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Home My WebLink About1055 SHOOTFLYING HILL RD - Health 1055 Shootflying Hill Rd Centerville P A = 191 027 df�J UPC 12543 t!o. 53! 01,3 •g ° ,..a. •..,nq yH TOWN OF BARNSTABLE LO!:ATION JOSS Sl%ooiC)Q;nc N,'/1 AUSEWAGE# 20// - /,,Z_ VILLAGE L ASSESSOR'S MAP&PARCEL 9 J - Z' INSTALLER'S NAME&PHONE NO. S3 ,� ExmL x4 on '177- NS3 SEPTIC TANK CAPACITY 000 9Q J LEACHING FACILITY:(type)T cncA c 5 ( Z) (size) Z x 3 x 33 NO.OF BEDROOMS OWNER rrcn c Coons PERMIT DATE: 7-rJ - 11 COMPLIANCE DATE--,, 77- Z 7-J/ Separation Distance Between the: ` Maximum Adjusted Groundwater Table toAhe 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 AZ •��" !3Z •1go ` _ f A 3 • `� Fro., B A 4•bq / .9fcK 3y e; No. 1 ai , ^— Fee ✓- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNST,,ABL , MASSACHUSETTS Yes 0ppYication for Wgpo5al *pgtem Cougtruction 3permit Application for a Permit to Construct( ) Repair(VKUpgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 1055 5h010-r'-9 y I A Owner's Name,Address,and Tel.No. will eo _3 --rre nv2_ Coon Assessor's Map/Parcel ' 71 10,455 D 5 TIst I G I ler am e Address,and Tel.No. esigner's Name, ress and Tel.No. L Og 43 3_Z1 1�1 ,XLG1`o-iton v4�D L15on J £.�Ja.�1Du�iiJ I Type of Building: 4 Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures hh Design Flow(min.require ) 330 gpd Design flow provided .3 � gpd Plan Date (0 ( ( Number of sheets Revision Date Title Size of Septic Tank ( i 000 Gj A'( Type of S.A.S. " Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed ZQ�.Qlo Date 7 I L f 11 Application Approved by ► 1\ �� Date -2`--7 Application Disapproved by: Date for the following reasons Permit No._ •� l Date Issued 77�� I No. Fee — _ THE COMMONWEALTH OF MASSACHUSETTS s� Entered in computer: 1 PUBLIC HEALTH-DIVISION - TOWN OF BARNSTAB.L€ MASSACHUSETTS Yes Zfpprication, or�Ii,5pogaY 6paem Con5truction permit k a Application for a Permit to Construct( ) Repair(Vf'Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 5 hGU-T —Ti Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 4 CID 1 Ci I 'Pr, t'!C ' J Installer's-Name,Address,and Tel.No. Designer's Name,A,d ress and Tel.No. 3 3 1^7 7 �f1V 0 t1Ci1-jton 1 I P-1 6. h-f ( r ,,, L. L a( ,J(-gala 1')(3� Type of Building: ' Dwelling No.of Bedrooms —113 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures !� Y Design Flow(min.required) �3 V gpd Design flow provided gpd Plan Date (0 Number of sheets + Revision Date - Title I Size of Septic Tank �( DDa Gj a-( Type of S.A.S. C Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed -2t V-e? Date -7 14, 1 + ) Application Approved by Y� C. 7i6 , Date ` 2- Application Disapproved by: Date for the following reasons Permit No. 0 �� Date Issued —7 - —7—k THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) `A6andoned( )by at { D IS c:l has been constructed in accordance with the proyissiions of Title 5 and the for DisposalSystem Construction Permit No. dated 1 Installer �-1[ hC-( 6 i I f, "i Designer ("j t l\t I f fJ r)Fn-p.() t C #bedrooms �� Approved design flow gpd The issuance of this permit shall(fit,e ogpsst/td as a guarantee that the system will funs t'on s design d. -Date ( l / Inspector —.———— —————————— — — ——— — —3=7 — —————- - - R - - No. V { ( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS Tigpogal 6p5tem Construction 3permit Permission is hereby granted to Construct ( ) Repair O Upgrade�(� ) Abandon ( ) System located at a1 �'1 f�/�'T �•t I 1 ( � 1 � 9 )A �-b land as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date (� Approved byfL— i i Town of Barnstable Regulatory Services *;. Thomas F.Geiler,Dir4ctor" + BARN vE,0► `a � Public Health Division Thomas McKean,Director 200-M.Ain Street,Hyannis,MA 02601 Office:.5084624644- Fax: 50 8-790-6304 Installer&i DesiLyner Certification Form Date: p t Designer: Installer: t C�4yI�TII � (s Address: . 1k) Address: On was issued a permit to install a (date) (install septic system at d 1H based on a design drawn by ad d s) • '"b��:;_ dated- (D I21 (designer) certify that the septic system referenced Sbove was installed substan all accc} rding to e design, which may rnelude:minor:approved changes Such as latalTocaticn of the d�;strrbution box andlor septic tank,., /102 I cert that the septic System:referenced above was instated wi ;,r �-- greater t '10' .lateral relocate of the SAS,or-any ve�cal aocatja a£any- Plan comport' of the septic��D3stem)but is a ordance with State&Y.ocal IZeg nations. rev sirs of ce�ified as-b"tit by desk er to fallow. ; (Installer's Sign to ) --- s'�N11AFi�P (13 er s Signature) (Affix �tatp,Here) PLAS REiJRN TO IBAPTSTA , 'PUBI�IG 1I]EALT� I)IYI5IO1� C TtTI(EI,G T , � ' C .IY]CP .I .NCE WII{1L N '► SSIiD Off T�[SFQ► = BUILD: ARID ARC R�CT"A 't ]HJ : ` 'AD P TB r F......A r ; Q:HOaiCpi/SephcfDeslgner certific6tipn Farm. r .l� l6 - 3- if Certified Mail:7006 0810 0000 3525 6481 Town of Barnstable Barnstable Regulatory Services snxivsrnst.L Mnss. g Thomas F. Geiler, Director Public Health Division 2007 Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 �,o Fax: 508-790-6304 September 7, 2011 Irene Coon 24 Clemons Street South Portland, ME 04106 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 1055 Shootflying Hill Road, Centerville MA, was inspected on September 6, 2011 by Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint received at The Barnstable Health Division. The following violations of the State Sanitary Code were observed: 105 CMR 410.351 —Owner's Installation and Maintenance Responsibilities Downstairs bathroom fan is not functioning as intended (does not have proper air exchange). The second floor bathroom fan was not working You are directed to correct the State Sanitary Code violations listed above within thirty (30) days of your receipt of this notice by repairing/replacing said bathroom fans. 