WA Y r V=Czsi'S IV* AN L WA Y Blind Stow ImA l NIA Y v L�or:3-b I A,Td L WA) Y , I wir:?r,Sash I)& M/I L WA Y 7hresho'4 I e, A.TA L WA Y Wmdz.v SM IMJI AIM L NIA Y ' I D= 141 AN L NIA I Y I i Win A;mn I I A!A L NiA Y 0ocr�zs:; I,�,/i A'.: Y I I Wm-zs:ng .I AXI L NIA i Y 0=;a.-J; Y I iieacerSap I 'A AN L W:. Y I I I ThtCL'r I —I A.V L N:A I Y I i i Ir.:S::.^s I Am L WA I Y I ( Oaor i ' A'/.L NSAI Y ' I Wr.Int sash IMA •M L NIA Y 0 'Cts-:; I ;0.!L N/A Y I I =z:ezx Sin VAR L N/Al Y Cax Ja-a I I :.0 N A Y ( I I I Par.Bead 'MJI wA I Y tm L WA Y I I I 3cr^.Sty I IMA HIA Y I I I rI I --v;, Y I Wa:_z:Sam i IMA L �AI Y I I I Doo•Czs::i I I;u n:A I Y I :.Icset_nor ' AA-1 L141 Y I ^'L I Y I I Ct casing AN l Nit Y I I I:i:esac I ,-%A� A:A Y ( I :-,se:Ja.—.o + "t I AN L WA Y I I Wmcr+c Sa I I AY Ally L WA I Y I i C=e!veal i I AN L WA Y i Win,',;= � AN L WA I Y C:Baseboar: AIM L WA Y I I win rasa'� I AM L WA Y Closet Pole AAA L WA Y Heaci r S� MA AN L N1:. Y Closet Shea AIM l WA Y Ira Sops ice, Mn AN..L WA Y I C!Suaao.M AIM L WA Y Mn In:Sash MA AN.L WA Y Closet Ftoor AIM L WA Y I Exterior Simi MA L WA Y C►cse!Ceding IVI I AIM L WA Y Par.3ead LM L WA Y I Fireptace I N AIM L WA Y Blind Step MA l WA Y Mantle I rN NM L WA Y m EA-Sam 16 I MA L NIA Y I I'M AIM L WA Y =OMNE'NTS I STRUCTURAL I IMn AN L WA Y i IMA AIM L WA Y IRI LAA AIM l NIA Y I I I I MA AM L N/Al Y I I I tALLUt1_:J JUrrAC=S:Sursac2s uslet!ul tnese DcxeS can 0E-rnaoe inza^t onry oy a tic-enses aeteaaer. SIDE L:A—j rJN M_:SLI y.LO.CSE PAINT IC IC SID_ LOCATION MEASURE:LOOSE?HINT IC IC (MORE THAN 288 SC.IN.) DATE (MOR:THAN 21111 S.^. IN.) DATE. LETH01 DHi]Il 31Yo ('NI %.S OW NYH11IOW) r_ r !NIYd ssool-----dns`:W Nal_Y:)Ol =CIS 31 01 lNIYd NciL`r01 =01S 'taoearo casl:a,n a AQ Aluo::.e:ul Sce1.:l ao ue:,axon asaln ul calms I I I A I YIN 1 VVY Wil i I I A YM , �,► �+I I A YIN i VVY MI II A YM 1 w UNI I A IVIN 1 Wfd UW) A IVIN 1 IMI ,. r UMS:R=u1M A 1 YIN 1 WW I rx I Uen l? ' A YIN 1 UW dZIS;48 A YM 1 NUY aretCaad A YIN 1 UW 0>' tMd A YM 1 M rx�-10=0 Pj YM 1 UWYM1 M �lases YM I M IM" yes M I M z A YM 1 WM S:.roc'dnS;7 I ( A YIN i WM UW I sd--M lul A N, 1 WM AaYS lasot^ A IVIN 1 All UW dC•,$;Mmjq A YIN Md MOO A Ym 1 if!"! I 6uesz;yam i I A YM 1 ' I maeocasee:^ A IYm 1 MY ua:;urM A YM 1 W,Y I I S;IeVI:as•�^, I I ( A iYM '.rrr: 'lrV I e$,,C=M I I A YM 1 iviY I I A e,N 1 Mly I I ��se,;� I ( I A '.Y ( I __e;xoC I I I A 7 y 1 ley i toc�las;:,: i I A IY N l I ill i Lies•z=Ulm I I I A I�"• ' i l A IVIN 1 1rell r2l dCl$:me A Ym ':YY A IYIN 1 UWI PD I peDS''ed I A IVIN 1 wlI rVi 1 -=a-%= A I I A YM 1 rtiN vrll Ms lul LAM t I I A I`:w :?.Y N I Ma A IVIN 1 ;vr. lmi V) I �=�s I• I i I A iY:N I AY I i ==T.: I I A YM 1 K-1 uvI lot I da.S aa¢a:: g� I A I Ym :V Y I ( I A IYfN i •r1Y I7r 5u:52�ta1,, I I ( A I:'IV ''l�Y •• i i I A �� 1 rV,N I I ucdY�,t, A IY�N i r1Y Irv: I I I A I Ym 1 WM bell I eS PAC;.u1M I I A I YIN 1 YtY I I , I i A I YIN 1 U'M 041 YsYs x:.aryl I A I YIN 1 P&IY I "I � A YM 1 . UWI Cot$o<�tg A YM i NM 6ras3",00- y I .. u A YIN 1 UW PROS red A JYIN 1 M lrfi I J000 A Ym 1 UK @S xuaw AC A IVIN 1 YWY a� A YM l YVM UWI use$:ul w1y1 A WN 1 ivy i A YM 1 YVM M wol5 lul A YIN 1 MY mepetl A YM 1 WM UW do1S apeaH A "M 1 Wrd Lred>'QY7 3 a Y A YIN 1 Wiz 6u!s20+aM A YIN i PUY speogasn a v A YM 1 WM ua1dv aM A YIN ',WM SURM Mol 9 v A YM 1 W!V UW es MCPU!M A YM i w. If saeM do a v H_?W ?1 ya ( K i=W 2-1 YQ H :�Y3HnS l{!=yy r Yp ►. - H!3iv ?r 7o ZYFi Qi T H nS OI pan I So=du icy :1l Mol!:col :als cY--_rc CY--=o` of I � t, ( ac__As Iay=-il of�Yooi (gas � wooa R:eY Q # 6394IN 3SV:) mad to SSWPPV atz� am:et6g :orl ({uul):cssassy Isro --� alep amleu6ig :�rl Gln�>orslry . °1)p�°mod � � Q� il:=.rtl :spe�...or(,ant) - Lac Off Signature Gate isk Assessx(print) Lic s Signature Date idress of Rcp--Ay CASE NLMFR # ' �� Apt Z. city DOM a?B LOC:..ICW LEAo TY OF I URG IC IC IO_ AO DEELEAD SIOEI LOCATION IL:-.,-Oi iYP_OF JURGI IC IC IG,.SAO DESIiIRD v DA—.c hET.H OAT- WTH SURFACE KAZnK7 HAc. DA�c Mi}t OAr c-,H n�Up Ways AN L WA Y , Window Sin €. MA AIM L WA Y ' 0 jLow waits I Uj AN L NIA Y ( Win Apron a AN L WA Y I Geaseboar:a ""I' AIM L NIA Y Wm Casing I AIM L WA Y "L MA Y i Header Stop 94IM11 AIM L WA Y lRad a;or v ! MA L WA Y ( D Int Stop IM4 AM L WA Y Float ! AJAR L WA Y ! Wit Inv Sast ! IMA AIM L WA( Y I ! Ceinng kW AN L W; Y I mer,x Sin Mn L WA I Y Oaor ( AN L WA Y Par,Bead W IMA L WA I T I Loon AIM L WA Y ! Sunc Stap Wjf IMA L WA I Y I ti2A: N/A l Y I I Will Sr Sash I f (Mn L WA( Y I I `Ares.=, A"L WA I Y I I I Wfndcw Sin IMA AM L W:.I Y I ! Dxr I ° I AM , Ni.;( Y I ( ! ( Win A^y^.1 I `�I AM L fvA Y I I I j( Cam- 1-N.; N„I Y I I I v4M Cas:N 11 AN _ N/Al Y I I I +� uoG.a:. I AM L N,,,I Y I I peace S«.; I AM L WA Y Thr.3'M i ! A.V L N.-A Y i ! I ( In:Step IIM 'IV L WA Y I I I Doer I AU L NIA 1 Y I ! I ( Win Inc Sash I IMA L NIA Y I I I I A.V._ N;;, Y I l I Ere::a:Sin I It.r NIA I Y I I I I ciao tea.--- I :.'.: %:A( Y ( ( I Par,Bead ( (6ul L kAI Y I I I IVA I Y ;ilr-c sty, I itln L W Y I i I Lxr i I �•: ;;,I Y I I ! 1 —4— %•u_::Sasa IM L N;A I Y I 1 330.:as;.; I I - KC.; Y ( I C;cset Aa. L IAA Y Y I I I I Cas-.y i I ". Y I 1 I AAA rr A Y I I I ( ^�Cs_::a=-* I ( AV . NIA Y I I I Wtrc--w Sa ( • ( .0 ;Al L WA I Y I I i ( Close:Wars ! ( A:M L WA Y I Wan A;.za I I Ark!L WA I Y I C:Baseocar ( ( AM L WA Y Eoe-S� (cam; . I MA AN L W:. Y ( C(eset%ore ANL WA Menace: I Closet Shed AIM L WA Y IM S'w;3 ! '.IA AIM L N;A I Y { I I C:Sv;=-s I AAA L WA Y Wir. %ISam (� W A,M L WA Y ! C:cset=toot AN L WA Y I rz:e' r Sul i Mn L NIA Y Cicsev Ceiling AM L MA Y Par.=ead I i %I L MA Y Fueptace AIM L WA Y e&nd St-; I MA L NIA Y Mantle AIM L WA Y I Wu.l=z Sasa I .- A L WA Y 1 1MII . L N/A Y COMMEW,S/S.R;IC-,URAL:_-=_'.S: I I MA AIM L N/Al Y ! 111II AN L NiAl Y I I I I JIM ABM L NAl Y I I ! 1 1160 AM L MIAJ Y I zzcr.CCas IlStec in mesa acxej can De trace U'i:2Li omy Oy a ncense.^.9e:eacer. L::.. 1CN W-4S:i==.LOCS=PAINT IC IC SIZE LC ICN MESURF..LOOS=?AINT IC I( (M:---i nAN?SZ SC.IN.) DATc 1 i k r: (MC-RE T14AN-M SC.IN.) 0ATt LE SILt v rage %%outw. Inspedor iprint) Uc# Signature Date Risk Assessor (print) Ud Signature Date kddress of Property CAS E NLMER # 56017 Apt# City 3ATHROOM SIDE LOCATION/ LEAD TYPE OF UM IC IC DELEAD DELEAD SIDEJ LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD HAZ? DATE METH_ DATE METH SURFACE HAZARD HAV DATE METH DATE METH c o Up Wald N/� A/M L WA Y LOW Cab Frarn AIM L WA Y A 8 Wags AIM L WA Y j� LOW Cab Door AIM L WA Y C o Baseboards A/M L WA Y Y Low Cab Walls AIM L WA Y A a Chair Rag AIM L WA Y Low Cab Sh ittiC/ AIM L WA Y Radiator AIM L WA Y Supports AIM L WA Y Floor AIM L WA Y Drawers AIM L WA Y Ceiling AIM L WA Y Closet Door AIM L WA Y �r AIM L WA Y Closet Casing AIM L WA Y Door Casing AIM L WA Y Closet Jamb AIM L WA Y Door Jamb AIM L WA Y Closet Wald A!M L WA Y Threshold --- AIM L WA Y Cl Baseboard M L N/A Y Door AIM L WA Y Closet Pole L WA Y Door Casing AIM L WA Y Closet Shelf AIM L A Y Door Jamb AIM WA Y CISupports AIM L NX Y Threshold AIM L WA Y Closet Floor AIM L WA Y Window Sig Aw Mn AIM L WA Y Closet Ceiling AN L WA Win Aprcn AIM L WA Y MA AIM L NA Y Win Casing AIM L WA Y W AIM L NA Y r Header Stop Mn AIM L WA Y Mn A/M L NA Y nt Stops Mn AIM L WA Y Mn AIM L NA Y Win Int Sash W AIM L NIA Y W AIM L NA Y Exterior Sig Mn L NIA Y W AIM L NA Y Part Bead Mn L WA Y Mn AIM L NA Y Blind Stop M I Mn L WA Y Mn A/M L NA Y Wm Ext Sash WV W L WA Y Mn AIM L NA Y Up Cab Frame AIM L WA Y Mn AIM L NA Y Up Cab Door AIM L NIA Y Mn AIM L NA Y Up Cab Wags L WA Y Mn AIM L NA Y Up Cab ShNs AAtL WA Y Mn AIM L NA Y Supports AIM L A Y Mn AIM L NA Y Mn AIM L WA Y Mn AIM L NA Y Mn AIM L WA Y Mn AIM L NA Y Mn A/M L WA Y I Mn AIM L NA Y OMMENTS/STRUCTURAL DEFECTS:' COMMENTS/STRUCTURAL DEFECTS: EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only by a licensed deleader. IDE LOCATION MEASURE.LOOSE PAINT IC IC SIDEJ LOCATION MEASURE:LOOSE PAINT IC IC (MORE THAN 288 SO.IN.) DATE METH00 (MORE THAN 288 SO.IN.) DATE METHOD LURA RepBath,8/6102 Inspestor(print) --Tjc# Signature pate Risk Assessor(print) Lic# Signature Date Address of Property CASE NUMBER # Q 3 Apt# City HALLMY SIDE LOCATIOW LEAD TYPE OF URG IC IC DELEAD OELAD S10E LOCATIOW LEAD TYPE OF URG IC IC OELEAD OELEAC SURFACE HAZARD HAZ? DATE METH DATE METH SURFACE HAZARD HAZ? DATE METH DATE- METH c 0 Up Waft AIM L WA Y Window S MA AIM L WA Y A 8 Low Watts AIM L WA Y Win Apron AIM L WA Y d o Baseboards AIM L WA Y Wm Casing AIM L WA Y A Il Chair Rail ""► AIM L WA Y Header Stop AIM L WA Y Radiator AIM L WA Y Int Stops M4 NM L WA Y Floor A/M L WA Y Wm Int Sash MII L WA Y Cog AIM L WA Y Exterior SillhVl L A Y Door AIM L WA Y Part Bead MA L Y GDoor Casing AIM L WA Y ti nd Stop MII L WA Door Jamb AIM L WA Y