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 a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. OF HE BOARD OF HEALTH s .M Kean, Director of Public Health Town of Barnstable t r � 1 • • FORM30 C&w Ho8Bs&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF L H rig � � -� CITY/TOWN W oPIV Al �+ y�DE ARTMENT ^ t ADDRESS TELEPHONE� Address f) _ Occupant '�'�/�- Floor Apartment No. No.of Occupants__— _ No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units__ lo.Stories Name and address of owner Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual E ress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: 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. to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted 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 INSPECTIO EPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENAL JU Y." �. INSPECTOR TITLE DATE TIME r� ( •M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of 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 11, 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). (1) 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. ^^ THE COMMONWEALTH OF MASSACHUS,ETTS , C&w HOBB$&WARREN rN, I �,,,4) t FORM30 BOARD OF H AL THE ',� �. CITY/TOWN IV QT �D /► DEPARTMENT ✓ �✓(/W� ADDRESS #. M svey`0 (4t TELEPHONE ' ' Address Occupant__ P � Floor Apartment No. No. of Occupants No.of Habitable Rooms No.Sleeping R oms _ No.dwelling or rooming units_ o.Storie3 Name and address of owner O Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish f ) ; Containers:.4 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: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: " HEATING Chimneys: Central 11 Y. _, -quip.❑ N E ui Repair ..y.. _ .. 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 ,, iV,;e�ntiT L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen _�/: mow' ........--sw-- .0,c, )4A, L_ Bathroom t _ .Pant 8 of Den r —Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: s' Kitchen Facilities Sink Stove ' Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: ` Egress Dual and Obst'n: General Building Posted Locks on Doors: +-- y 4 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." - E�u ; r INSPECTOR TITLE - l • , > r A.M. DATE TIME a �P.M. A.M. THE NEXT SCHEDULED REINSPECTION / P.M. � 5 � 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of 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 11, 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). (1) 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. L 'Citizen Web Request Page 1 of 3 Mh Le m . s, Logged In As: Citizen Request Management `Tuesday, September 62011 TOWN\oconnelt Route to Users Search Requests Create Requests Request Information Request ID: 35592 Created: 9/1/2011 12:30:08 PM Status: Assigned To Staff Assigned To: O'Connell,Timothy Health Office Anonymous: No Request Category: Chapter II : Housing Substandard edit Routine work: No Estimate: No edit Date scheduled: edit Estimated 9/16/2011 Change Estimated Aug September 2011 Oct Completion Completion Date: Date: Sun Mon Tue Wed Thu Fri Sat l X + 28 29 30 31 1 213 4 5 6 7 8 9 10 11 12 13 14 15 16117 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 Created By: Wadlington, Ellen Priority: Medium edit Health Office Citation Numbers: edit Requestor Information Requestor Request Parcel Number Have reported that the air Map: F07 Block: 000 I Lot: 000 exhaust fan in the bathroom does not work to our landlady who has done Parcel Lookup nothing about it. Email: Edit Requestor Information http://issgl2/intemalwrs/WRequest.aspx?ID=35592 9/6/2011 r Health Master Detail Page 1 of 1 Logged In As: TOWN\oconnelt Health Master Detail Wednesday,September 7 2011 Application Center Parcel Lookup Selection Items Parcel I Septic Perc Well Fuel Tank Parcel: 191-027 Location: 1055 SHOOTFLYING HILL RD, CENTERVILLE Owner: COON, IRENE G Business name: I Business phone:17755507J Rental property: ❑ Deed restricted: Number of bedrooms : 0� IContaminant released: I— Fuel storage tank permit: r Save Parcel Changes Return to Lookup Parcel Info Parcel ID: 191-027 Developer lot:LOT 16 Location: 1055 SHOOTFLYING HILL RD Primary frontage: 100 Secondary road: Secondary frontage: Village:CENTERVILLE Fire district:C-O-MM Sewer acct: Road index: 1484 Asbuilt Septic Scan: 191027 2 Interactive map Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info Owner: COON, IRENE G Co-owner: Streets:24 CLEMONS STREET Street2: City:SOUTH PORTLAND State:ME Zip: 04106 Country: Deed date:12/22/2006 Deed reference:C181931 Land Info Acres: 0.73 Use: Single Fam MDL-01 Zoning:SPLIT Neighborhood: 0105 Topography:Level Road:Paved Utilities:Public Water,Gas,Septic Location: Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bathrooms 1 1974 5182 2962 13 Bedrooms2 Full Buildings value:o250,800.00 Extra features: A0.00 Land value: 0120,300.00 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=191027 9/7/2011 f A� �FtHE rqk, Town of Barnstable �O Regulatory Services � BARNSfABI.E, v MASS. Thomas F. Geiler, Director i639. ♦� e�f 39n Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 LEAD DETERMINATION REPORT FORM Date of Determination: September 6, 2011 Inspector: Timothy B. O'Connell, R.S. License#: 1356 Method Used: X Sodium Sulfide Expiration date: October 1, 2011 X-Ray Fluorescence Model: Serial#: Property Address: 1055 Shootflying Hill Road Centerville,MA 02632 Description of Property: X Single family Multi-family # units Garage Fence Other structures Age of Property: 1974 Pre-1978 Post-1978 Occupant: Robert Horsman Occupants under six year of age: Violet Horsman DOB: 12-27-10 DOB: DOB: Occupant's Telephone: 508-534-9151 Property Owner(s): Irene Coon Owner's Address: 24 Clemons Street S. Portland Me 04106 Owner's Telephone: Not known Lead Hazards found? Yes No X An X-ray fluorescence reading greater than 1.0 mg/cm2 or a gray or black reaction to sodium sulfide indicates a dangerous level of lead and constitutes a positive determination. Deleading should not be undertaken based on this report. A licensed lead inspector must do a full inspection in order for you to qualify for a Compliance Letter. Deleading of lead painted surfaces must be performed by an appropriately authorized person, including a licensed deleading contractor, a licensed lead-safe renovator, and an owner/agent who is trained to perform specific work as required under the Lead Law. Contact the Childhood Lead Poisoning Prevention Program for additional information regarding deleading and training. BOH Determ Form Revised 1-05 Page I of 2 X LOCATION SOURCE Pb 1. Child's bedroom Window parting bead/exterior sill area NEG 2. Child's bedroom Window sill NEG 3. Child's bedroom Baseboard NEG 4. Kitchen Window parting bead/exterior sill area NEG 5. Interior Front Door Flaking paint on hinge NEG 6. Front Door Flaking paint NEG 7. Bed Room ls`Floor Walls NEG 8. Bed Room 15`Floor Base Board NEG 9. Bed Room I"Floor Top of base board Heater NEG 10. Bathroom Exposed Beam with chipping paint NEG 11. Bed Room 2nd Floor Closet door NEG 12. Living room Base Board NEG 13. Laundry room Closet baseboard NEG 14. Laundry room Door NEG 15. Laundry room Baseboard NEG 16. Closet in Hall way off Living room Wall NEG 17. Closet in Hall way off Living room baseboard NEG 18. 2 nd floor office/bedroom Cabinet door NEG 19. 2 nd floor office/bedroom baseboard NEG 20. 2" floor office/bedroom wall NEG BOH Determ Form Revised 1-05 Page 2 of 2 5 REQUEST FOR DETERMINATION OF LEAD HAZARDS AND ENFORCEMENT OF THE LEAD LAW Date: q 20 I 1 1-ko re uest the � q c1 it Al print name of occupant Health Department to inspect my residence or dwelling unit for lead paint: / P The address of this residence or unit: [�- Street and Apt. o. 1 , Massachusetts. The telephone City or Town number to reach me there is: ( 576V �✓' `�� l Phone Number The child (ren) un er the age of six (6) years who reside(s) in this household is/are: v o 14or4m.A, Name The following Race/Ancestry information is optional. Please circle one: (1) Black, non Hispanic (2) Hispanic (3) White, non Hispanic (4) Asian/Pacific Islander (5) American Indian/Alaskan Native (6) Other Was the residence built before 1978? Yes No I understand that the lead determination requested may include all rooms of the dwelling unit or residential premises, common areas, porches and accessible exterior areas, as well as other buildings within the property lines. I further understand that if there is a child under six (6) years of age in residence, and the determination hereby requested identifies lead hazards in violation of Massachusetts General Laws, chapter 111, section 197, and Regulations for Lead Poisoning Prevention and Control, 105 Code of Massachusetts Regulations 460.110 and .750, such violations must be either deleaded for full compliance, or the unit must be brought under interim control, at the property owner's expense. The property owner must correct all violations, whether for full compliance or interim control, within 120 days of the receipt of an Order to Correct Violations. The property owner must also submit within 60 days of the receipt of such an Order, a copy of a signed contract with a licensed deleader, if one will be necessary for the required work. If the owner or his/her agent is going to perform owner/agent deleading work,the owner must also submit a special form within 60 days. If the owner fails to comply with the ' Order to Correct Violations, the Health Department shall initiate judicial proceedings against the owner to enforce the Order. The Massachusetts Department of Public Health, Childhood Lead Poisoning Prevention Program (CLPPP) conducts random audits of inspections conducted by private inspectors and risk assessments conducted by private risk assessors following lead determinations. Such monitoring is performed to assure the quality of services being provided to the public. By requesting this determination, you agree to allow CLPPP access to.your residential premises or dwelling unit after the initial determination and prior to your returning once any deleading, whether for full compliance or interim control, is completed. Not all private inspections or private risk assessments will be audited, so you may not hear from CLPPP requesting access for these additional visits. Signature of Occupant CLPPP Form No.4,11-84 (BOHREQUEST.DOC) Parental Req.for Detertnin. Rev.6/99, 10/97,10/02 REFERRAL Date of Referral: 09/07/2011 Code Enforcement Lead Determination Inspector: Timothy B. O'Connell, R.S. License Number:#1356 Board of Health: Barnstable Health Divsion BOH mailing address: 200 Main Street Hyannis,MA 02601 BOH Telephone Number: (508) 862-4644 Address:. 