Wm Ext Sash IMA L WA Y Threshold AIM L WA Y Closet Door AIM L WA Y , Door AIM L WA Y C1 Casing AIM L WA Y Poor Casing 1r/ AIM L WA Y Closet Jamb AIM L WA Y Door Jamb AIM L NIA Y aoset Walls AIM L WA Y Threshold AIM L WA Y CI Baseboard AIM L WA Y Door LV AIM L WA Y Closet Pole , AIM L WA Y Door Casing AN L WA Y Closet Shelf AIM L WA Y DoorJamb AIM L WA Y a Supports AIM L WA Y Threshold AIM L WA Y Closet Floor AIM L WA Y Door AIM L WA Y CI Ceding jvAIM L WA Y Door Casing AIM L WA Y Closet Door AN L WA Y DoorJamb AIM L WA Y Cl Casing AIM L NIA Y Threshold AIM L WA Y Closet Jamb )V11(L WA Y Door AiM L WA Y Closet Walls ABM WA Y Door casing AIM L WA Y Cl Baseboard AIM L Y Door Jamb AIM L WA Y Closet Polo AIM L WA Threshold AIM L WA Y Closet Shelf AIM L WA Y Window Sill All AIM L WA Y CI Supports AIM L WA Y n Apron AIM L WA Y Closet Floor AIM L WA Y Wm Casing AIM L WA Y ICI Ceiling AIM L WA Y Header Stop MA kM L WA Y MI AIM L WA Y Int Stops Mil AIM A Y Mn AIM L WA Y Win Int Sash MA AIM L WA, Y W AIM L NIA Y Exterior Sin Mn L WACOMMENTS/STRUCTURAL DEFECTS: Part Bead Mn L WA Y Blicd Stop MII L WA Y Win Ext Sash Mil L WA Y XCLUDED SURFA ES:Surfaces listed in these boxes can be made intact only by a licensed deieader. SIDE LOCATICN MEASURE:LOOSE PAINT IC IC SIDEJ LOCATION MEASURE:LOOSE PAINT IC IC (MORE THAN 288 SO.W.) DATE METHOD (MORE THAN 288 SO.IN.) DATE METH( LURA RepHali,8/6102 Ri' BEAM.i '3 �$���� Page f2a 1 G Inspector(print) Lic# Signature Date Risk Assessor(print) Lic# Signature Date Address of Property r'L_SF NI IMRFR# Apt# City RTTG SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SIDEJ LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEA[ SURFACE HAZARD HAZ? DATE METH DATE METH SURFACE HAZARD . DATE METH DATE METH A 0 Up Walls A/M L NIA Y N Window S81 Mn AIM L NIA Y A a Low Walls AIM L WA Y Apron AIM L NIA Y c o Baseboards AIM L N/A Y Win AIM L WA Y A Q Chair Rao �. AIM L WA Y Header p Mn AIM L WA Y Radiator AIM L WA Y Int Stops Mn A/M L WA Y Floor A/M L WA Y Win Int Sash Mn AIM L WA Y Ceiling A/M L N/A Y Exterior Sill Mn L WA Y Door A/M L NIA Y Part Bead L N/A Y Door Casing AIM L N/A Y Blind Stop L NIA Y Door Jamb AIM L WA Y Wm Ext Sash IMA L WA Y Threshold AIM L WA Y Closet Door A,?IL WA Y Door L N/A Y CI Casing AIM L A Y Door Casing Ah4 L N/A Y Closet Jamb An+A L Y Door Jamb WA Y Closet Wafts AIM L WA Y Threshold AIM L A Y CI Baseboard AIM L WA Door AIM L N/A Y Closet Pole AIM L WA Y Door Casing A/M L NIA Y Closet Shell AIM L WA Y Door Jamb AIM L WA CI Supports AIM L WA Y Threshold A/M L WA Y Closet Floor AIM L WA Y Door AIM L WA Y Closet Ceding AIM L WA Y Door Casing AIM L WA Y Up Cab Frame AIM L WA Y Door Jamb AIM L N/A Y Up Cab Door AIM L NIA Y Threshold AIM L WA Y Up Cab Walls AIM L NIA Y Window Sri Mn AIM L WA Y Up Cab Shhrs 1A AIM L WA Y Win Apron AIM L.WA Y Supports IiIA AIM L WA Y Win Casing A/M L WA Y Low Cab Frain AIM L WA Y Header Stop Mn AIM L N/A Y Low Cab Door AIM L N/A Y Int Stops Mn A/M L WA Y Low Cab W AIM L WA Y IVUW Win lat Sash Mn AIM L WA Y Low Cab S ru AIM L N/A Y Exterior Sri Mn L WA Y Supports J-441 AIM L WA Y Part Bead Mn L NIA Y Drawers JAA AIM L N/A Y Blind Stop Mn L WA Y Mn AIM L WA Y Win Ext Sash Mn L WA Y Mn AIM L WA Y COMMENTS I STRUCTURAL DEFECTS: Mn AIM L NIA Y Mil AIM L NIA Y Mn AIM L WA Y I A AIM L NIAJ Y EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only by a licensed deleader. SIDE LOCATION MEASURE:LOOSE PAINT IC IC SIDE LOCATION MEASURE:LOOSE PAINT IC IC (MORE THAN 288 SO.IN.) DATE METHOD (MORE THAN 288 SO.IN.) DATE METHC rage Le ui nspcstor(print) Lic# Signature Date isk Assessor (print) Lic# Signature Date ddress of Proms rASF Ni mFR # S�G Apt# City XTERIOR ME LOCATION/ TYPE OF URG IC IC OELEAD OELEAD SIDEJ LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD A SURFACE HAZARD . DATE METH DATE METH A SURFACE HAZARD HAV DATE METH DATE METH Siding L WA Y Z Window,SW AIM L WA Y comers L WA Y Win Casing AIM L WA Y A Lower Trim to L WA Y Window Sash AIM L WA Y Upper Tnm L'WA Y Window SRI AIM L WA Y Wm Above S L WA Y A Wm Casing AIM L WA Y Pour Above T L WA Y `� Window Sash AIM L WA Y Stan Door AIM L WA Y Cellar Wm SRI AIM L WA Y Door • ( AIM L WA Y A Cel Wm Sash AIM L WA Y A Door Casing AIM L WA Y Cel Wm Fran AIM L WA Y Door Jamb AIM L WA Y Cellar Win SRI AIM L WA Y Threshold AIM L WA Y A Cei Win Sash AIM L WA Y "late AIM L WA Y Cel Win FrameAIM L N/A Y Storm Door AlM L N/A Y Cellar Win Skll AIM L WA Y Door A M L WA Y A Cel Win Sash M L NIA Y A Door Casing A/M L WA Y Cel Win r"rd L WA Y OoorJamb AIM L WA Y Cellar Wm Sill L WA Y Threshold AN L WA Y A Cel Win Sash AIM WA Y fGkykplate AIM L WA Y Cel Wm Frain WM L WA Y Door L WA Y Foundation L WA Y A Door casing I AkL WA Y A Bulkhead AIM L WA Y Door Jamb AIM WA Y Fences AIM L NIA Y Threshold AIM L Y Shutters AIM L WA Y Door AIM L WA Y Newel post 1 L WA Y A Door Casing AIM L WA Rang Cap L WA Y Door Jarro AIM L WA Y Handrail AW WA Y Threshold AIM L WA Y A Balusters AIM L Y Windowsill AIM L WA Y Lower Rail AIM L WA Y LA Win Casing AIM L WA Y Treads AIM L NIA 3 Window Sash AIM L WA Y Risers AIM L NIA Y ' - Window SRI AIM L WA Y Stringer AIM L WA Y iA Win Casing J�W AIM L WA Y AIM L WA Y Wndow Sash AIM L WA Y AIM L WA Y :OMMENTS I STRUCTURAL DEFECTS. AIM L NIA Y A AIM L WA Y AI61 L WA Y AIM L WA Y Excluded Surfaces:Surfaces listed in this box can be made Soil Test Results intact only by a licensed deleader (Must be less than 400 ppm for play area 11200 ppm for bare soil) SIDE LOCATION MEASURE:LOOSE PAINT IC IC LOCATION AREA IMEASURENIENT RESULT REMED REMEC A (MORE THAN 1440 SO.IN.) DATE METH (Square Feet) (ppm) DATE METH A Play Area A Bare soil A Comments: A L.URA RepErt&816/02 •-.RT BEALYUL:.L' 1-1Lvi < -3 - Page \'i Of -!nspector(print) Lic W Signawre Date Risk Assessor (print) UC# Signature Date Address of Property CASF Nt MFR # SU '77 Apt K City EXTERIOR SIDE LOCATION/ TYPE OF URG I IC IC IDELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEA[ B SURFACE HAZARD K DATE METH DATE METH B SURFA ' HAZARD HAZ? DATE METH DATE METH Sung AIM L WA Y Window Sill AIM L WA Y Comer Boards L WA Y B Win Casing AIM L WA Y B Lower Trim L WA Y Window Sash AIM L WA Y UpperTmn L WA Y Window SEU AIM L WA Y Win Above 5' L WA Y B Win Casing L WA Y Pore Above 5 L WA Y W ndow Sash L WA Y Storm Door AIM L WA Y Cellar Win S1, AIM WA Y Door AIM L WA Y B el Wm Sash AIM L Y B Door Casing AIM L WA Y Cel Win F AIM L WA Y Door Jamb AIM L WA Y Cedar'Nin Sad AIM L WA Threshold .p AIM L WA Y B Cel Win Sash AIM L WA Y fGCtplate ; AIM L N/A Y Cel Win Frame AIM L WA Y Storm Crcr AIM L WA Y Cellar Win Still AIM L WA Y Door "q AJM L WA Y B Cel Win Sasn AIM L WA Y B Door Casing AIM L N/A Y Cat Win F AIM L WA Y Coor Jamo AIM L N/A Y Cellar Win S11 AIM L WA Y Threshold AIM L WA Y B Cel Win Sash M L WA Y Kick;wte L WA Y Cel Win FrameL WA Y Door L WA Y Foundation L WA Y B Door casing WA Y B Bulkhead AjM L N/A Y Door Jamb AIM L A Y Fences AiM L WA Y Thtesnct0 AM L Y Shutters Alht L WA Y Door AIM L WA Y Newel post L WA Y B Oocr Casing AIM L WA Rairmg Cap AIM WA Y Door Jame ArM L WA Y Handrad AIM L N Y Threshold AIM L WA Y B Balusters AIM L WA Y Window Sal AIM L N/A Y Lower Rail AIM L WA B Win Casing L WA Y Treads AIM L WA Y Window Sash WA Y Risers AIM L WA Y Window Sig AIM L A Y Stringer AIM L WA Y B Win Cas" AIM L Y AIM L WA Y Window Sash AIM L WA Y AIM L WA Y COMMENTS/STRUCTURAL DEFECTS: AIM L N/A Y B AIM L NIA Y AIM L WA Y ABM L WA Y Excivaed Surfaces:Surfaces listed in this box can be made Soil Test Results intact only by a licensed deleader (Must be less than 400 ppm for play area!1200 ppm for bare soil) SIDE LCCATtON MEASURE:LOOSE PAINT IC IC LOCATION AREA`IE.ASUREMENT RESULT REMEO REME 8 (MORE;THAN 1440 SO.IN.) DATE: METH (Square Feet) (PPM) DATE MET $ Play area B Bare soil $ Comments: 8 . LLRa ReoErtB.8/6l02 t IJ L-.4k jt..tL�U _L-A0-1 T - -� fl a-5 PageLOfJSs . InsK_-!or(print) UC 9 Signature Date Risk Assessor (print) UC# Signature Date Address of Property CASE NUMER # a&3 Apt# city EXTERIOR SIDE LOCATIOw TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD C SURFACE HAZARD HAV DATE METH DATE METH C I SURFACE HAZARD DATE METH DATE METH Siding PW4 L WA Y G Window SO AIM L NIA Y Comer Hoards L NIA Y C Win Casing VA AIM L NIA Y C Lower Trim L NIA Y ? Window Sash 041 AIM L WA Y Upper Trim L WA Y Window SO AIM L WA Y Wm Above T L WA Y Win Casing AIM L WA Y Porch Above S +- L MA Y Window Sash AIM L WA Y Stone Door AIM L WA Y Cellar Win SO AIM L WA Y Door AIM L WA Y C Cel Win Sash AIM L WA Y C Door Laing AIM L MA Y 1 Cel Wm-Frame 94 AIM L WA Y Door Jamb AIM L WA Y Cellar Win SDI & AIM L WA Y Threshold AIM L WA Y C Icel Wm Sash AIM L WA Y lOckplate AIM L WA Y Z-Cel Wm FrainVA AIM L WA Y