1055 Shootflying Hill Centerville, MA 02632 Was the residence built prior to 1978? X Yes No In accordance with 105 CMR 410.750 (J) and 105 CMR 460.700 (B), I conducted a lead determination at the above address on 9-6-11 (date of determination). A copy of the determination report is enclosed. I tested twenty (20) surfaces for the presence of lead paint and no positive results were detected. I am referring this case to the Childhood Lead Poisoning Prevention Program for a follow-up determination. l' Inspector A CLPPP inspector will be in contact with you to schedule a follow-up site visit to thisproperty. P Y P Fm:Common Cents Bookkeeping To:Tim O'Connell(15087906304) 11:35 10102111GMT-05 Pg 02-02 ® ® 9 D 9-29-11 Irene Coon 1050 Shootflying Hill Rd. Centerville, Ma 02632 Remove and replace 2 bathroom fan light units and correctly vent to the outdoors. Labor and materials::::..::.$945.00 : P_Q_ Box 1143,Barnstable,MA 02630 Phone&Fax 508-362-2300 FwCommon Cents Bookkeeping ToMm O'Connell(15087906304) 11:35 10102M1GMT-05 Pg 01-02 1 5 To: Tim O'Connell From: Common Cents Bookkeeping Fax: 15087906304 Pages: 2 Re: 1055 Shootflying Hill Road -Date: Oct 02, 2011 Urgent X For Review X Please Comment X Please Reply For Information •Comments: Tim - as per our agreement, i am sending a copy of the bill from Woollard Builders LLC for the new bathroom fans for my home at 1055 Shootflying Hill Road Centerville. I appreciate your help in resolving the issues and would like a reply to know that you have received this fax (sent through my business account) and that I am in compliance with the Town of Barnstable Board of Health. Thanks! Irene G Coon www.mvfax.com Town of Barnstable P# Department of Regulatory Services MANSUBi Public Health Division Date, 3 / �. 0J9. 200 Main Street,Hyannis MA 02601 . lfD M1tt� Date Scheduled / bi Time_ 6 Fee Pd Soil Suitability Assessment for Se age Disposal Performed By: lJ � Witnessed By: y/ LOCATION&GENERAL INFORMATION Location Address Owner's Name Address Assessor's Map/Parcel: lei) CeAf ` Engineer's Name Q r NEW CONSTRUCTION REPAIR Telephone# ,�� — 4/7 0� Land Use Slopes(Ct) Surface Stones Distances from: Open Water Body ft Possible Wet Area . ft Drinking Water Well ft Drainage Way ft Property Line —________ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands{n proximity to holes) (,rAj i �fy I c Hi *tftto Parent material(geologic) drock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: in. Depth to Soil Mottles., In, Depth to weeping from side of obs.hole: in, Groundwater Adjustment fr. Index Well# Reading Date: Index Well level „ Adj.factor- �„,4 Adj.droutidwater Level l 1L I Observation PERCOLATION TEST bate_. Thne �f • Hole# Time at 9" Depth of Pere � O Time at 6" Start Pre-soak Time @ v 'Time(9"-6") End Pre-soak Rate:Min./Inch Me e Site Suitability Assessment: Site PasselSite Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC ' w DEEP-OBSERVATION HOLE LOG Hole# F from Soil Horizon Soii Texture .Sdil Color Soil e(in.) (USDA) Other (Mansell) Mottling (Stnucture,Stones;Boulders. „ I L �I '� ✓� 013istencv 46'Qrgven ----------------- Olt� L� /• . -------------- G CS o ------------ DEEP OBSERVATION HOLE LOG Hole#Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) Other (Munsell) Mottling (Structure,Stones,Boulders. on i 7% m E. DEEP OBSERVATION HOLE LOG Hole# Depth front Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) Other (Munsell) Mottling (Structure,Stones,Boulders. 1t %Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. u s Flood Insurance Rate Mau: Above 500 year flood boundary No— Yes "Within 500 year boundary No es ' Within 100 year flood boundary No _ _ Yes . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us terial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of it turally occurring pervious material? Certification I certify that on �� y (date)I have passed the soil evaluator examination approved by the Department of Enviro mental Protection and that the above analysis was performed by me consistent with . the required training,expe 'se perience described in 3 10 CMR 15.017. SignatA Date 2,1 Q:1S.EFTICVERCFORM.DOC °p THE Tp� Town of Barnstable Barnstable Regulatory Services Department WftmicaCft + [ARNSCABLE, + 11"Ass. Public Health Division i639. �� ArEb MAt a' 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.GeilerLeach pit is only3f )undwagter,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 5323 May 31, 2011 Ms Irene C. Coon 24 Clemons Street South Portland, ME 04106 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system 1055 ShootFlying Hill Road, Centerville,MA was last inspected on 5/3/2011 by Ricky L. Wright a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool • Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future 1 enforcement action PER ORDER OF THE OARD OF HEALTH �as cKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc r oFYWME raw Town of Barnstable Barnstable Regulatory- Services Department A"mmicacrtp O1 + UARN6"CABLE, 9 MASS.t639. Public Health Division�� m ArFD MAC a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.GeilerLeach pit is only3f )undwagter,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 5279 May 17, 2011 Irene Coon 1055 ShootFlying Hill Roae