Stone Door L WA Y Cellar Win SIR A/M L WA Y Docr AAL WA Y C Cel Win Sash ' -�! AIM L WA Y C Door Casing AIM L WA Y �/ CH Wm Frame AIM L WA Y Door Jamb AIM L Y Cellar Wm SO AIM L WA Y Threshold AIM L NIA, Y C Cel Win Sash AIM L MA Y Mckplate AIM L WA Y Cel Wm Frame AJM L WA Y Door AIM L MA Foundation L WA Y C Door Casing AIM L WA Y C Bulkhead ,{, AJA L WA Y Docr Jamb AIM L WA Y Fences AM L WA Y T hreshcld AIM L WA Y IShutters AIM L WA Y Door AIM L WA Y Newel post AIM L WA Y C Coor Casing AIM L WA Y Railing Cap AIM L WA Y Coor Jamb AN L NIA Y Handrad VA AR.b L WA Y Threshold AIM L WA Y C Balusters AIM L WA Y Window SDI #A AIM L WA Y Lower Rao �„�/ ArM L WA Y r C win Casing AIM L WA Y Treads 1WAIM L WA Y 3 Window sash AIM L NIA Y Risers F1 JA AIM L WA Y L Window Sig AIM L WA Y Stringer AIM L WA Y Wm Casing $A AIM L WA Y AIM L WA Y Window Sash AIM L WA Y AIM L WA Y :OMMENTS/STRUCTURAL DEFECTS: AIM L WA Y C AIM L WA Y �t M 9 A%A a AIM L WA Y 4/�J AIM l WA Y Excluded Surfaces:Surfaces listed in this box can be made Soil Test Results intact only by a licensed deleader (Must be less than 400 ppm for play area/1200 ppm for bare soil) iIOE LOCATION MEASURE.LOOSE PAINT IC IC LOCATION AREANIEASURENtEMT RESUL REMED REMEC C (MORE THAN 1440 SO.IN.) DATE METH (Square Feet) (PPM) DATE METH C Play Area C Bare soil C Comments: - C LLIL-%RepExtC,816102 I ros;+e- 7. Tarr AOIc H01A 2-,joWdrJ- 1, '''YJ=L' G '-J1S=_ 1\�1V�Z3�!$':1�� YCI::=C� :I �I N.7� -Cv: :one-=;J >JC::�__• =_„!e (pos;jeq:o}iidd;OZ:!e;je Ae;d,oj'.udc 007 ue'.1 ss;l;q Isnk♦I) t►uc Sins-;,.:IS;;: IiCS 'sc YCc sar.uI M";:Sail S;:Q:.'C I I I A I7/N i ; tj I I I A I�IN 1 Ycro ( I I I i I A 1`:IN - �- i I / s- ===--y=:�_ '�.•J_m: I I A i V.N ' I I I i I A Yam I Imps••::.M 2 i I A I`:IN ' MV ( I I I A I`IN -Wy `,last:%PM Q I i I A ISM : nlr: I I nem s I I A Ir--, -:J-• I I es.4:,qM I ( I A I='.'N 1 Yi,'Y ( I T::s:: I I I A I.;.w -IT, 19 I Ms I I I A I VN i ftV I I =ea i I I i A l::N -:r- I I !_Tt:=m Q 1O, I I red::.>:- I i i I A I::N ' 11 PS.1--141M I I I I A Nq � I ! I I • I::i . - ( I -e-_mot: I I \ I I .: I.., -„- I ! ...>: .;�^ c f l I I I ; 1-•+ ' I I :T:_ ;..0`.1 I I I i . I= I I -.c: I I I I ♦ I:,1 I s.;: .I I I I , I- :.- I I ___>:._ I I _sec r.-: I I-'s-a% 1 i i I A I�.N ; <<1 Viz:a►A'a^ i I I ! I �'� I I ��st�:cr� Q I I 1 I ; i:�� ' ��`• I I :•ste.1.;�- � I I I i � l='� .;`• i I i I I I l i:.. ,:,� I ! .c,:;.>-•e- i I I I : I- I i :�-_-w5 I I IAI: - ~ IW.tViz= —c I i i I : I:• i I ae ,�„ I I I I { I:ti . ::� I I •=zs a.:.3^ � I I I 1 � 1::. - ;:- I I I=:�:�_ I I I I : I-� - �L ( Y�l ys-ti:.e�:. I I I I ; 1-�• '•-�� �I I �=ro'� I i i IAI-w , :�,� }�:>r•:�M�^ � I I IAI-�N :J`: I ��:� c I I IAI-V - rzy .VA I -Tts i C. I i I A I.N ' YJh.' I ma I I I IAI I ,ocr.,:oig I I I A I::N i t 11 est;N♦;�11;• I I I IAI: I 1=;,.�'�roQ I I I A 1::!4 ' !on-_Ara I I A Iy:V -i riv I I Is-am":+ I I I A l-:V 1 1+ 1 a'::amowrt I I { I A I�:N 1 -ee I I =s"'c=°'�+ A l::N ; I �i ev_:aMo; e I 1 A :IN " YJ't ( 6wst�wtq Q ( I I I A I lIT�e:e:as.�� I I A I'::u - MV I His-cva:ti i•L`:iY _�K H_:iV �:'�i '':F Cti..::-I �C:u1$ � .�::i �'yC .::YJ _:'.r. L! Cti:_:.: ��:=��:$ � ="=1=G IC:r==�� 71 I 71 r��I �C-�i.! I�;"�1 •NCI�`_L I=��S = =C I:`•-" CI `�1 I �I �r:�1I �= __` IC`r=I :1C:�`•�01 = A%Q--.�'o SSG: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED ® JUN. 1 5 2004 TOWN OF BARNS.TABLE TITLES HEALTH DEFT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 139 Phinney' s Lane MAP Centerville, MA PARCH Owner's Name: Gera 1 do Da S i 1 va ` Owner's Address:_ -; -� LOB - Date of Inspection: _ ��'' f/l Name of inspector:(please print) Wi 1 1 i am . •Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776 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 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 15340 of Title 5(310 CN'IR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: L 6'0 L The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heankor . DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments •`"'This report only describes conditions at the time of 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. Title S Inspection Form 6/15/2000 page I ;F, Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:- 1 3 9 Phinney' s Lane Centerville MA Owner. Geraldo DaSilva Date of inspection:. InspectioZrasses- I ary: Check A,B,C,D or E I ALWAYS complete all of Section D A. Syst 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: -7777-7 System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or re fired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass." Ans er yes,no or not determined(Y,N,ND)in the for the following statements.lf'%ot determined"please expla . The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiitration or tank failur.c is imminent.System will pass inspection if the exist' g tank is replaced with a complying septic tank as approved by the Board of Health. •A m tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic 'ng that the tank is less than 20 years old is available. ND plain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obi cted pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with app val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or laced ND ex lain: e system required pumping more than 4 times a year due to broken or obsmxlcd pkw(s).The system will pass ins,ection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is icmorod ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:- 1 3 a � lnne�z s—1,�ne Owner: Date of Inspection: . 0 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 fail g to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety_and the environment:- Cesspool or privy is within 50 feet of a surface water Cesspool or privy,is within 50 feet of a bordering vegetated wetland or a salt marsh 2. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 s rface 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 frodl 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 colifonn 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3 Other: 3 Page 4 of 11 L r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SE WAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A _ CERTIFICATION(continued) Property Address: 139 Phinney' s Lane Centerville, MA Owner: Geraldo DaSilva Date of Inspection: D. Sstem Failure Criteria applicable to all systems: You m st indicate').res".or"no"to each of the following for.all inspections: Yes o 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 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within I00.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.IThis system passes if the well water analysis, performed at a DEP certified laboratory.,for colifoem bacteria and volatile organic compounds Indicates that the well is frce.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes/No)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. arge Systems: To b considered a large system the system must serve a faci!ity with a design now of 10,000 gpd to 15,000 hpd• You ust indicate either"yes"or"no"to each of the following: (The Ilowing criteria apply to large systems in addition to the criteria above) yes 110 the system is within 400 feet of a surface dr'utking 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 11 of a public water supply well If yo 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 0%%Mer ar 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. 4 Page 5 of 11 Z OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 139 Phinney' s Lane Centerville, MA Owner: Geraldo DaSilva Date of Inspection: 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? 