Centerville, MA 02636 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system at 1055 ShootFlying Hill Road, Centerville MA was last inspected on 5/3/2011 by Ricky L. Wright a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or Cesspool You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc r Town of Barnstable Barnstable �►�rOwti Regulatory Services Department 0ftaicaC'j BARNS-TABLE, 9 MASS.i6gq. Public Health Division �g m ATf°"4 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.GeilerLeach pit is only3f )undwagter,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 5279 May 17, 2011 Irene Coon 1055 ShootFlying Hill Roae Centerville, MA 02636 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system at 1055 ShootFlying Hill Road, Centerville MA was last inspected on 5/3/2011 by Ricky L. Wright a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed.that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or Cesspool You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action OFF E BO OF EALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms /1 on the computer, use only the tab 1. Inspector: IVn11`Vn key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. ,y Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 Cityrrown State Zip Code 508-477-0653 S 14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority A 5/3/11 -A Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a`'�shared systeml..or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submq the-n report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �v t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage sposal System•Page 1 of 17 L Commonwealth of Massachusetts v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,. safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310.CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CLAM , 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage Septic Tank (locate on site plan): Depth below grade: 22"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5.2x5.2x8.6 Sludge depth: 6" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 'L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G"M , 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good shape tees present however there were signs of back up on the outlet pipe at one time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert no d-box 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in hydraulic failure water level was 3 inches below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is Centerville. MA 02636 5/3/11 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately fRONT_ O f oDo Ai- 29 ' + c A Zz H5 `5fl 13 35 ` t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1055 Shoot Flying Hill Road Property Address Irene Coon Owner Owner's Name information is required for every Centerville MA 02636 5/3/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >11 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Hole in yard across street. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1055 Shoot Flying Hill Road. Property Address Irene Coon Owner Owner's Name information is Centerville MA 02636 5/3/11 required for every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Z5 � , COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ( ARCEE LOT I,- TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAJZY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ®EJr� z,el?GW "A 6 Owner's.Name., Owner's Address: Z. llcvlell�4?lw Al Date of Inspection: p Name of Inspect : (please print) f 0 Company Na J Mailing Address: _ r Telephone Number: `; CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the:a'nformation repafted below is true, accurate and complete as of the time of the inspection. The inspection was performed based on nly-" training and experience in the proper function and maintenance of on site sewage disposal systems. I am a.DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sys cm: co L/ ►✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: It Ill A J The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. 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 5 Inspection Form 6/15/2000 page I Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACK SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) y Property Address: � s 4 Owner. Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.71themavepasos es: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: B. System Conditionally Passes: One or mores stem components as described in the"Conditional Pass section need t e re ace . } n to I dor P p repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain, The septic tank is metal and over 20 years.old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank.is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed%pipe(s)or due to a broken,settled-or uneven distribution box. System will pass inspection if(with:, approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more.than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):.' broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 4 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: A Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system.is functioning in a,manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 aseptic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for 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,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 