1✓— Has the system received normal flows in the previous two week period? _ e' ave large volumes of water been introduced to the system recently or as part of this inspection? ✓_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? v Was the facility owner(and occupants if different from owner)provided with information on the.proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: - Yes -no / _ _✓Existing information.For example,a plan at the Board of Health. (J Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance. is unacceptable)13 10 CMR 15.302(3)(b)) 5 - b Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 139 Phinney' s Lane Centerville, MA Owner: Geraldo DaSilva Date of Inspection: 0' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual): 41 DESIGN flow based on 310 CMR 1 .203(for example: 110 gpd x#of bedrooms): . Number of current residents: Does residence have a garbag • der{yes or:no) U Is laundry on a separate sewage system(yes or no). o[if yes separate inspection required] Laundry system inspected(yes or no) Cl Seasonal use:(yes or no): ,n Water meter readings,if avai ble(last 2 years usage(gpd)): '2003 = ' 14 0,':60 0 Sump pump(yes or 2002 — 164, 000 Last date of occupancy: ;i-5'e—a CO MMof ERC IANDUSTRIAL Type establi ent: Design flow ed on 310 CMR 15.203 : gpd` ) Basis of design ow(seats/persons/sgft,etc.): Grease tra/escribe): ent(yes or no):_ Industrialholding tank present(yes or no):_ Non-sanitste discharged to the Title 5 system(yes or no): Water medings,.if available: Last date upancy/use: OTHER GENERAL INFORMATION Pumping Records Source of information: /, 5� 2 Was system,pumped as part of the inspection(yes or no): id If yes,volume pumped:_gallons-=1ow was quantity pumped determined? Reason for pumping: TYPfi"OF SYSTEM 4, 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) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date ins- led(if known)an sourc elf information: Were sewage odors detected when arriving at the site(yes or no):� 6 I'agc 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART_C SYSTEM INFORMATION(continued) Property Address: 139 Phinnev' s Lane Centerville . MA Owner: Geraldo DaSi Iva Date of Inspection: _-g i1 BUILDING SE R(locate on site plan) Depth below grade: Materials of cons ction:_cast iron _40 PVC_other(explain): Distance from pr. ate water supply well or suction line: Comments(on ondition of jousts,venting,evidence of leakage;ctc.): SEPT • ,.( IC TA)\K. . (locate on site plan) Depth below grade:_ / Material of construction._concrete metal fiberglass__polyethylene _other explain) _ If tank is metal list age:_ Is age confumed•by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �k Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom o,joutlet tee or baffle:01 How were dimensions determined:_- ® �,v Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to ou)et invert,cv1dencq of Ieaka ,etc.): 0 C-) ;a GREASE TRAP: (locate on site plan) Depth below grade _ Material of eonstru tion:_concrete metal fiberglass_polyethylene_other (explain): _ Dimensions: Scum thickness: Distance from top f scum.to top of outlet tee or baffle: Distance from bo om of scum to bottom of outlet tee or baffle: Date of last pum ing: Cotttments(on umping reconunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to o let invert,evidence of leakage,etc.): 7 1.. Page 8 of 11 OFFICIAL.INSPECTION FORM: NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 3 9 Ph.inney' s Lane Centerville, MA Owner:_ Geraldo DaSilva Date or laspectlon: e l TIGHT or HOLDING ANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity. gallons Design Flow; gallons/day Alarm present(yes or o): Alarm level: Alarm in working order(yes or no): Date of last pumpin Comments(conditi n of alarm and float switches,.etc.): 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.): , U PUMP CHAMBER: (loc a on site plan) Pumps in working order(yes o no): Alarms in working order(yes r no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 I ' Page 9 of 11 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .139 Phinnev' s Lane Centervi11 f MA Owner: Gt-ra1dn DaSilva Date of Inspection: � (,T) SOIL ABSORPTION SYSTEM(SAS):Zoocate on site plan,excavation'not required) If SAS not located explain why: Type thing pits,number._ c/(eaching chambers,number: leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): OVA d. CESSPOOLS: Z(cesspool ust be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet' verrf Depth of solids layer: ✓) Depth of scum layer: Dimensions of cesspool. Materials of construction: Indication of groundwate inflow(yes or no): Comments(note conditi n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (loc a on site plan) Materials of on ction: Dimensions: Depth of solid Comments(n to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 1 r l 9' i Page l0 of 1 l OFFICIAL INSPECTION.FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: 139 Phinney' s Lane Cenlxrvi 1 1 P, Ma Owner: Geralc3e DaSi 1 va Date of Inspection: �--30—e �l SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 10 I .Page 1 I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ 139 Phinneys' Lane Centerville, MA Owner. Gerald DaS' lva Date,of Inspection: `I' —6 �f SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water `'/feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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) ccessed USGS database-explain: You must describe how you established the high ground water elevation: ll I I CO..IBIO' IVEALTH OF MASSACHI;SETTS E _ Expo TINrE OFFICE OF EINWIRO.NN E\TAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION O\£WL\=R STREE7.BOSTON ILA 02W t6I"j 242-55(►t, C 3 0 vt TRH DT C0\_7 Secretart ARGEO PAIL CELLt;CCI DAVID B STP.7_7H5 Governor Commissioner SUBSURFACE SEWA�GF/PISPOSAL STEM OM LollWN M d�FI L � � 3� f'�s�/C cE ica `$ fjMt-z..t�s� �— rn�n 066 Ds� . 06( Property Address: 139 Ph inneys Lane N,rrta of OM11fer nald �Cen erville Address of oa►rrar:197 airi Z .;�ennisport Date of inspection: f 4 —6� Name of inspector:(Please Pratt)Wm. E. Robinson Sr. 1 am a DEP approved s errl inspector to Section 15.340 of Title S(310 CMR 15.000) Company Name: Wm. E . Robinson ptis Service Mailing Address: PO Box i0 9. Centerville � Telephorm Number: 7 7 5-8 72 0 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: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: „�. j Date: The System Inspector shall submit a copy of this inspection report to the Approving AAuut-h-o-riity(Board'of Health or DEP)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. NOTES AND COMMENTS 10 oil CEIVE® S E P 8 2000 tOW)!Of'9AgNg1�� �l revLse:5 Paprlor11 C? -,-+ed o-Reo-cird Pane, • r SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION(continued) NopertyAddress: 139 Phinneys Lane , Centerville awe: Scott MacDonald. Date of Inspection: WSPECTION SUMMARY: Check 6 B, C, o/ A A. SYS PASSES: 71 have not found any information which indicates that*any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS:. B. STEM CONDITIONALLY PASSES: e'at more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon co pletion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes, o, 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if twith 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 then four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed revises 9/2/98 Page 2ofII rt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION fcontinued) Property Address: 139 Phinneys Lane , Centerville Owner: Scott MacDonald. Date of Inspection: �/O^6) 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) S STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CIYIR 15.303(1)(b)THAT THE SYSTEM IS OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYS M WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNC ZONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTH R PaQc 3 of 11 F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prop"Adciress:139 Phinneys Lane , Centerville Owner: Scott MacDonald. Dace of Inspection: g-14—G-v D. SYSTEM FAILS: You ust indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described 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 faiiure. Yes No Backup of sewage into 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 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. 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 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. LARG SYSTEM FAILS: You must in icate either "Yes" or "No' to each of the following: ThL following criteria apply to large systems in addition to the criteria above: 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 he ilth and safety and the environment because one or more of the following conditions exist: Yes N 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 r operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of th Department for further information. reVi.Se Pagc4or11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Prop"Address. 139 Phinneys Lane , Centerville Owner: Scott MacDonald. Date of Inspection.- Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner,occupant, or Board of Health. — None of the system components have been pumped for at least two weeks and the system has been reeeiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.. — As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. — The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. — All system components, excluding the Soil Absorption System, have been located on the site. — 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. The size and location of the Soil Absorption System on the site has been determined based on: — Existing information. For example, Plan at B.O.N. — Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) n / 115.302(3)(b)] — The facility owner (and occupants.if differeru from owner) were provided with information on the proper r aintana-ce f SubSurface Disposal Systems. re;-_sad 96 Page 5 of I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART C SYSTEM INFORMATION 'rap"Address: 139 Phinneys Lane , Centerville Owner: Scott MacDonald. Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:A.l0 g.p.d./bedroom. Number of bedrooms Idesign): Number of bedrooms (actual):4 Total DESIGN flow-6 4 0 Number of current residents..- Garbage grinder(yes or no): O Laundry(separate system) (yes or no)- 0; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use )yes or no):b-0 Water meter readings, if available (last two year's usage (gpd): 1999 70, 000 gal Sump Pump(yes or no): 0 1998 60 r ga Last date of occupancy: I—� CO MERCIALfINDUSTRIAL: Type f establishment: Design low: gpd ( Based on 15.203) Basis of esign flow Grease tr p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non•sani ary waste discharged to the Title 5 system: (yes or no)_ Water eter readings. if available: Last d e of occupancy: OTHER: Describe) Last da a of occupancy: GENERAL INFORMATION PUMPING RECORDS an soyjce of information: System pumpe'das part of inspection: (yes or no) C7 If yes, volume pumped: gallons Reason for pumping: TYPE O SYSTEM Septic tank idistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records:if any) I/A Technology etc" Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other /ems f APPROXIMATE AGE of all components, date installed(if known) and source of information: /•� F Sewage odors detected when arriving at the site: (yes or no)�O gel*ised 2; 9c Page 6(if ll i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) *ropem Address: 139-Phinneys Lane , Centerville Owner: Scot MacDonald. Date of Inspection: BUIL9 NG SEWER: (Locate n site plan) Depth belo grade:_ Material of onstruction:_east iron_40 PVC_other(explain) Distance fr m private water supply well or suction line Diameter Comments (condition of joints, venting, evidence of leakage,-etc.) SEPTIC ANK: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ (sage confirmed by Certificate of Compliance_(Yes/No) b? Y► Dimensions: 4 &4 6 (J l� Sludge depth: 2-40 1 It Distance from top of sludge to bottom of outlet tee or baffle:&L Scum thickness:_ ) Distance from top of scum to top of outlet tee or baffle: r I Distance from bottom of scum to bottom of outlet tee or baffle:_ How dimensions were determined: comments: Irecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struc ral integrity, evidence of leakage, etc.) b 6"o f �w dZ "f ;><LN �r GR ET : (locate n site RAP plan) Depth be w grade:_ Material construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensio s: Scum thic ness: Distance om top of scum to top of outlet tee or baffle: Distance rom bottom of scum to bottom of outlet tee or baffle: Date of st pumping: Comment (recomme dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence cf leakage, etc.) rev_SeC 9/2/58 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION(continued) 'roperty Address: Owner: Date of!ns TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locat on site plan) Depth low grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design ow: gallons!day Alarm resent Alarm vel: Alarm in working order: Yes_ No_ Date of revious pumping: Commen s: (conditio of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_v (locate on site plan) Depth of liquid level above outlet invert: \� Comments: (note if level and distribution is equal, avid ce of solids carryover, evidence of leakage into or out of box, etc.) PUMP CH MBER:_ (locate on ite plan) Pumps in orking order: (Yes or No) Alarms i working order (Yes or No) Comm ts: (note co dition of pump chamber, condition of pumps and appurtenances, etc.) revises 9/2 /98 P�FcBoflt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 139 Phinneys Lane , Centerville e Owner: Scott MacDonald. Date of Inspection: / SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required.location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries, number:_ leaching trenches. number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil,, ns of hydrau c W'ure, level of Danding.Zmp soil condition of vegetation, etc.) CESSP OLS:_ (locate site plan) Number a d configuration: Depth-top f liquid to inlet invert: Depth of so ds layer: )epth of sc layer: Dimensions cesspool: Materials of c nstruction: Indication of roundwater: inflo (cesspool must be pumped as part of inspection) Comments: (note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on s•te plan) Materials of c nstruction: Depth of soli s: Dimensions: Comments: (note conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Pagc 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) bop"Address: 139 Phinneys Lane , Centerville q lwrw: Scott MacDonald. ame of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 F �P 1[ Q S 1 1 1 V i V p� L re-v serd 5;'2/5E PAgc10ofII I -- • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icon rtued) ropertyAd&*"-. 139 Phinneys Lane , Centerville Owner- Scgtt MacDonald. Dace of Impeebon: NRCS Report name 6 (� Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Deep Groundwater depth: Shallow- Moderate SITE EXAM Slope Surface water Check Cellir Shallow wells Estimated Depth to Groundwater eet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property.observation hole. basement sump etc.) Determined from local conditions VChecked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Ye'visec 5/2/5E Page II of II `a. Town of Barnstable Regulatory Services • M ' E MASS. Thomas F. Geiler,Director v ass• g' � i63q. 10 ArF039 1% Public Health Division Thomas McKean,Director 367 Main Street, Hyannis,MA 02601 Office: 508-862-4644 -�3 O&& _ Fax: 508-790-6304 Mr. Scott MacDonald_. l 197 Main Street Dennisport,MA 02639 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00,STATE SANITARY CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 139 Phinney's Lane, Centerville was inspected on August 24,2000 by Edward Barry,Health Inspector for the Town of Barnstable,because of a complaint. The following violations of 105 CMR 410.00,State Sanitary Code II,Minimum Standards of Fitness for Human Habitation were observed: • 410.351 Kitchen sink leaks, wash basin leaks,water closet leaks. a 410.480 No key for front door. 0 410.501 Leak in ceiling by front door. Basement floods when it rains. • 416.600 No containers supplied for trash. 0 410.601 Large pile of trash on ground at rear of house. 0 410.481 No 20 sq.inch Notice bearing owner's name,address,and telephone number. You are also directed to correct the remaining above listed violations within five(5)days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven(7)days after the date order is received. However,these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than$500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH omas A.McKean Director of Public Health O a, r Jyo,.rcro,e The Town of Barnstable • - Health Department 367'Main Street,'Hyannis, MA 02601 i raa Office 508-790-6265 /T b,awA"o, Thomas A. McKean FAX 50b-j7P0344 z ov Director of Public Health NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION �.arL The property owned by you located at f 3?phfvriu�4v, was inspected on g,-,-Z4 , 'aVW0 by,244,A-ef:�9 Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code II, Minimum Standards of Fitness for Human Habitation were observed: GUr�t 7.�r° iz 4 0� 7- 410 .*fro � /// �J{ �/.. �;��.y f w�.,,�/, .[ }�/✓�/� ��/sue/ / 4/ '(���/ r' /M Il• ti-177�"F'�1���/..7 ��1/79i!R'L�jJ�- d '✓'IG� ! B"'�/T � You are d' ed to corn t the e�v-iolatio with' — p'we - 00 four 4) hours receipt of—this nice. ��n You are also directed to correct t j bj.-- �rozvtno—;vIr within ty�� �iays/bouts-of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH A0 �' �. Thomas A. McKean Director of Public Health f M THE COMMONWEALTH OF MASSACHUSETTS .y FORM 30 C&W HOBBs 8 WARREN BOARD OF HEALTH CITY/TOW o DEPARTMENT ADD ESS ? / TELEPHONE Address- 4o"_7_ upant 9721ir�x->zA zW7 Floor , Apartment No. No. of Occupants _ No.of Habitable Rooms ---No.Sleeping Rooms-1 _ No. dwelling or rooming units_ No.Stories Name and address of owner_,`-✓_ 4 �"�'�' Remarks Reg. Vio. YARD Out Bld s.: Fences: �G f Garbage and Rubbish t - Containers: �� vu Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: y l Stairs: Lighting: STRUCTURE INT. Hall,Stairwa : ,0JC' _ f A,1 Obst'n.: ' Hall, Floor,Wall,Ceiling: Hall Lighting: 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 Aq q.571 Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: 3i5 / Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted 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 OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR(, l TITLE r DATE "` TIME !:�74' '!S P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. ^i ":tft^"i;r'Y'ri+.T4 .. w;n17- to '.:M�St(� �4`v mZ,n' �'t ' ! c.