I 1 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURF,ACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property.Address: ) r\��22,4CP V1927-1�1 Date of Inspection: C D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Nol _ V 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 u e p m d P Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. ]This system passes if the well water analysis, performed at a DEP certified laboratory, 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, provided that no other failure criteria. are triggered. A copy of the analysis must be attached to this form.] (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. Large Systems: To be considered a large'system the system must serve a facility with a'design flow of 10,000 gpd to.15,000 gpd.. You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within y n 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection.Area—IWPA)or a mapped Zone II:of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304..The system owner should contact the appropriate regional office of the Department. 4 I I Page 5 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CI3ECKLIST Property Address: Owne Uj Z2 Dgjx 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? VHas the system received normal flows in the previous two week period? - v Have large.volumes of water been introduced to the system recently or as part of this inspection? _ Were as built-plans of the system obtained and examined?(If they were not available note as N/A) V _ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of breakout? V _ 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 tl e baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? - 'Was.the facility owner(and occup ants 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. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 f i � Page 6 of 1 I' OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: Owner. Date of Inspection:_ ( _ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 C R 15.203 (for example: 11:0 gpd x#of bedrooms): Number of current residents �(� � Does residence.have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no): . [if yes separate inspection required] Laundry system inspectedPlable no): L)o Seasonal use: (yes or no):Water meter readings, if a (last 2 years usage(gpd)):03 low Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL. ✓ "`^' Type of establishment?. Design flow.(based on 310 CM11.15.203): gpd Basis of design.flow('seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part o�nspection(yes or no . If yes, volume pumped: gallons-- lo4v was q amity pumped cieterniined: - Reason'forpumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system —Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology.Attach a co of the current operation and maintenance contract to be — PY p obtained from system owner) —T'ght tank —Attach a copy of the DEP.approval Other.(describe): y A pp oxiim to e of all components, date installed(if known)and source of information: Were sewage odors detected when arriving.at the site(yes or no./ 6 Page 7 of 1 1 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � C Owner: / Date of Inspection: o7Glo� BUILDING SEWER(locate on site plan)) Depth below grade: . Materials of construction:_cast iron _40 PVC_other(explain):- Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) P Depth below grade: - . Material of construction: concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of certificate) Dimensions: -,!; Sludge depth: LpJ/ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from to of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom o outlet tee or baffle: How were dimensions determined: Comments(on pumping recommen tions, Viet and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert,evide ce of leakage, a .): f� GREASE TR/A,I (locate on site plan) �� ... Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels 'as related to outlet invert,evidence of leakage, etc.): 7 1 r Page 8 of 11 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: (� ? eo/ Owner. Date of Inspection: TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BO?.&(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): PUMP CHAMBER%/ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued)) Property Address: � CJ' Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers, number: _leaching galleries, number: leaching trenches,number,length: leaching.fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, e N ii 2 CESSPOOLS/�(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRI`�(locate on site plan) Materials of constniction: Dimensions: Depth of solids: Comments'(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address:. 