� T11 i ..,,WASy:;*,.. t i y r' 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following,conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing.is composed of those 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 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions 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 such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include 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 CMR 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) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon 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 disposal 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 any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). r (I) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, 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 leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (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 facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) 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: (1) 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 inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, 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. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair 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. , -7- 5=00/ ( /mob TOWN OF BARNSTABLE /rOCYA720N 3 7 ® � 7- i�� SEWAGE# VILLAGE '' '� ;/4� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 77 SEPTIC TANK CAPACITY LEACHING FACIL17Y: (type) (size) NO.OF BEDROOMS :n� �+ BUILDER OR OWNER 1✓11 S// V A PERMTTDATE: � !'°" COMPLIANCE DATE: Separation Distance Bet)ng Maximum Adjusted Grouable to the Bottom of Leaching Facility Feet Private Water Supply Waching Facility (If any wells exist on site or within 200 ching facility) Feet Edge of Wetland and Lecility(If any wetlands exist within 300 feet of leality) Feet Furnished by . h � � ��. ;� � �� 1 � �, �' � .� .�__ _ , � n a �. � p �b ti a. Q t � ��-'� �/ �. C,�� � ��� -ass= o�� ����� �► l 0 C`A .� i G E P E it IT No. jL P, I N S T A LLER'S=vRx NAME " 1�� ADDRESS BUILDER -' OR OWNER-. � DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 3�Cy� �v ✓ � _ `� t l��. �, 3�'� , � �� 8/2/2021 Health Master Detail Health Master Parcels Search Selections Reports 'IT Applications Logoff crockersh Parcel Septic Perc Well Fuel Tank Parcel: 209-055-001 Location: 239 OLD POST ROAD(CENT.),Centerville Owner: APA INVESTMENT CORP Septic changes have been saved. Septic 2, 11/8/2013 Septic 1,Cottage-Rt I New Septic... Permit number: 2004337 Permit type: Select type v Complete system: ❑ Issue date : 7/9/2004 Complete date : 7/12/2004 Septic tank size: 1500 Type/Size of SAS: 2-500 gallon chambers Installer: Select Installer Card on file: Innovative/Alternative Technology type: I/A service type: Select service Select IA type v Variance date : Abandon complete date : Abandon permit number: Repair deadline date : Repair notification date : Keyword: Cottage-Rt Comments: 3 BED (for 3rd dwelling on premise # aka 229 Old Post =^% Delete Septic Rd, Cent New Inspection... Number Inspection Date Inspector Result 0 Select Inspector Select result v Received Date Comments 8/2/2021 ? Save Septic Changes I Return to Lookup R�4- 17r3 https://itsgldb.town.barnstable.ma.us:8431/HealthMasterDetail.aspx?ID=14876&mp=209055001# 1/1 No. � Fel 1 0 0 .0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MAS,ACHUSETTS es 01pplication for Mizponl 6p$tem Con5tru dion Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot Not 3 9 O 1 d Post Road Owner's Name,Address and Tel.No. Centerville Geraldo DaSilva Assessor's Map/Pazce1 209/55-1 239 Old Post Rd, Centerville Installer's Name,Address,and Tel.No. 7 7 5—87 7 6 Designer's Name,Address and Tel.No.3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco-Tech PO Box 1089, Centerville 43 Triangle Cr, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grindergo ) ther Type of Building No.of Persons Showers( ) Cafeteria( ) ther Fixtures esign Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install n Pw Tit 1 P 5 system to plans of Eco-Tech #ETE-1658 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 nvironm ntal Code and not to place the system in operation until a Certifi- cate of Compliance has be ssu�d b of Health S' ned Date�. Application Approved N, Date (> Application Disapproved for the following reasons Permit No. 3 7 Date Issued I I 4 ff� F100.00 �'�o• �� _J3. � - . . . . . . . - . ,:.', ete' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS s ZIppYication for aigozal *p6tem Con!5tructton 30ermit Application for a Permit to Construct.( _ )Repair(X )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot Not 3 9 'Old Post Road Owner's Name,Address and Tel.No. ^ f Centerville ''' deraldo DaSilva Jta Assessor'sMap/Pazcel 209/55-1 239 Old Post Rd, Centerville Installer's Name;Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco—Tech PO Box 1089, Centerville 43 Triangle Cr, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinderr�o ) l i ®ther Ij�pe of Building No.of Persons Showers( Cafeteria( ) ther Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Instal 1 n Pw T i i-1 p S c p n t-i o system to (plans of Eco—Tech #ETE-1658 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 nvironm ntal Code and not to place the system in operation until a Certifi- cate of Compliance has be �issued�bi�19,0- 110f Health. Signed Date V Application Approved b Date d Application Disapproved for the following reasons Permit No. 3 3 .Z Date Issued O�- THE COMMONWEALTH OF MASSACHUSETTS DaSilva BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( ) Abandoned( )by Wm E Robinson Sr Septic Service at 239 Old Post .Road, Centerville has been construe d i accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2u i tl- � da*wd- 7 �/ V Installer Designer The issuance of permit shall not be construed as a guarantee that the syst�°mwilI function Date �1 � l Inspector l N qj. I Fee10 0.0 0 DaSilva THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi5pozal bpaem Conotruction Verinit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 239 Old Post Road. Centerville i and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions Provided:Cons"ccttionflnu t be completed within three years of the!te of this pDate: ll�-�� Approv by ��� _ TOWN OF BARNSTABLE d LOCATION �'► 3 ! �' r KJ SEWAGE# - +� t a � VILLAGE � '%'°`' ��7 CC ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 116 J / Al SEPTIC TANK CAPACITY LEACHING FACII.ITY: (type) :a. "'`�6'°- �� > (size) NO.OF BEDROOMS �• BUILDER OR OWNER /-7/1 S// &0 PERMITDATE: % � COMPLIANCE DATE: 7 r lZ- 0 Separation Distance Between the: Maximum Adjusted Groundwate able to the Bottom of Leaching Facility Feet Private Water Supply Well an Leaching Facility (If any wells exist on site or within 200-feet f leaching facility) a Feet Edge of Wetland and Leac ng Facility(If any wetlands exist within 300 feet of lea ng facility) Feet j Furnished by i,A (• fir, ,v � e S �b J e v. .r t, r / f 1' Town of Barnstable e 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 Installer&Designer Certification Form Date: ✓6 Designer: Eco-Tech Installer: Wm E Robinson-,Sr Address: 41 Tri angl a C'i rrl a Address: _PO Box 1 089 sanawirh., MA -enterville, MAMA On Wm E Robinson Sr Septiepvas issued a permit to install a (date) (installer) septic system at 239 Old Post Rd, Centerville based on a design drawn by (address) _ Eco-Tech dated (designer) 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. O F3��H•OF' s DAt iD o�� r o 9OyG (Installer's Signature) ryR o 9 J v y (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE w 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 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Uifipniial Works Tomitrurtinn ramit ` Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal, System at: . .. ....�...J. .. .. r ........... .. . ...... ..-_-...-----------.-_------•-------------------_-- nAd or Lot .N_.o.. ..............--. Owne IAdt. /: = -. v Y ( _... Installer Ad ress Q Type of Building - - Size Lot............................Sq. feet V Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building .............. No. of ersons..............---....