4 m'4—61� Owner: Date of Inspection: ,�QQ 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. A �vj � poi. ceh �3 O a� pit 10 Page I 1 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION (continued) i .Property Address: Owner. r/ Date of Inspection• �tJUy 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: hecked with local excavators, installers-(attach documentation) Accessed USGS database=explain: You must describe how you established the high ground water elevation: 11 Permit Number: Date: Completed by: 5o ' / HIGH GROUND-WATER LEVEL COMPUTATION �L l l Site Location: /OAS (��e�r / y�� /I/ Ord Lot No. Owner: � 10 /Cml® , Address: �— Contractor:— ll��/ )� ®d/�v�" Address' ) Notes: ll/5�� 5 STEP 1 Measure depth to water table tonearest 1/10 ft. ............................................................................... .Date month/day/year STEP 2 , Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well....................................................QrZ Water-level range zone ..................................................... G STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to ©G !7 l water level for index well ........................... �G month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) -q determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) .............................................................................................................. Figure 13.--Reprobucible computation form. 15 alo, __.. .... .... .�.... TOWN OF BARNSTABLE � { l6 LOCATION / SEWAGE # VILAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NSEPTIC TANK TANK CAPACITY /® c �i��✓. LEACHING FACILITYAtype) �/7� �� (size) [OX NO. OF BEDROOMS =�— PRIVATE WELL PUBLIC WATE BUILDER OR OWNER pi-5 FE('1/610 PAIR RRD vUT DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 3_)v9a 6 , j��v'"—UG/Yr�JccSE o ' Q , a ASSESSORS MAP 7 EST HOLE_ LOGS PARCEL ,-- NOTES. g ` SOIL VA UATOR, , �, FLOOD ZONE: OT � F�,/ �,..� ....._ N TNESS l,.. _. 1 The installati on shall comply with Title V and Town of B p Y Barnstable Board REFERENCE. , - of �`�` !� -� � DATE . c / C u . /' - .L.--?- =Health Regulations. PERCOLATIONF: . � R T_ . . . A 1 if2 , T �/ /�,, ` �'�', ) he installer shall verify:the loea� �,. /�� y tion of utilities sewer coverts and septic comp onents pr ior to installation P P nand setting base elevations. � � g 3 All gravity septic i in to be 4 s� - ) g Y p p p g inch Sc1i 40 PVC at 1/8 TH I TH 2 er foot. The first `t _ p two feet out of the d box to the leaching shall be level. t g 1 4 T 1� _ e his 4 plan is not to be utilized d �I�l,.� ) p for property line determination p ermmation nor an other p Y r u ose t Y a other than t --�--(-� purpose he proposed system costa � p ,P Y Nation. i 5 Al t 1 1 septic . � components � T� � ) must meet Title V specifications. 6 ` P 2 � arkm shall n l3� u,•,� , l•�> ) of be constructed over � g HI0 septic components. o �' � 7 Th p p , e property s bounded b MAP �� ,,� 10 � ) p P Y ro ert corner LOCATION � Y p sand property lines. 8 Th� e property owner shall p p y 11 review design considerations to g approve of total : PP , �CO n�'n des ign si n�2. flow and number�� g of bedrooms to be considered s eyed for design. Receipt � g p of pa yment for th e plan and installation P Y on based P on the plan sha ll be deemed . vL ,a .. C; royal of the d' pp design flow b the owner. I � g Y wn r. h ex isting leaching g cesspools shall be pumped and filled.with material W p p 1 Ili per . Tit V� le abandonment p nment procedures.\; �� • ,� p s. Those within the proposed SA p p S shall be removed al ong with contamina ted ted soil and replaced with clean sand per Title V specs. - p 10 System,components to be 10 Y p feet from water line. Sewer line c - • s crossing the wa ter line sha ll besee ' sleeved d with 4 inch SCH 40 PVC with ends routed if ` 'SEPTIC.. SYSTEM DES l GN g `,applicable. The proposed SAS is being installed P p g below the water service line. The •h line is to be sleeved as af orementioned and maintained m lace. 11 If a p • garbage `grinder FLOW E.- f.MATE ) g der exists it is to be re g g moved and is the responsibility of the .�. p Y _ owner:to ensure such. 12 Th e installer j is to take caut_un BEDROOMS AT � GA�./DAY/BEDROOM ,E' GAL/DAY ) m excavation the. as line i I �� g f such r , exists. , • . , 13 Th e inst aller shall verify the location..� 41EPTICY quantity and elevation of the se I TANK - q Y sewer ; lines exiting the dwelling prior to g g p the installation. _ .._.._ !D DAYS ,� V GAk_ AY x 2 AY GAL � _. USE ( GALLON SEPTIC TANK r , I r` T L I lSl L Af:.,t}4T ION SYSTEM Vk OFAf s O DA . s 141 '« ..1.- _ ^i S I U E AREA. .� ( � a � � � bss I' c t �17� 0 _ STE Ca T M .AREA ��.- � � �;C)�1 I � � R „ r i e TAR1 ` SEPT I C SYSTEM S - — � Y TEM SECT I ON -�: �, � '� u�� it n / - � •� is ,� ��t�•• ��_� ,� r» (� �a 10 F-7- _ __. ram-•, La(jo 1 f eq �- GALSEPTIC TANK c rP . . . .. ......._µ___. ._co,_.. .� �— ,I C TT�I l I" a - � SITE AND SEWAGE PLAN r � . OC Q 6 LOCATION :I ON / .. ��f� � PREPARED FOR . � �4 V 77 H a 1 — — o - scaLE . 20 D 0 �-�-- DAV ( D B . MASON, DATE: �' o! Z DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA W DATE G HEALTH AGENT W ('S08 ) 833 2177 Z - 77'71 �.. ✓ IgW},�Ml P f L S �L'K•C� nY 3e 5* T A4� 4-1, - 4""�.n".`a REFERENCES.- Plan Book 1431155 Deed Book 9876 144 `\ tia ' - . r,6 ss LOCATION MAP: Scale: 1 = 2000 f Last Wrack Line ASSESSORS REF.. Located 05/DEC/06 Map 259, Parcel 10 OVERLAY DISTRICT: �G +lo - GP Groundwater Protection District FLOOD ZONE: 20 s ' \ ` � ��-...• � � �\ \� wetland Resource Line Zone V13 (e115), & C (see plan) As Flagged By Others Community Panel No. Located 05 DEC 06 / / #250001 0015 C August 19, 1985 Paved Drive 2,5.\ DH 1 Fnd - 1J t o e \ \ \ \ ' 1 \ \ ZONE. CO Area (min.) 87,120 SF (RPOD) Right of way ,J 0' ` \ / Fron to e min 20' ~\ \� \ If Setbacks: ( ) 0 y� ` Fron t 30' \, . Side 15 \ \ `. . Grass \ i °`o . Rear 15' 27 79 If Grass30 -Lot A~ �2.13 A'cr s f o� � If Grass\ \ \ ` \ J APPROX. LOCATION Lawn\ 'OF EXISTING 1(EACH PIT \ \ � \ \ \ � � � � \ \ ' /TO,BE \ OR' 11 EDNED TH-1 \ \ \ i GrassTH IJ� CoT \ \ s j \ / f! \ l\ PROD \ �� gY \ �� \S �� tj \ /If \ ` f \ SEPTIC T NK l \ / 0 O 3 \ �\ ..-.fir 1 f � \ 1 "" •,. \ \1 2 ` �Lawn woad 1 12' Patio Deck o �S PR1110PSS�D \ %/\ /ems( t 1 / }} Elec _ PROPOSE t I , I Mete D-BOX 20. Ent ` � � � � � \ � \ / #180 \ \ Trellis .,� J lCrow/ 2 Sty w f Crawl Plies Dwelling \ \ \ / Full, a� FF=46.6 k 0 1 If ` e ceIf B Lawn f . i f t �ee� // / ° ode / ' --. 1 t 1 45 j o 1 II f PROPnD OS� t f vVeE i J iIf stone W , � Calves /? Pasture ' ' f J f f 1 f, It / If / Parcel 8 /� DESIGN DATA SEPTIC NOTES i 1 d J \ ,l If Single Family-6 Bedrooms 1.Location of Utilities Shown on This Plan Are Approx.At Least 72 Hours t / 1 Paved Lawn ` i 1 Jl J 1 ! ff/ ,/ \\ \ With NO Garbage Grinder Prior to Any Excavation For This Project the Contractor Shall Make 1 \ drive \ J 1 / 1 1 1 f ! \ / Daily Flow=110 x 6=660 GPD the Required Notification to Dig Safe(1-888-344-7233). f \ \ 1 J 1 1 1 1 t j Lot 1 `� ` /- Septic Tank:660 GPD x 200%=1320 GPD 2.The Contractor is Required to Secure Appropriate Permits From Town t ! f r \ \ //� Use 1500 Gallon Septic Tank Agencies For Construction Defined by This Plan. 1. \ 1 i 1 I r9.3 Acrest \ " 1 J 1 l f ! ! f ! \ / 3.Install Risers to Within 6 of Finished Grade(5 Required). Pf LEACHING AREA 4.All Structures Buried Four Feet or More or Subject to Vehicular Traffic to be H-20 Loading.It is the Engineer's eel 1 ( 1 f /f \ / ~ \ 660 GPD/0.74=892 SF Required g f \ } !✓ J f j� f f Recommendation that H-20 Always be Used o / Sidewall=2(12'+55')2'=268 SF 5.Septic System to be Installed in Accordance With 310 CMR 15.00& 1 f 1 C! f f Bottom Area=(12'x 55')=660 SF k 248 CMR 1.00-7.00 Latest Revision and the Town of Bamstable 928 SF Total Provided Board of Health Regulations. It U� a I i i f J {> f j f f 1 /s'- �/ 6.All Piping to be Sch.40 PVC. ti j I / / 1 �/ / /a� LEACHING CHAMBER DESIGN 7.Inlet Tees Shall Extend aMinimum of 10" 0 1 I/ ! f� 11 1 I J I / / j �y All Pipes to be Schedule 40. Use Below the Flow Line. l 1 J 1 J / / I / 6-500 Gal.Leaching Chambers in 8•An Outlet Tee With a Gas Baffle th le Shall Extend 14"Below e Flow Line. ��VII It 1 lb 12'x 55'Washed Stone Fields as Shown. 2.3' It [�♦ �� Lawn ` 1 f 1 l f/ �! J �f /J 1 f ✓ �� r^V a/ ` 3 1 Lawn vJ Garages \ \ I 1 �! { f ll J NI t /� ... T13M EI=51.3' NGVD Slob-49.9 I l { 1 /•a f� Drill Hole in Wall a r°i \ Ih/o PERC TEST: 11,537 PERFORMED BY:JOHN O'DEA,E.I.T.-SULLIVAN ENGINEERING WITNESSED BY:DONNA MIORANDI,R.S.-TOWN OF BARNSTABLE MARCH 12,2007 Fnd 2 _ �,\\ \ 4 l J \ /A, ` _ TEST HOLE-1 EL.3s2 TEST HOLE-2 EL.39.4 TEST HOLE-3 EL.362 Finish Grade 4'--•-. 011e \ \ 1 1 / ( d ` l l \\/ �, I LOAM LOAM LOAM 3'Max. i NOW 11 'R.^ � ,0111-i II�= :� 4 \� 12"1 372 12" 38.4 12" - 352 9"Min Compacted Fill \ Se \ t 5 ` B LAYER I OYR 5/6 Filter \ fbaC'� IJ DARK YELLOWISH BROWN YELLOWISH BROWN - YELLOWISH BROWN ric t \ I/8"-U2" Stan �\ a3` ` ! I ` \ \ \ \ \ `\ \ \ / ND 33" LOAM SAND 35.5 31" LOAMY SAND 36.8 19 SLOAMY OME COBBLES 34.6 p :/OR Drive S,\ /�(� ( 1 l ` \ ! \ 1 ` \ /Y\ j YELLOWISH BROB2 LAYER 10 YR W/6 LAYER 2.5Y N LIGHT YELLOWISH BROWN 2 3/4".1 1/2" LOAMY SAND \ MED SAND LIGHT YELLOWISH BROWN 3' SOME BOULDERS Double Washed ' MBEMR ` \ \ \ \ i ! t \ y 32.9 SOME COBBLES MED SAND LEACHING { Stone CLAYER 2SY 6/4 FEW BOULDERS 2' CI H-20 i LIGHT YELLOWISH BROWN 6° PERC TEST 35.6 <.. H-20 MED SAND 3.3 MIN./INCH 34.1 1 t 1 ` \ \ \ \ \ \'� \ \ Y•~\3\ \, 120" 282 NO GROUNDWATER ENCOUNTERED w Otlw \ \ \ \ x. \ „ ```.. "^�, NO GROUNDWATER ENCOUNTERED �--- 4'-10" Legend: ' �-� \\ \\��; 1 57 1 9E°f \„� �\ NO GROUNDWATER ENCOUNTERED 12' CROSS SECTION OF CHAMBER ® Iron Pipe NOT TO SCALE QQ Drill Hole o,./Lt � `� `� `ti. \\\ e ��/"/ '4 \ �'` ~+ ~ \ \ F.F.EL.46.60 Vent-Final Locatation to be Determined \ ..,,, \\ al Time of Install so as to ba ® Catch Basin ' 1 �'�yth \ �� \ �\ as Inconspicuous as Possible O - 1 AC/b�,} �/p "� \ F.G.EL.43.0 Hydrant E/e r,./C+ `� \�. F.C.EL.393 - F.G.EL. p F.G.EL.40.0 Wetland FI o g tf /Q s Oy� t^�' \ EL.42.10 F.G.EL.37.0 © Water Gate (round) saRa°�r \ \ '�iQ\ \ EXISTING CLAY PIPE ¢4�, TO BE REMOVED Sae Note 3(typ.) El CB/DH Concrete Bound -1 Guy Anchor R�°¢o,� EL.38.00 n n -0- Utility Pole TOIN CONFIRMED F1 - -25- - Elevation Contour BY INSTALLER EL.37.00 zo - 1500 Gallon Top EL.35.00 Septic Tank D-Box Flow Equilizers Beech Tree As Required EL.34.00 Leaching Chamber v. H-20 But.EL.32.00 Bedding,"T"s,&Baffels 10, as Per Title 5 If Encountered Remove&Replace Min. All Deciduous Tree (See Notes 8&9) The OuterPerimterwitheSyst Yof 10'Min.-Slab The Outer Perimeter of The System N 0'Min.-Foundation DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM EL.5.0 Approx.Groundwater NOT TO SCALE Per T.O.B.Groundwater Map Coniferous Tree Modify Septic Location Based REVISION: Lot Division by Others DATE: 10 19 07 TI TLE. Site Plan PREPARED B Y. PREPARED FOR: NO TES: Proposed Septic Upgrade Sullivan Engineering, Inc. 1. The property line in PO Box 659 Joanne Lyman Tr ) P P y formation shown was (b compiled from available record information. cu At Osterville, MA 02655 163 E 81 ST ST '~- 180 Scudder's Lane (508)428-3344 (508)428-3115 fax New York City NY 10028 2.) The topographic information was obtained PsullPECool.com from on on the ground survey performed on ►�. or between 251SEP106 and 15/DEC/06. o Bamstable (L'3crnstoble Village) MASS, Draft: JOD 30 0 15 30 60 120 3.) The datum used is Based on NGVD DATE. March 26, 2007 SCALE: 1 „_30F Review: MD/PS Project # 26045