--..... Showers — Cafeteria a yP g -------------- P ( ) ( ) a 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 ( ) Percolation Test Results Performed by...................... _.. Date........................................ 1.4a Test Pit No. 1----------------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.....................--. o Description of Soil........ ------ ._------- V ----------------------------------------- ---------------------- ------------------------------------ •------------------------------------------------------------ .......----------•----------•---- W .: U Nature o rs or Alterations—Answer when applicable.------�". ?�® .�t✓loL _4------------------------------------------------•-----...... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in boar of healt e Dilate operation until a Certificate of Compliance has bee issued b 6 �� Application Approved By d............. Z ? Date Application Disapproved for the following reasons:................................................................................................................ ..................••---..--•--•••---•-•--._.....------•-----------------------•--•--........---•....-••--•----------•-•-•-••-----••-----•.............................................................. Date PermitNo......................................................... Issued-....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...---...... ..................O F..........................---..........---------------------......---..................... ApplirFation for Disposal Works Tonstruriiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ... 1/1 ��.. ..............':-r.... � !.--'.............................. .. -•...................•---------- ..........._..._...........--•----•---•••. ............. ` Location-Address or Lot No. / Owner a J ' Address W i /a � /�✓P l''1��{if! F C t.fJ I.(/ 'i f.... / f'p ? / f s r !` ,-a - ......... ........ .. Installer Address d Type of Building,/ Size Lot............................Sq. feet U Dwelling—/No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building No. of persons............................ Showers — Cafeteria P4 Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. .W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................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........................ a O Description of Soil........ '"-y' %'� x W --•---------------------------------------------------•-----•---••-•------•-...-----•....•-----------------------------------------•---------•-----•-------------......--....=........................ x U Nature of,Repairs or Alterations—Answer when applicable....... �``..".....:J"_. �✓ . `.. -- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITA 1E 5 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.' / Date Application Approved BY ---- ..... ........................................ Date Application Disapproved for the following reasons-------------------------------------------------- ------------------------------••--•........................ .....................................•-......----_...._........-----------------------•-•-••-----...-•••--•--------------------•-------•------•----•--•---------•---------•-------------•------••-..._.. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, �- .. ......o F...... :.........:................................................................. Trrtifiratr of Toutplianr THIS-IS TO CERTIFY, That the Individual Sewage-Disposal System constructed ( )'or Repaired J Installer / has been installed in accordance with the provisions of TI E 5 of T e State Sanitary Code as described in the C-A In application for Disposal Works Construction Permit No._ ...__....- dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU ® AS A GUARANTEE THAT THE SYSTEM WILJL F NCTION SATISFACTORY. DATE...... 3/i- li-3 Inspector.....---••------•--•---------------------------------•-•------------_._. __._.-•----•----------------------------••------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................�................. ----....................................... ......... .......................... No.. — FEE.............:'........ Disposal Iforks TDOnot union rrmit,_ Permission is hereby granted------ ` = ,/// r'/ 2ef _ := ��" ~`6=r� = ........,...---•..................•---•-----......--•----------------------- ..._•----- to Construct ( ) or Repair: ( Zy�,ail Individual Sewage Disposal-System' at No Street as shown on the application for Disposal Works Construction,Pe�t No..................... Dated.......................................... a... ........._''___-. 4 - -----------------------•--__-•-----_--.__ �j oard of Health DATE............................?`..".., �' .............. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS CENTERMLE. MA ` CONTOURS PLAN REFERENCE d =w ASSESSOR'S MAP: 209 ROUTE 28 ILW o 4 EXISTING - - - - - - - 50 D O° Fa3 MINIMAL GRADING PROPOSED LOT: 55-1 otp POSt ao^ o<W <oZ PLAN BOOK 257 PAGE 75 LOWS ��N t pw0 ' PLAN BOOK 92 PAGE 97 z °D`i"�' 0 w<n(7 PLAN BOOK 394 PAGE 91 y5 In EO D P PLAN BOOK 133 PAGE 123 � MN w GE 0'�P4v OST PLAN BOOK 302 PAGE 62 Q� N LOCUS MAP w o \ NOT TO SCALE z v, v c �+ 0 0 <iv C7 , j�G w S W �� roPwE�4 o� G Q J o Ft . 6p D� `Ef. M W Q w �PTIG Svs -9 J 0 sE \��` w . x � / LEGEND W i 1500 GALLON o 0 w SEPTIC TANG J Io `` w 21 r+ o o D-Box C 24ftx12.5fix2ft N n in in N sa {, TEST PIT ? I o LEACHING GALLERY E)STM ILL! LL sa s o E � t Pt� CESSPOOL O LL U z w ; �— 56 . op� s�s UTL/TY POLE $ � -O� / SE W .9 (o N m TREE N r7F. To°WETiE3 rnF"° �O Q / o-W "AWLE PAW /� �� P, / tp A � / in o\ LOT 55-0I �75 f, v, AREA - 0.71 ac •- / �i W k PLAN . t •s L p,N✓ w V,Q J Z SCALE. 1 i - 30 ft 52000 Ne, U :3 V)-i LL m J BENCH MARK pHiN a o cam Z Q TOP OF FOUNDATION / SEWAGE DISPOSAL SYSTEM PLAN O ZO 0 J o (D U ELEVATION - 60.96 2 o LL I', m N 0 F= USGS DATUM ASSUMED -TO SERVE EXISTING DWELLING FIN rEm FRA 0- -� r= Ln w GERALDO & ISMENIA DaSILVA =O a, 's D D O 239 OLD POST ROAD CENTERVILLE. MA LL CO'jGHAN°WR ECO-TECH ENVIRONMENTAL O LL •9 # 1093 o JJ g011"� F 43 TRIANGLE CIRCLE SANDWICH MA 0256 LL p W n ' . �•9b0�A��p�? 508 364-0894 ino �-S ETE-1658 I JUNE 30. 2004 1 13 1 1/2 (� 1 THS PLAN IS TO BE CONSIDERED A DRAFT PLAN UNLESS IT eVtSe q j 1.Y 2, 2� BEARS THE STAMP AND SIGNATURE OF THE DESIGN ENGINEER ORIGINAL PLANS INTENDED FOR SUBMITTAL TO THE BOARD OF HEALTH WILL BE SIGNED N BLUE AND STAMPED N RED. SOIL TEST LOG DESIGN CALCULATIONS DATE OF TEST:`" MAY 21. 2004 I t SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN FLOW: 3 BEDROOMS X IIC GPD - 330 GPD WITNESSED REQUIREMENT WAIVED - NO VARIANCES SOUGHT NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS TEST PIT I PARENT MATERIAL: PROGLACIAL OUTWASH INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) ELEVATION - 59.39 +- PERC AT 52 in : 2 MIN/INCH IN C SOILS DISTRIBUTION BOX: USE 3 OUTLET D-BOX. DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING A b o t - ( 24 x 12.5 - 300 s f Aadw - ( 24 • 24 12.5 ; 12.5 ) x 2 - 146 sf 0-6 Ap LOAMY SAND 10 YR 4/4 NONE FRIABLE Atot - 446 of Vt 0.74 x 446 - 330.04 GPD 6-32 B LOAMY SAND 10 YR 5/8 NONE LOOSE USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED 32-144 C MEDIUM SAND 10 YR 6/4 NONE LOOSE GROUNDWATER ADJUSTMENT LEACHING GALLERY EXISTING GROUNDWATER LEVEL BASED ON BARNSTABLE GIs CONSTRUCTION -DETAIL DEPARTMENT RECORDS INDICATED GW: 34.5 �DRYWELL UNIT STONE INDEX WELL: SDW-252 e'-a-x 4-i ZONE: B 2 it EFF. DEPTH READING: APRIL 2004 24.0 ft LEVEL: 47.2 a ADJUSTMENT: 2.0 f t ' ADJUSTED GW: 36.5 1A N to N N NOTES 14 3.5' 8.5- 8.5- 3.5' 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN 24.0 ft NOT To 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. SCALE 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. 5) EXISTING CESSPOOLS TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 6) ALL STONE TO BE DOUBLE WASHED AND FREE - O:FARON. FINES AND DUST IN PLACE SEWAGE DISPOSAL SYSTEM PLAN 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2 ,OiBEFORE�PITCHING DOWN ' � r 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE;�INSTALLATION OF LOW FLOW FIXTURES -TO SERVE EXISTING DWELLING AND APPLIANCES. AND BIANNUAL PUMP IN oL THE SEPTIC TANK 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT GERALDO & ISMENIA DaSILVA PARK OR DRIVE VEHICLES OVER SEPTIC SYST;EM.t 239 OLD POST ROAD CENTERVILLE. MA 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT,: RE STARTING WORK. 11) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL ECO-TECH ENVIRONMENTAL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE HAS BEEN,.PLACED TO 'MINIMIZE UNEVEN SETTLING 43 TRIANGLE CIRCLE SANDWICH MA 02563 ETE-1658 JUNE 30. 2004 2/2 _ t CENTERMLE. MA o CONTOURS PLAN REFERENCE _�� LLX o Q EXISTING - - - - - - - 50 ASSESSOR'S MAP: 209 ROUTE za ^D oN W<3 MINIMAL GRADING PROPOSED LOT: 55-1 oLp POS1 ROAD 000w <O? PLAN BOOK 257 PAGE' 75 LOCVS sic PLAN BOOK 92 PAGE 97 rah o�ti�,s z mov) o w"'� _� PLAN BOOK 394 .PAGE 91 Q. e 0o ED D P T PLAN BOOK 133 PAGE 123 \ � M�' ,n �E 0p PA� � OS;/ PLAN BOOK 302 PAGE 62 Q� N ROA - - LOCUS MAP z LL o \ NOT TO SCALE 00 1� w+n �' 9A S A 58 <N Z1 2 B�ST�NG _ Fo N < 2 LU w 1 �� r�oPw�4C NG W U J F� - 6o9H / EXL �K' tE g Q o r D SEP tEM z aN e`� -9 W x � � �i � LEGEND (500.GALLON o 0 (� SEPTIC TAW J o �` w Df+ �� ! D-BOX G n � �, N za r+ 24 ft x 125 ft x 2 ft TEST PIT W , N o ,� LEACHING GALLERY S E)STNG W 58 s o �7C4`'1., CESSPOOL O� LLJ �` �"� �5 tee` • � U O o cwn '. / 56 •5 (IG 5� UTLITY POLE W.9 +o u~i m TREE _W v. z�, pAr£76P Q - 56 / - m4v" � 7YI£ rY /3 �ss P / o o� :LOT 55-OI AREA = 0.71 ac •- / PAN mb ui N �t PLAN 001,J w W N o w 000, y Z LL m J z SCALE: 1 m - 30 ft 52 H oLL J BENCH MARK PHINN oin Fin z TOP OF FOUNDATION SEWAGE DISPOSAL SYSTEM PLAN 0 ZO °0 LL O � U ELEVATION - 60.96 o I� ppo 0 c - VSGS DATUM ASSUMED -TO SERVE EXISTING DWELLING CL CL o �, -� GERALDO & ISMENIA DoSILVA D b a DAVID 239 OLD POST ROAD CENTERVILLE, MA LL 0;�°''�R ECO-TECH ENVIRONMENTAL O t �os� o ' o i � 43 TRIANGLE CIRCLE SANDWICH MA 0256 -J d W ems, `~' I �999TOafR�N . o w 508 364-0894 �-5 ETE-1658 JUNE 30. 2004 1/2 THIS PLAN IS TO BE CONSIDERED A DRAFT PLAN MESS IT ev, °� ��Y Z, BEARS THE STAMP AND SIGNATURE OF THE DESIGN ENGINEER ORIGINAL PLANS INTENDED FOR SUBMITTAL TO THE BOARD OF HEALTH WILL BE SIGNED N BLUE AND STAMPED N RED. SOIL TEST LOG DESIGN CALCULATIONS DATE OF TEST: MAY 21. 2004 SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN FLOW: 3 BEDROOMS X IIC GPD - 330 GPD WITNESSED REQUIREMENT WAIVED - NO VARIANCES SOUGHT NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS TEST PIT I PARENT MATERIAL: PROGLACIAL OUTWASH INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) ELEVATION - 59.39 +_ PERC AT 52 in : 2 MIN/INCH IN C SOILS DISTRIBUTION BOX: USE 3 OUTLET D-BOX. DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING A 6 o t - ( 24 x 12.5 ) - 300 s f A s d w - ( 24 - 24 12.5 - 12.5 ) x 2 - 146 sf 0-6 AP LOAMY SAND 10 YR 4/4 NONE FRIABLE A t o t - 446 s f Vt 0.74 x 446 - 330.04 GPD 6-32 B LOAMY SAND 10 YR 5/8 NONE LOOSE USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED 32-144 C MEDIUM SAND 10 YR 6/4 NONE LOOSE GROUNDWATER ADJUSTMENT LEACHING GALLERY EXISTING GROUNDWATER LEVEL BASED ON BARNSTABLE GIS CONSTRUCTION -DETAIL DEPARTMENT RECORDS INDICATED GW: 34.5 �IDRYWELL UNIT STONE INDEX WELL: SDW-252 e'-6-X EFF. DEPTH ZONE: B 2 ft FF 24.0 ft READING: APRIL 2004 LEVEL: 47.2 ADJUSTMENT: 2.0 ft ADJUSTED GW:. 36.5 M tn in N N NOTES 3.5' 8.5, 8.5, 3.5' 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN 24.0 ft NOT To 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. SCALE 3). ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM, 5) EXISTING CESSPOOLS TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 6) ALL STONE TO BE DOUBLE WASHED AND FREE_ QF,_IRON. FINES AND DUST IN PLACE SEWAGE DISPOSAL SYSTEM PLAN 7) LINES EXITING D-BOX 'TO RUN LEVEL FOR 2 0;'BEFORE PITCHING DOWN -TO SERVE EXISTING DWELLING 8) ECO-TECH ENVIRONMENTAL RECOMMENDS T'HE. INSTALLATION OF LOW FLOW FIXTURES AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK GERALDO & ISMENIA DaSILVA 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYS.TEM.. 239 OLD POST ROAD CENTERVILLE. MA 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMITBEFORE STARTING WORK. II) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL ECO-TECH ENVIRONMENTAL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING 43 TRIANGLE CIRCLE SANDWICH MA 02563 ETE-1658 I JUNE 30. 2004 212 ACCESS COVERS MUST BE WITHIN 9" MINIMUM.6" OF FINISH GRADE INVERT ELEVATIONS : DES I GN CR I TER I A : GENERAL NO TES : N 3' MAXIMUM COVER INVERT OUT SEPTIC TANK: 106.2 FIRST 2' TO DESIGN FLOW: BE LEVEL M1N 2" OF PEASTONE INVERT IN DIST, BOX: 105.97 4 BEDROOMS AT I10 G.P.D. PER 1. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION OR F I L TER FABRIC INVERT OUT DIST. BOX: 105.6 BEDROOM EQUALS 440 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. V DIAM PIPE 3/4" - I I/2" DIA. INVERT IN LEACH CHAMBER: 105.6 o�a 106,2 105.8 T2' q5o DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER: 103.6 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCHMARKS GAS_ �Pa 28 BAFFCE� 105.97 ��°� /05.6 3 6 ADJUSTED GROUND WATER: N/ASET SEE SITE PLAN. ROUTE 3 OUTLET 3-500 GAL LEACHING CHAMBERS OBSERVED GROUND WATER: N/A SEPTIC TANK REQUIRED: EXISTING 440 G.P.D. X 200% - 880 GAL. 3. ALL CONSTRUCTION METHODS AND MATERIALS AND p POST R°A_.L D-BOX W/4 ' STONE AROUND. 12,8 'w x 33,5'l x 2'd BOTTOM OF TEST HOLE #l: 96.0 SEPTIC TANK PROVIDED: 1000 GAL. EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL ° 1000 GAL CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL � oro' \ � SEPTIC TANK 6" CRUSHED STONE OR SOIL ABSORPTION SYSTEM REQU I RED: BOARD OF HEAL TH REGULATIONS. 1. COMPACTED BASE DES l GN PERC RATE ! 5 M/N/INCH sT PROF I L E : NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT L OAD l NG RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREA TER 440 GPD / 0. 74 GPD/SF - 595 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: 3-500 GAL LEACHING CHAMBERS W/4' STONE AROUND, A-614 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 614 S.F. x 0.74 - 454 G.P.D. APPROVED EQUAL. 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED LOCUS MAP SOIL TEST p I T DA TA & PRECAST CONCRETE OR APPROVED POLYETHYLENE. INDICATES _v INDICATES BOTH SHALL BE WATERTIGHT, D-BOX SHALL BE WATER PERCOLATION - OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE TES T GROUNDWATER OUTLET. TP #/ P#14136 TP #2 7. BEFORE CONSTRUCTION CALL "DIG-SAFE". HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR 1-888-DIG-SAFE AND THE LOCAL WATER DEPT, 0" 106.0 O" 106.5 FOR L OCA T I ON OF UNDERGROUND UT I L l T l ES FILL FILL 24" 104.0 1 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE LOAMY I QYR L OAMY I OYR DES 1 GN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION. EDGE OF PAVEMENT A SAND 3/3 A SAND 3/3 OF THE SYSTEM TO ALLOW FOR SCHEDUL/NG OF THE PICKET FENCE 38" - - - - - - - - - - - - - - - - - - - - IO2.8 20" - - - - - - - - - - - - 104.8 CONSTRUCTION INSPECTIONS. n LOAMY 1 O YR D p LOAMY I OYR A O SAND 4/6 SAND 4/6 9. EXISTING LEACH PIT TO BE PUMPED DRY. REMOVED R.I F�/1 48" - - - - - - - - - - - - - - - - - - - - 102.0 30" - - - - - - - - - - - - - - - - - - - - 104.0 AND BACKFILLED WITH CLEAN SAND. . 05. /*I MED-COARSE 10YR C I MED-COARSE IOYR l' SAND 5/8 SAND 5/8 /0. ALL UNSUITABLE MA TER I AL t A & B HORIZONS) • p \ \� �� /} 60" ENCOUNTERED BELOW THE INVERT OF THE LEACHING PAyEM�N� 1 1\ Tp*l FACILITY TO BE REMOVED FOR A DISTANCE OF 5' �/ AROUND AND REPLACED W l TH SAND IN ACCORDANCE EpGE Of , �yG� f \ i ow5' WITH TITLE 5. AD s� // qQ NO WATER NO WATER RO ..- ya�o yea\ � A f' o� J 20" 96.0 120" 96.5 < > 0 09,7 / `�\ .09�� �/ � �a��' DATE: SEPTEMBER 19, 2013 V � � KApE FENCE j P4 o� F-JlgrING EXISTING ,.� TEST BY: STEPHEN HAAS P6 oc �4, �� 40 SEBTIC TANK �ti'..,;,;. ....�. a� PIT F4/ WITNESSED BY: DONNA M10RANDI 1 p. o t�v�l / :s, 3-5�O GALLON / / / f 22 ��' a�qo / ;;;,;';�; -„ LEAC�•IING CHAMBERS / // // / PERC RATE: C 2 MlN/INCH DUP 32912 "� 4� p� p r.:'..... .. . �..... W/4' STONE AROUN l ' V \ ° 9 0 1 �5 i_ t ���r� ://D-BOX ofi.o ' WALK / /05. ME�yf GUY WIRE ~ <p� \ Wr� / / / // / \- / / c1 109. } BY. CORNER OH GE °F / boy \ // / EL•I09.65 TO TAL,'L O T AREA : ti // / /// GCIr w/R 103.4 218384 f\ �,. F. < OHW C OHW / UP 38/II o, 1 ( / �� 0a.71 � n i MENt �� LNG \ I \ / � 0� •' t / // � // EpGE °F PACE �� \ S�IN6 pp51 °pp 0 1 l /' /l ro2.9 wv� EX 0�0 / I \y� Q� / / /' / /' 0229 sk UP 2 I/2-0- 40 \ �� CK EAU EXISTING SEPTIC SYSTEM FOR �29 OLD POST RgZD �' // bap ,C TF tl l °h4✓� 20941-337/ / // g�� i SUP 38//O SEF T l C S YS TE-M DE' S / ON 239 ' OLD POST ROAD AND l 39 PH l NNE' Y ' S LANE MAP 209 . PARCEL 055001 B .4 R N S TA B L E . ( C E N T E R V I L L E ) PREPARED FOR : LEGEND A NGE7 L O A T S / K NO UDA S ■ CB CONCRETE BOUND -W WATER LINE 125 BELMONT STREET . BELMONT . MA 02478 HYDRANT -G GAS LINE SCALE I - 20 SEPTEMBER 27 . 2013 OHW- OVER HEAD WIRES -0 LIGHT POST STEPHEN A . HAAS ----- UNDERGROUND ELECTRIC LINE ENGINEERING , INC -T- UNDERGROUND TELEPHONE LINE \ 923 F2 ra u t e 6 A -CTV- UNDERGROUND CABLEVI S ION LINE / -�`� Y a r ma u t h r t , MA . 02675 +40.4 SPOT ELEVATION � �� 111;4\�� p o( 508 ) 362-8 1 32 ........40....... EXISTING CONTOUR ��MI F4-01 PROPOSED CONTOUR 0 /0 20 40 JOB NO: 06-025